Dealing With Payers With Physician Driven Cost And

Dealing with Payers with Physician Driven Cost and Quality DataHilton Sandestin Beach & Golf Resort, DestinAugust 2, 2011William F. (Bill) Cockrell, FACMPE

What’s the Next “Big” Option“Accountable Care Organizations (ACOs), Why They Will Fail and What We Will Need to Learn From the Experience”The main ingredients (who can argue with these?)Cost Effective QualityBecauseIn 2014 we have Healthcare Exchanges

Healthcare ExchangesThe Affordable Care Act requires each state to establish by 2014 a health insurance exchange where individuals and small businesses can purchase affordable health insurance plans. The exchanges are the centerpiece of the reform law: they will be the main portals for people without employer-sponsored or public insurance to both find a health plan and learn about and apply for any federal subsidies for which they are eligible.

Essential Elements of a Healthcare Exchange *offering the essential benefit package (to be determined in regulations later this year); adhering to cost-sharing limits; being licensed and in good standing to offer health insurance; compliance with quality standards established in the law, including required quality data reporting, quality improvement strategies, and enrollee satisfaction surveys, all of which will be addressed in future regulations; offering at least one qualified health plan at the silver and gold benefit levels;

Status of State Legislation to Establish Exchanges,as of July 2011AKNHWAMEVTMTNDMNORNYIDWIWIMASDRIWYMICTPAIANJOHNENVDEINILMDUT WVIAVACODCCAKSMOKYILNC WVVATNSCOKAZARNMGAALMSLAHITXFLState exchange in existence prior to passage of ACALegislation pending in one or both housesLegislation signed into law post passage of ACAPending legislation failedLegislation signed: intent to establish an exchange, creation of study panel, creates an appropriationGovernors have pursued/considering non-legislative optionsGovernor veto or decision not to establish exchangeLegislation passed one or both housesSource: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis.

What are Our OptionsWe can runWe can hideWe can retireWe can complainBut – There will be changes in the Healthcare Delivery System

Here’s an OptionWhat patients and doctors need is a U.S. government Web site run by an enlightened, well-intentioned policy elite that studies various treatments for the same condition and compares their performance. That’s how we can find effective, less costly care.” July 4, 2011 Birmingham NewsFroma Harrop is a member of The Providence (R.I.)Journal’s editorial board and a syndicated columnist.

Can an Enlightened, Well Intentioned, Elite Group Design One Plan to Fit All?

Can the Government (Federal or State), Employers (the current primary insurance coverage purchasers), Payers (Medicare or Private), or any other one group design one plan to fit all?

“The barrier to change is not too little caring; it is too much complexity.” -Bill Gates

2007 Medicare Beneficiary Cost and Readmission RateLouisiana - $9,500 and 22 day readmission rateWest Virginia - $7,600 and 23 day readmission rateAlabama - $7,600 and 17.5 readmission rateVermont - $7,400 and 14.5 readmission rateOregon - $6,100 and 13 day readmission rateRhode Island - $8,600 and 18.5 day readmission rate

Cost and Readmission Rate RangesLouisiana $9,500West Virginia 23 day readmission rateOregon $6,100Oregon 13 day readmission rate

Dealing With Payers With Physician Driven Cost And

Achieving SavingsThere are three basic ways to reduce Medicare and Medicaid spending: cutting eligibility or benefits—that is, reducing the number of people, the range of services, or the share of spending covered by the programs;

trimming payments by reducing the prices paid for covered services; or reducing utilization of services.

While the third way is sometimes disparagingly referred to as rationing, there is a significant body of research showing that when patients receive the right care for their condition, and in the right amount, we can not only reduce the total cost of treatment but also improve access, quality, and outcomes.5Those are the options facing us if we (as providers) don’t accept the challenge of working with all of the above on data driven plans that include cost andquality.

Option Three Depends on Real Data that Requires a Number of Sources and Results in Some Providers Changing, or Being Left Out

The Financial IssuesDefine cost effectiveComparison to the current fee for service / transaction based model?This is the initial policy under the ACO modelLong term model?How do you find outPayersBCBS and others have great information but difficulties in accessing it in a usable formData sourcesIndependent sources have data but it is blinded by individual patient name

The Quality IssuesThe Accountable Care Organization (ACO) Quality Performance MeasuresInitial 65 quality measuresThe measures are divided by five “domains” that are weighted equally:Patient/Caregiver Experience (7 measures)Care Coordination (16 measures, including transitions of care and HIT)Patient safetyPreventative HealthAt Risk Population/Frail elderly Health (31 measures) on the followingDiabetes, Heart Failure, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease, Frail Elderly

Scoring of Quality PerformanceProviders are scored on their overall achievement relative to a national or other benchmarkQuality performance standards will be issued in future rulemakingPerformance ScoringCMS sets benchmarks at beginning of each reporting year using FFS, Medicare Advantage or data it has modeledPoints are assigned to each measure (and summed by domain) based on performance related to the national benchmark.There is a maximum of 2 points per measure, with a maximum of 130 points for 65 measuresDomain scores are determined by dividing the actual points by the maximum potential points to determine a % of performanceThe 5 domain scores are averaged to determine the overall score

So, If We See Traction on Alternative Delivery Systems, and We Will, We Are Going to Be Faced with Getting from Here:

Medical TreatmentCathSample Referral Decision Tree DiagnosticsHospital AHospital BCT SurgeonCathCardiologistCT SurgeonHospital CPCP Interpreter AMobile DiagnosticsInterpreter B

Medical TreatmentHospital ACathSample Referral Decision Tree - ModifiedHospital BDiagnosticsHospital CCT SurgeonCathCardiologistCT SurgeonPCP Interpreter AMobile DiagnosticsInterpreter B

And the New Decision Tree Must be Based On:CostQuality

What do Providers NeedInformationKeeping track of the rulesUnderstanding modelsOrganizationSystemsEMR’sReal medical record data sharingRealityThere will be those who don’t get to participate

What’s Out there now for Patients, Payers and Providers

Robert Woods Johnson FoundationComparative Healthcare Quality: A National DirectoryJune 28, the RWJF “launched the nation's most comprehensive online directory for patients to find reliable information on the quality of health care provided by physicians and hospitals in their community.”“Data on the performance of healthcare providers helps patients take a more active role in managing their healthcare because it lets them see what proper care looks like and whether local hospitals and physicians are delivering it.

Data Research Resultshttp://www.rwjf.org/pr/product.jsp?id=71857

Other Information Sourceshttp://healthcarequalitymatters.org/?p=fqchttp://www.checkbook.org/patientcentral/?cb=hmct&ref=www.healthgrades.com

Sample Using Real DataA hospital in Alabama25 primary care physiciansReferral to cardiologists based on top diagnosesMedicare data used available through Freedom of Information ActHPI information scrubbed

BCBS Patient Satisfaction and Quality Measures for Selected Cardiologists

Healthgrades Patient Satisfaction Measures for Selected Cardiologists

What about the Financial Side of Things

ICD9 Diagnosis CodesEffective Year: 2010(5)Category: (CUSTOM) TOP FIVE CARDIOLOGY DIAGNOSES(5)4011 - Essential hypertension, benign41400 - Coronary atherosclerosis of unspecified type of vessel, native or graft41401 - Coronary atherosclerosis of native coronary artery42731 - Atrial fibrillation78650 - Chest pain, unspecified7/26/2011 ©RealTime Medical Data (205) 941-1211 [info@rtmd.org] 00:00:09.1553124 Page 1 of 1 The Source for Timely and AccuratePaid Medicare Claims Data™

CY MGMA 2010 Cost per Physician for Top Five PDX Total InPatient Discharges(DRGs) by PrincipalDx then Physician and Major Diagnostic Categories(MDCs)(1).xls

Coronary Atherosclerosis of Native Coronary Artery

Ranking system5 to 1 point(s) for high to low volume5 to 1 point(s) for low to high LOS5 to 1 point(s) for high to low CMI5 to 1 point(s) for low to high cost5 to 1 point(s) for high to low BCBS Patient SatisfactionPoints totaled and physicians ranked high to low

Coronary Atherosclerosis of Native Coronary Artery Ranking

Now WhatIf I’m a specialist and highly ranked, I find the way to get the word out to referring doctors and payersIf I’m a specialist and ranked low, I find out why and work to change or get better informationIf I'm primary care, I let the specialists know I need this information in the future

What can we (Providers) Do Today?Start gathering data internallyAs Primary Care Physicians ask for quality and cost data from our specialistsAs Specialists, be proactive in gathering the necessary data and providing it to our PCP’sAs organizations, find out data sources, communicate this information to our members and help our members understand the information (MASA, MGMA research?)Work with payers when the opportunity presents itself for meaningful analysis of information

The Role of Electronic RecordsIn May, the federal government awarded its first payments to physicians who successfully demonstrated that they are making meaningful use of electronic health record systems (EHR). To qualify for the payments, physicians had to prove that—among other things—their EHR systems were capable of capturing and exchanging health information on patients, including lists of medications, allergies, and test results. Physicians were also required to demonstrate that the EHR had the functionality for computerized physician order entry, electronic prescribing, and reporting of clinical quality measures to state and federal bodies.

The Role of Electronic RecordsReality, we cannot get the information we need through paper chartsWe have to have discrete, searchable data elementsWe have to have dashboardsWe have to efficiently communicated reports and dataWe have to share information, appropriately

Dealing With Payers With Physician Driven Cost And

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