Sutter Medical Network - ehcca.com · * will not work without Enterprise ID links across Provider, Member and transactions * * * standardize. standardize. standardize. standardize.

Sutter Medical NetworkSutter Care Pattern Analyzer…making the case for affordability

Fifth National Pay for Performance SummitMarch 9, 2010

Michael van Duren, M.D., CMO Sutter Physician ServicesColleen Thilgen, VP Ingenix ConsultingKristin Tschida, Consultant, Ingenix

•

Sutter Medical Network

•

Demonstration of Sutter Care Pattern Analyzer–

High level roll out plan

•

Optimal Use Activities–

Low Back Pain

–

Best Practice Alerts

2

Overview

Sutter Health & Sutter Medical Network

“Sutter Health leads the transformation of health care to achieve the highest levels of quality, access and affordability”

1. Quality2. Affordability

3. Process Redesign & EHR

5.

Sutter Medical Network

4. Prudent & strategic capital investment

Five priorities flow from the vision:

Transparency Transformation

Sutter Health Vision Statement

Vision

The purpose of the Sutter Medical Network,

working in partnership with the overall Sutter

Health network, is to provide consistently

superb and affordable health care –where, when and how patients want it.

Goals

•

Consistently delivers top‐decile clinical quality and patient outcomes

•

Enhances affordability

by collaborating with hospitals to improve institutional performance and reduce the total cost of

care and reducing variation and optimizing utilization management in physician care

•

Aligns physician organizations to provide a convenient, organized care system

•

Is

preferred by customers, patients and health plans

Strategic Objectives

Key Strategy Quality Patient Experience(Service)

Disease

Management/ Care

Model

Affordability

Strategic

Priority

•

Pay for

Performance•

Patient Online Access•

Ease of Referrals•

Reducing Patient Wait

Times•

Patient Satisfaction

•

Advanced Illness

Management (AIM)

Program

•Optimal Use

of Clinical

Services and

Supplies

Why address these issues?

•

Affordability–

For our patients, healthcare system, society

•

Service–

Provide a consistent experience for all our patients

•

Quality of Care–

Evidence based medicine

–

Professional standards–

Avoid unnecessary radiation, risks, complications

National Health Expenditures and Their Share of Gross Domestic Product, 1960‐2007

2,241.2 2,112.7

1,980.6 1,854.8

27.5 74.9

253.4

714.1

1,124.9 1,190.1 1,265.2

1,353.2 1,469.4

1,602.3 1,734.9

$0

$500

$1,000

$1,500

$2,000

$2,500

1960 1970 1980 1990 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

NHE as a Share of GDP

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2007; file nhegdp07.zip).

Dol

lars

in B

illio

ns

5.2% 7.2% 9.1% 12.3% 13.5% 13.6% 13.7% 13.8% 14.5% 15.3% 15.8% 15.9% 15.9% 16.0% 16.2%

http://www.cms.hhs.gov/NationalHealthExpendData/

$5,791

$4,824

$2,196

$7,061*

$8,003*

$9,068*

$9,950*

$10,880*

$11,480*

$12,106*

$12,680*

$13,375*

$6,438*

$4,704*

$4,479*

$4,242*

$4,024*

$3,695*

$3,383*

$3,083*

$2,689*

$2,471*

$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999 Single Coverage

Family Coverage

* Estimate is statistically different from estimate for the previous year shown (p<.05).

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2009.

Average Annual Premiums for Single and Family Coverage, 1999‐2009

High Deductible Plans

11

•

The latest “big idea”•

Lower satisfaction with consumer‐driven plans

•

Higher out‐of‐pocket costs•

More missed health care

•

More cost‐conscious consumers•

Lack of information

12

13

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15

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http://www.nytimes.com/

Physician driven utilization

•

Can we measure it?–

# of Visits–

Specialty Referrals–

Ancillary testing (Imaging, Lab)–

Treatment choice (drugs, interventions)–

Decision to operate

•

Can we manage it?

Reasons for over‐utilization

Behavior driver Ability to

influence

Speed of

results

FFS payment system F F

Self‐referral N/A N/A

RVU physician comp system C D

Professional identity C C

Training, practice style F F

“I had no idea” A A

So…

what can we do about this?

•

Gather systemwide data in a standardized manner –

Solution: Sutter Health Enterprise Data Warehouse

•

Utilize a methodology that provides “apples‐to‐apples” comparisons between clinicians

–

Solution: Implement episode grouper software (Ingenix)

•

Methodology for changing individual physician behavior–

Solution: Engage physicians to examine, address and

reduce variation in each specialty

‐‐

Led by Sutter Health IS

‐‐

Led by Sutter Physician Services

‐‐

Led by Sutter Medical Network

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Data Challenges

•

Disparate systems

•

Data not standardized

•

Workflow variations producing varying data results

•

Varying levels of discrete & detailed data available

•

Varying technical database platforms

•

Access to systems

•

Inability to integrate and uniquely identify patients across multiple platforms

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Sutter Connect Claims

Sutter Connect Eligibility

PAMF Claims

Sutter North Claims

Pharmacy

MiSys Lab

Ext. Lab

Sutter Select Claims

Sutter Select Pharmacy

Sutter Select Eligibility

SCPA Data Mart

Claims

Pharmacy

Member

Provider

Lab

PAMF Eligibility

SCPA without SHEW

*

* will not work without Enterprise ID links across Provider, Member and transactions

*

*

*

standardize

standardizestandardize

standardize

standardize

standardize

standardizestandardizestandardize


standardize

standardizestandardizestandardizestandardizestandardize

standardizestandardizestandardize


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SHEW

Sutter Connect Claims

Sutter Connect Eligibility

PAMF Claims

Sutter North Claims

Pharmacy

MiSys Lab

Ext. Lab

Sutter Select Claims

Sutter Select Pharmacy

Sutter Select Eligibility

SCPA Data Mart

Claims

Pharmacy

Member

Provider

Lab

ProvidereID Match

Member eID Match

PAMF Eligibility

SCPA with SHEW

eID

eID

eID

eID

Standardize

Aggregate

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Integrated Data Warehouse Advantages

•

Centralized data standardizations and business logic

•

Integration of Enterprise identification of patients & providers

•

Synchronization of data loads across all environments to SCPA

•

Normalization of data

•

Ability to “QA”

data quality in one place

•

Reusability of all data stored in data warehouse for future projects and needs

Variation Reduction Implementation

1.

Make variation visible2.

Safe environment

3.

Physician led variation reduction4.

Reproducible Process

24

Sutter Care Pattern Analyzer Demonstration

Exploration Process

•

Select a clinical area–

High volume, high cost, ability to impact, curiosity

•

Narrow to one “Episode Treatment Group”–

Drill down into all areas of variation; look for

differences and patterns–

Ask questions; don’t assume

Link to Sutter Care Pattern Analyzer

http://scdc310as/cognos/

26

27

28

29

30

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35

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“That doesn’t look right…”

Possible causes of underlying variation•

Coding patterns•

Data completeness•

Explainable patient characteristics•

Explainable provider characteristics•

Unexplained characteristics–

Ask, don’t assume

–

Probe for “best practice,”

evidence‐based guidelines, or professional standards

Physicians identify an opportunity

We should be able to fix that…

1.

Define standard / guideline2.

Define defect3.

Define metric for ongoing analysis4.

Generate ideas for possible improvement efforts

38

Possible methods for improvement efforts

1.

Group discussion2.

Send out data by mail3.

Individual counseling (academic detailing)

4.

Ongoing audit & feedback5.

Design Epic “best practice alert”

40

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Prioritize interventions

44

Counsel

Individuals

Counsel

Individuals

EHR AlertEHR Alert

Group discussionGroup discussion

Mail out dataMail out data

Ongoing audit &

feedback

Ongoing audit &

feedback

Web portal with

reports

Web portal with

reports

EHR Decision Support

•

Inclusion: any low back pain dx

•

Exclusion: cancer on problem list

•

Trigger: any imaging ordered•

(regardless of first or recurrent

episode)

•

Frequency analysis: 1‐9 x per mo.•

(highest utilizers: once per day)

46

Results at Pilot Site 1




Variation reduction vs. follow standard care?

Variation reductionVariation reduction•

Voice of the process

•

No need to define standard of care

•

Allows for clinical variation

•

Can start immediately with variation

exploration•

No clear endpoint (what

is the right amount of variation?)

Defect reductionDefect reduction•

Voice of the customer

•

Must have evidence based guideline

•

Must make sure all cases are very “pure”

•

Must spend time to gather consensus

•

Endpoint can be defined as percent compliance

with guideline

Next steps

•

Training for Medical Directors–

Navigating and exploring variation with the SCPA Tool

–

Engaging physicians•

Identifying key leaders to drive initiative –

Identifying preliminary departments to engage•

Meeting with physicians to generate, evaluate and select concepts

–

Determine best practices/guidelines•

Monitoring and quantifying improvement efforts

Risks

•

Impact on revenue due to decreased utilization–

Affordability is a long run goal

•

Provider satisfaction–

Professional autonomy

–

Respectful communication•

Culture change–

Discussing practice patterns is new

–

Potential for lack of engagement

•

Biggest risk: doing nothing

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Questions?Questions?

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Michael van Duren, MD, [email protected]

Sutter Medical Network - ehcca.com · * will not work without Enterprise ID links across Provider, Member and transactions * * * standardize. standardize. standardize. standardize.

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