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Health Care Reform and Health IT:Making Health Care Value Real
Charles Kennedy, M.D.
VP Health Information & Technology , WellPoint, Inc.
H.I.T. Policy Committee Insurance Industry Representative
Payer Panel on Health I.T.
Company Confidential | For Internal Use Only | Do Not Copy 2
Expectation Mismatch Challenge
1. Medicare Chronic Care Pilot
• Running for over 2 years
• Incentives, chronic disease management strategies
• Many electronic records
• NO EVIDENCE OF INCREMENTAL VALUE
2. According to a study published in the Archives of Internal Medicine using 1.8 billion records with around 20% electronic, there was no difference between paper and electronic records on 14 of 17 axes, and splits on the other 3.
3. BCBS usage of heavily promoted PHRs is currently 0.2%
4. NRC/NAS 2009 study says current approaches will not meet objectives
First Consulting Group (among others) completes white paper indicating net benefits of Health Information Technology worth $39 -$47 billion annually in care savings
Center for Information Technology Leadership estimates deployment of ambulatory health record worth $44B in savings
Office of the National Coordinator for Health Information Technology references studies which indicate savings from Health Information Technology deployment worth $78-$112 billion annually
Real World ResultsExpectations
.
Company Confidential | For Internal Use Only | Do Not Copy 3
Health Careis about what happens to
IndividualsIndividuals
not
Institutions
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The Current Care Process – A Typical Cancer or Chronic Disease “Journey”
Hospital unit
Diagnostic unit
Multidisciplinary team
Radio/chemotherapy center
Surgical center
Home nursing
Hospice
Primary care
Symptomatic care
Follow-up
Follow-up
Second case conference
Follow-up
First case conference
Specialist consultation
Investigations
Consultation & referral
Time
Second treatment
Surgery
Specialist palliative care
Pre-operative treatment… … and and
self self carecare??
Company Confidential | For Internal Use Only | Do Not Copy 5
Speaker #1
Health IT in a Tightly Integrated System
Andy Wiesenthal M.D.
Associate Executive Director
The Permanente Federation
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Creating Patient Centric Solutions in Solo and Small Group Settings
Providers in PPO networks deliver care across institutions yet institutions arrange their I.T. systems with an inward focus. WellPoint’s Health IT solution must be able to integrate data from disparate databases to reflect how care is delivered across a variety of separate institutions.
Provider 1
Provider 2
Provider 3
Provider 4
Provider 5
Time
Hospital I.S.
MD 1 EMR
Pharmacy
MD 2 EMR
Radiology Center
Systems
Company Confidential | For Internal Use Only | Do Not Copy 7
Speaker #2-- Availity
Leveraging the Infrastructure that is Already Deployed in Physician Offices—
Julie Klapstein
CEO Availity
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Where’s the Patient?
HIE Infrastructure Design Overview
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HIE Output: Unassembled Data
HIEs attempt to create value by presenting more data to the treating physician at the point of care
HIEs add value primarily when a physician who did not order the test needs to see the result and will take the time to look .
Company Confidential | For Internal Use Only | Do Not Copy 10
Binding The Individual’s Health History in Non Integrated Delivery Systems
Time
Care Setting 4
Care Setting 1
Care Setting 2
Care Setting 3
Care Setting 5
Aggregated Information Around the IndividualInformation and processes of most importance to Individual’s overall health and care
Information S
ystems
Specific to C
are Setting
Specific to
Individual
Company Confidential | For Internal Use Only | Do Not Copy 11
Speaker #3: Ingenix
Turning Data into Information
Health Plan experiences with tools and technologies
Andy Slavett
CEO
Ingenix
Company Confidential | For Internal Use Only | Do Not Copy 12
Pay for Performance Program Components
Commit FundsEstablish Performance Criteria
Recognize QualityReward performance
Support Improvements
Measure Performance
(Quality)
Critical Steps in Executing a Successful Pay for Performance Program
Several critical steps to executing a successful pay-for-performance program were identified. Programs reviewed are assessed against this value chain to determine areas of excellence. Program specific observations are then aggregated into a series of best practices along the value chain
• Clinical
• Technology
• Patient satisfaction
• Prevention
• Disease management
• Hospital safety
• Applicability to different medical groups
• Other
• Clinical
• Technology
• Patient satisfaction
• Prevention
• Disease management
• Hospital safety
• Applicability to different medical groups
• Other
• Incremental funds
• Realigned funds
• External funds
• Incremental funds
• Realigned funds
• External funds
• Data collection
• Data analysis
• Data collection
• Data analysis
• Comparative internal profiling
• Public profiling
• Comparative internal profiling
• Public profiling
• Financial incentives: Flat fee per member
• Financial incentives: Incremental revenue per unit or case
• Recognition and awards
• Contract negotiations and tiering strategies
• Financial incentives: Flat fee per member
• Financial incentives: Incremental revenue per unit or case
• Recognition and awards
• Contract negotiations and tiering strategies
• Funding
• Information sharing
• Funding
• Information sharing
Awareness Process Outcomes Structure
Company Confidential | For Internal Use Only | Do Not Copy 13
Speaker #4-- WellPoint
Considerations in Metrics and Metric Development in Pay for Performance Programs—
Cathy MacLean MD
Vice President Clinical Quality Interventions
Company Confidential | For Internal Use Only | Do Not Copy 14
Speaker #5: WellMark
Programmatic Implications for Quality Incentive Programs
Rick Miller, D.O., is a medical director for Wellmark Blue Cross and Blue Shield. He is responsible for the Collaboration on QualitySM program, whose enrollment reached nearly 15,001 primary care clinicians this year.
Company Confidential | For Internal Use Only | Do Not Copy 15
Health IT Market Overview
Capabilities for health care value from Health I.T.
Capture data from source systems or
Interoperability
Understand the data in the context of the
patient’s clinical status
Apply evidence base and business
rules to data
Inform patient and doctor to take action
as care occurs
Claim Data • WLP MMHp • E-Prescribing--
AllScripts, MedPlus, Prematics…
• CalRHIO • Google Health
• RHI • ActiveHealth
• RHI• ActiveHealth• E-Prescribing
E-Prescribing
Clinical Data • CCHIT Certified EMRs
– E Clinical Works,
– United’s Care Tracker
– EPIC• Most RHIOs• Interface companies
• Orion
• Kaiser KP Connect with Dz Registry
• NY Health Information Exchange
Integrated clinical and claim data
• MS HealthVault• WellPoint’s IHR
WellPoint’s IHR WellPoint’s IHR WellPoint’s IHR
Resulting Record
Unassembled jig saw puzzle– narrow impacts to cost/quality
Assembled puzzle—cost and quality impacts likely
Actionable data to improve cost and quality
Transformed health care??
Company Confidential | For Internal Use Only | Do Not Copy 16
WellPoint’s Real Time Clinical Integration Platform in Dayton Ohio
This project integrates clinical and claim data creating a comprehensive, shared clinical and financial profile for patient, doctor, and health plan use
•A Personal Health Record (PHR) for the patient
•An electronic health record and ePrescribing
•A data exchange infrastructure allowing health coaches and physicians to use a common record
•A rules engine with evidence based medicine rules and benefit optimization rules
•In development: Health plan business rules that automate administrative functions
Company Confidential | For Internal Use Only | Do Not Copy 17
Physician ViewHealth Summary
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Company Confidential | For Internal Use Only | Do Not Copy 19
Company Confidential | For Internal Use Only | Do Not Copy 20
.
.60 higher
risk score
7.5% trend
reduction
Dayton Results Summary
20 04/21/23
Continuous Enrolled Study Cohort Health IT Non-Users
2007 2008 VarianceAllowed Cost 9,077,150$ 11,661,058$ 28.5%Mbrs 4126 4126 0.0%MM 37134 37134 0.0%Cost PMPM 244.44$ 314.03$ 28.5%Avg DXCG 2.13
Health I.T. Users2007 2008 Variance
Allowed Cost 1,839,258$ 2,226,974$ 21.1%Mbrs 666 666 0.0%MM 5994 5994 0.0%Cost per Pt 2,762$ 3,344$ 21.1%Cost PMPM 306.85$ 371.53$ 21.1%Avg DXCG 2.72
Measure IHR User IHR Non User DifferenceColonoscopy 41.50% 25.60% 15.90%Mammogram 10.50% -11.20% 21.70%Pap Smear 12.70% 0.80% 11.90%PSA 62.50% 24.40% 38.10%LdL Test 21.70% 1.10% 20.60%Hemoglobin A1C 13.90% 2.30% 11.60%
Measured in year over year change
Financial Results
IHR Utilization Stats
Quality Results
• Employees: ------ 70%
• Dependents: ------ 15%
• Total*: ------------- 48%
• 6 or more log ins---- 45%
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