Getting Beyond P4P: PROMETHEUS Payment

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Getting Beyond P4P PROMETHEUS Payment

• Alice G. Gosfield, Esq.
• NERVES
• April 13, 2007

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• Alice G. Gosfield, J.D.
• Alice G. Gosfield and Associates, PC
• 2309 Delancey Place
• Philadelphia, PA 19103
• [phone]
• Agosfield_at_gosfield.com
• www.gosfield.com
• www.uft-a.com

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Overview

• The contemporary quality moment
• P4P
• Why the physician nexus matters
• Understanding the doctor-patient essentials
• Five principles and a theory
• Another way
• Why bother?

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Bridges to Excellence Mission Statement

• To create significant leaps in the quality of
  care by recognizing and rewarding health care
  providers who demonstrate that they have
  implemented comprehensive solutions in the
  management of patients, and deliver, safe,
  timely, effective, efficient, equitable and
  patient centered care.

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The Development of Quality Policy

• The Woodstock Era 80 definitions of quality by
  1984
• The Rise of Toyota and Value Purchasing
  selection means comparison
• Order Out of Chaos NCQA and HEDIS, unexplained
  variation and CPGs
• Values Coalesce managed care backlash,
  Presidents Commission
• IOM Studies where we are now -- STEEEP

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The Point of P4P

• Propel change to more science, more safety, more
  patient-centeredness made known with more
  transparency
• By paying for results, processes and systems will
  be compelled to change by the application of
  purchasing power
• Faster than incremental change would produce

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Typical Forms of P4P

• Threshhold bonuses (BTE)
• Tiering bonuses (IHA, CFHCC)
• Cost savings against a benchmark with tiering
  (CMS)

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P4P Pitfalls

• You move up to the raised bar then what?
• Where is the money coming from?
• There is no contractual obligation to pay
• These are add-ons to contracts that are
  inconsistent -- what about their UM?
• Margins, margins, margins
• Adverse selection
• Relationship to disease management?
• The data is self-reported or comes from claims
  data are we getting what we want?

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Early Assessment P4P Is Transitional at best

• A good moment for quality and payment
• Chronic care low hanging fruit conceptually
• Add ons to an inconsistent world which has
  demonstrated its inability to produce what we
  want
• Carve out would be better
• Is there a better way?

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• Every system is perfectly designed to achieve
  the results it gets.
• Donald Berwick, M.D.

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• The contemporary moment in health policy is
  nothing short of a Dionysian rhapsody of
  regulation, the inhospitality tradition gone
  riot, the formal and final enshrinement of the
  doctrine that everything that is not mandatory is
  prohibited.
• ---James C. Robinson

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Todays Regulatory Quality Context Welcome to
Wonderland

• Federal regulation of quality
• PROs/QIOs EMTALA conditions of participation
  Patient Safety and Quality Improvement Act, QISMC
  and QAPI in Medicare managed care HCQIA
• Fraud and abuse based on quality failures
• Premature discharge false claims services in
  excess of patients needs
• Civil money penalties exclusions

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Why Is the Physicians Business Case for Quality
So Important ?

• Physician Centrality
• Plenary legal authority
• Portal to the system
• Their critical and fundamental role in the system
  and to their business significant others AMA
  White Paper IHI White Paper --- www.ihi.org
• Expertise (Reinertsens Axioms)
• Explain, predict and change patient futures the
  healing relationship

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Hazards to Time and Touch

• Irrelevant documentation of many types
• E M codes false claims exposure Medical
  necessity of services Ministerial minutiae (CMNs
  for DME)
• Health plan programs
• 1-800-nurse-from-hell redundant safeguards
  (capitation and prior authorization and encounter
  forms and post-payment audits) inconsistent
  formularies
• Self-induced
• Defensive medicine inefficiencies clinical
  science as individual sport

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Time and Touch Hazards (contd)

• Rampant consumerism
• Olympic caliber Web surfingalternative
  therapies direct to consumer advertising
• Administrative demands from hospital and medical
  staff
• Messaging and work flow interruptions
• Pharma reps prescription management-- writing,
  renewing
• Burgeoning physician report cards
• Disease management approaches
• Explosion of knowledge base

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Escaping the Rabbit Hole Five Principles

• Standardize
• Clinical processes, documentation, office
  systems, use of NPPs highest and best use and
  more
• Simplify remove barriers to time and touch
• Make Clinically Relevant
• Budgeting, capital expenditures, payment
• Engage the Patients
• For risk management and patient centeredness
• Fix Accountability at the Locus of Control

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Clinical Integration for Collective Bargaining

• Held out in every network settlement with the FTC
  to date
• Elements (1) protocols and CPGs (2) internal
  review and profiling (3) investment in
  infrastructure (4) corrective action (5) data
  sharing with payors
• Fee bargain must be ancillary to the real reason
  you are doing this

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How to begin?

• Find compatible practices and work together
• Agree on documentation that will save time and
  facilitate your own profiling
• Pick just a couple of issues condition-specific
  reflecting PM initiatives or cross-cutting
• Find CPGs and use them, explicitly
• Begin to standardize documentation, simplify
• Share with each other
• Once you have saved time move on to more and then
  begin to price

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• Provider Payment Reform for Outcomes, Margins,
  Evidence, Transparency, Hassle-Reduction,
  Evidence, Understandability and Sustainability

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The Design Team

• Jim Bentley, AHA
• Francois de Brantes, Bridges to Excellence
• Doug Emery, eHI
• Michael Pine,MD, Michael Pine Associates
• Alice G. Gosfield, Alice G. Gosfield Associates
• Mike Taylor, TowersPerrin

• Jeff Levin-Scherz, MD, HarvardVanguard/HealthOne
• Beth McGlynn, RAND
• Toni Mills, BCBS Association
• Meredith Rosenthal, Harvard School of Public
  Health
• Craig Schneider, MA Health Data Consortium

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Purposes

• Get beyond P4P which is not sustainable as a
  payment reform model
• Deal with the toxicities of FFS and capitation
• Reduce administrative burden on physicians
• Pay to deliver the right combination of services
  according to science

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Basic Concepts

• Amount of payment is derived from assessment of
  projected resources to deliver care in a good CPG
• Negotiated base payment takes into account
  severity and complexity of patients condition
• Bulk of it is paid prospectively

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More

• Evidence-informed case rate (ECR) encompasses all
  providers treating a patient for that condition
  and is allocated among them in accordance with
  that portion of the CPG they negotiate to deliver
• Comprehensive scorecard measures process,
  outcomes, patient experience of care, relative
  efficiency measured at the level of the
  contracting entity

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Still More

• Performance Contingency holdback of 10 on
  chronic care 20 on acute care provides basis to
  pay remainder of ECR in accordance with scores
• pro rata half for quality half for
  efficiency
• Better performing providers get better margins
  and potentially additional
• Voluntary, not total substitution, negotiated
• TRANSPARENCY OF EVERYTHING

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Who plays?

• IDS that bids for one payment for all in it
• Idiosyncratic teams of providers who bid to be
  scored together (need not be legally an entity)
• No one holds the money of someone else unless
  they negotiate for that
• Providers can configure their groupings, if any,
  any way they want 1sy 2sies can play single
  hospitals can play competitors can bid together

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Determining Payment Amount

• ECR is based initially on observed behavior with
  an up margin for clinical variability (eventually
  on actual costs)
• Stratifies within the ECR for common
  co-morbidities (not simple addition of more CPGs)
  up to a case-breaker
• Triggers, conclusions and breakers are
  established in advance

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Potential Benefits

• Clinically relevant
• Sustainable as a business model
• Offers certainty in payment amount
• Expects negotiation between providers and plans
• Should reduce admin burden (no E M bullets, no
  prior auths, no concurrent review, no postpayment
  claims audits, maybe no formularies)
• Designed to permit easy implementation by plans

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More Benefits

• Carved out in simple amendments from contracts
  that otherwise remain in place
• Will improve the quality of CPGs
• Lowers fraud and abuse risks
• Reduces malpractice liability
• Fosters clinical integration
• Tracks to STEEEP values
• Gives physicians more control over what they do

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Infrastructure to be developed

• ECR Translator --- to construct payment amounts
  from a CPG
• ECR Budget Estimator to establish the payment
  amount
• ECR Tracker to take data from claims and
  allocate to appropriate providers the pieces of
  the CPG they delivered
• ECR Reporter to figure out how much is owed, if
  any, at the end of the CPG
• Comprehensive Reportcard

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Caveats

• This will be complicated
• There will be transitional costs especially given
  parallel systems
• There are pitfalls
• There is short term reality and long range
  potential
• This will take work BUT
• There will be no change without struggle

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Next Steps -- 2007

• Model the ECRs
• (1) knee and hip replacement (2) preventive
  health (3) depression in primary care (4)
  diabetes (5) lung and colon cancer4 (5) STEMI,
  non-ischemic CHF, mitral valve regurgitation
• Create the Engine
• Identify pilot markets (Chicago, Seattle?,
  Winchester, MA, Philadelphia? Memphis?
  California? and contract for pilots
• Launch pilots second half of 2007-8

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Why bother now?

• What are the other options?
• Physicians are at the core of improved quality
• What PROMETHEUS rewards you should be doing
  anyway
• You can do well by doing good if you make the
  right thing to do the easy thing to do

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PROMETHEUS Payment

• Promethean (pr?-me'the-?n) adj. defiantly
  original so boldly creative as to have a
  life-giving quality
• In Greek mythology Prometheus brought
  understanding and light to humans, thus
  propelling them into the age of reason. Our
  version of PROMETHEUS carries the hope of
  bringing new light and understanding to payment
  systems thereby propelling health care far into
  this new millennium.
• ---The White Paper

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Resources (Most Recent First) www.gosfield.com/pub
lications

• Gosfield, The PROMETHEUS PaymentTM Program A
  Legal Blueprint, HEALTH LAW HANDBOOK (January,
  2007) 36pp
• Gosfield, PROMETHEUS Payment Getting Beyond
  P4P, Grp Prct J (Oct. 2006) 5pp
• Gosfield and Reinertsen, "In Common Cause for
  Quality Part 1 New Hospital-Physician
  Collaborations," Hospitals and Health Networks
  Online, October 10, 2006 Gosfield, "In Common
  Cause for Quality Part 2 PROMETHEUS Payment and
  Principles of Engagement", Hospitals and Health
  Networks Online, October 17, 2006

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More Resources

• Gosfield, PROMETHEUS Payment Better for
  Patients, Better for Physicians. Journal of
  Medical Practice Management (September/October
  2006) 5pp
• Gosfield, Contracting for Provider Quality
  Then, Now and P4P, HEALTH LAW HANDBOOK, 2004
  Edition, http//www.gosfield.com/PDF/ch3PDF.pdf
• Leibenluft and Weir, Clinical Integration
  Assessing The Antitrust Issues, HEALTH LAW
  HANDBOOK, 2004 edition, http//gosfield.com/PDF/ch
  1/PDF.pdf
• FTC MedSouth Staff Opinion on Clinical
  Integration, http//www.ftc.gov/bc/adops/medsouth.
  htm
• Reinertsen, Zen and The Art of Physician
  Autonomy Maintenance, Ann. Int. Med. 138
  992-995 (June 17, 2003) http//www.reinertsengroup
  .com/PDF/zen.PDF

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More Resources

• Gosfield, The Doctor-Patient Relationship as The
  Business Case for Quality, J. of Health Law
  (2004) http//www.gosfield.com/PDF/DrPatientRelati
  onship.pdf
• Gosfield and Reinertsen, Paying Physicians for
  High Quality Care, NEJM (Jan 22, 2004),
  www.uft-a.com/publications
• Gosfield and Reinertsen, Doing Well by Doing
  Good Improving the Business Case for Quality,
  (March, 2003) www.uft-a.com
• Gosfield, Quality and Clinical Culture The
  Critical Role of Physicians in Accountable Health
  Care Organizations (1998) http//www.ama-assn.org
  /ama1/pub/upload/mm/21/quality_culture.pdf