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The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization, Medical Director Associate Professor, Harvard Medical School
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The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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Page 1: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

The Engaged Provider Response to the Current Health Care Policy

Environment

July 18, 2011

Timothy G Ferris, MD, MPHMass General Physicians Organization, Medical Director

Associate Professor, Harvard Medical School

Page 2: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

2

The Engaged Doctor’s Dilemma

Uncertainty in payment reforms leaves the engaged provider with little direction regarding how to get started

So what is the engaged provider to do? Whatever the new payment system, there are some clear directional indicators:

Change focus - from units to episode and populations Move forward - move forward with the things that I know have been shown to improve

outcomes and/or reduce costs. Always improve - create incentive structure that rewards continuous innovation

Inpatient and Outpatient Encounters

Episodes of Illness

Population Management

Health care costs are rising too rapidly

We have been through this before Healthy skepticism that the next big idea

from an insurance company is actually going to solve this problem.

Physicians remain unsure of what reform will bring Multiple approaches in commercial, state,

and federal payers

Page 3: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

3

Engaged Provider Tactics

Longitudinal Care Episodic Care

Primary Care Specialty Care Hospital Care

Access to care

Patient portal / physician portal Optimize site of care

Extended hours / same day appointmentsReduced low acuity

admissionsExpanded virtual visit options

Design of care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care management

Required patient decision aids

Re-admissions

Hospital Acquired Conditions

Provide 100% preventive services

AppropriatenessHand-off standards

Continuity Improvements

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population Costs / episode

Page 4: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

4

Chronic Conditions – MGH Medicare Demo

Opportunity

10% of Medicare patients account for nearly 70% of spending

MGH Demo

• Medicare selected MGH to participate in a 3-year demonstration project focusing on high-cost beneficiaries in 2006

• Success validated in 2010 (RTI evaluation)

• Contract renewed through 2012

• Expanded to Brigham and Women’s and North Shore Medical Center

http://www.massgeneral.org/about/newsarticle.aspx?id=2531

Enrolled 2,500 highest cost Medicare patients with total annual costs of $68 M Average number of medications = 12.6 Average annual hospitalizations = 3.4 Average annual costs = $24,000

Payment model similar to proposed shared savings for ACOs Paid monthly fee based on number of enrolled patients Required to cover costs of program +5% Gainsharing if savings greater than cost +5% Success determined using prospective matched comparison

group

Page 5: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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Chronic Conditions – MGH Medicare Demo

Results from Independent Evaluator (RTI)

12 care managers embedded in primary care practices Coordinate care; point person for acute issues Identify patients at risk for poor outcomes Facilitate communication when many caregivers involved

Key characteristics Care managers have personal relationships with patients Care managers work closely with physicians All activities supported by health IT (universal EHR, patient tracking, home

monitoring)

Successful Outcomes Hospitalization rate among enrolled patients was 20% lower than comparison*

ED visit rates were 25% lower for enrolled patients* Annual mortality 16% among enrolled and 20% among comparison

Successful Savings 7.1% annual net savings (12.1% gross) for enrolled patients For every $1 spent, the program saved at least $2.65

*Based on difference in differences analysis

Page 6: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

Scatterplot of outpatient CT examination volumes (y-axis) per calendar quarter (x-axis) represented by red diamonds.

Sistrom C L et al. Radiology 2009;251:147-155

©2009 by Radiological Society of North America

Health IT – Integrated Decision Support for Imaging

• Radiology utilization management systems

Page 7: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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MGH Internal Physician Quality Measures

http://www-958.ibm.com/software/data/cognos/manyeyes/visualizations/mgh-quality-meas-overview-1209

Page 8: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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MGH Internal QI Program Measures

HH and MRSA Rates

1.95

1.79

1.331.25

1.090.99

0.88

1.031.08

0.82

0.66

0.96

0.61

1.52

1.00

1.33

0.81

1.121.081.21

1.18

1.22

1.51

1.33

0.60

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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2002 2003 2004 2005 2006 2007 2008

0.00

0.50

1.00

1.50

2.00

2.50

Before contact rates After contact rates MRSA Rate

Hand Hygiene / MSRA EMR Use (for Notes)

78.5%79.0%79.5%80.0%80.5%81.0%81.5%82.0%82.5%83.0%

Top

Box

%

Results 2010 Avg. 2011 YTD (prelim)

QI Target 2011 P4P Target

H-CAHPS Performance Radiology Turn Around Times

Page 9: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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Engaged Provider Tactics: Meaningful UseEngaged Provider Tactics: Partnership for PatientsEngaged Provider Tactics: Bundled PaymentEngaged Provider Tactics: Medical HomeEngaged Provider Tactics: HITECH

Longitudinal Care Episodic Care

Primary Care Specialty Care Hospital Care

Access to care

Patient portal / physician portal

Patient portal / physician portal Optimize site of care

Extended hours / same day appointments

Extended hours / same day appointments Reduced low acuity

admissionsExpanded virtual visit options Expanded virtual visit options

Design of care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care management Required patient decision aidsRe-admissions

Hospital Acquired Conditions

Provide 100% preventive services

AppropriatenessHand-off standards

Continuity Improvements

EHR with decision support and order entry

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting / performance dashboards

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population Costs / episode

Longitudinal Care Episodic Care

Primary Care Specialty Care Hospital Care

Access to care

Patient portal / physician portal Optimize site of care

Extended hours / same day appointmentsReduced low acuity

admissionsExpanded virtual visit options

Design of care

Defined process standards in priority conditions

(multidisciplinary teams, registries)

High risk care management Required patient decision aidsRe-admissions

Hospital Acquired Conditions

Provide 100% preventive services

AppropriatenessHand-off standards

Continuity Improvements

EHR with decision support and order entry

Incentive programs (recognition, financial)

Measurement

Internal variance reporting / performance dashboards

Publicly reporting of quality metrics: clinical outcomes, satisfaction

Costs / population Costs / episode

Page 10: The Engaged Provider Response to the Current Health Care Policy Environment July 18, 2011 Timothy G Ferris, MD, MPH Mass General Physicians Organization,

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Closing Thoughts

Doing all this will take quite a while – the stakeholders will need to be a little patient

How do we incent providers to do these other things? Gold card status for engaged providers resulting in lower administrative

costs for payers and providers

This presentation addressed only the engaged provider side of a two party relationship: Incentives for patients to be judicious consumers of health care would

be a powerful complementary set of policies

Type types of innovation Adopting and implementation of ideas known to be effective (i.e. “new”

processes) Development and testing of new technology and processes not yet

known to be effective