Upload
cornelius-horn
View
215
Download
1
Tags:
Embed Size (px)
Citation preview
© 2005 Med-Vantage, Inc. All rights reserved. Proprietary and confidential. May not be reproduced without permission
Beau CarterSenior Health Policy and Strategy Consultant
Med-Vantage
Sustainable Funding ModelsSustainable Funding Modelsfor RHIOsfor RHIOs
Get Connected Knowledge ForumGet Connected Knowledge ForumJune 28, 2005June 28, 2005
Med Vantage, Inc Med Vantage, Inc ®
Company Overview Company Overview
Founded 2001, San Francisco corporate office Domain expertise: P4P, Consumer Scorecards, EBM Metrics
& Deployment, ROI evaluation, Risk Adjustment First-to-market application, patent pending
QualScore - Physician Quality & Cost Decision Support Tool
Medical Cost Estimator – Treatment Cost and Provider Search Tool
EBMScore – EBM Measure Construction, ROI & Reporting Tool
Largest consumer quality scorecard deployment underway for CDH/PPO/HMO (Arkansas BCBS)
11 health plan clients (pay-for-performance clients) 200 EBM Measures, 18 specialties (road tested, defensible) National ETG and KPI benchmark data set (50M members)
© 2005 Med-Vantage, Inc. All rights reserved. Proprietary and confidential. May not be reproduced without permission
3
EBM Research & Evaluation
PhysicianScorecard
Clinical Informatics
Pay fo
r Per
form
ance
(P4P
)
Evidence-Based Physician Scorecard Solutions
Evidence-Based Physician Scorecard Solutions
4
IOM Call to Action IOM Call to Action
“If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.”
5
“I think the projects that seem to be making the biggest progress are really focusing on the real nuts and bolts of how they get interoperability to occur. …They are also looking at business models and financial alignment.”
Quoted in Jim Molpus “David Brailer's Year of Living Attentively” for HealthLeaders News, May 10, 2005
A First-Year Assessment of RHIOsFrom David Brailer, MD
6
2003 2004
n = 28 n = 50
IT - Fastest Growing P4P DomainIT - Fastest Growing P4P Domain
Category % Total n % Total n
Clinical (HEDIS) 89% 25 94% 47
Clinical (non-HEDIS) 46% 13 32% 16
Patient satisfaction 79% 22 56% 28
Efficiency/utilization 57% 16 46% 23
Administrative/market share 54% 15 40% 20
Information technology 39% 11 54% 27
Patient safety 29% 8 12% 6
Other 32% 9 22% 11
2004 National P4P SurveyP4P Measure Domains
© 2005 Med-Vantage, Inc. All rights reserved. Proprietary and confidential. May not be reproduced without permission
7
IT Incentive Models for PhysiciansIT Incentive Models for Physicians
Clinical Information Systems Model
Level 1 – Connectivity, electronic claims submission, eligibility verification
HIP, MVP/Taconic IPA, IBC
Level 2 - Health Plan Based Patient Registry, Care Alerts
Priority Health Plan (MI), Horizon BCBS (NJ), BCBS Excellus (Rochester)
Level 3– Electronic Prescribing IncentiveBCBS-MA, Anthem, MVP/Taconic, Bridges to Excellence (BTE), BCBST
Level 3 – Basic Patient Registry Use in MD Office, Adoption of EMR
Harvard Pilgrim, BTE, Anthem, BCBS-MA, IHA, Fallon, BCBS-MI, Dean Health Plan, BCBS-MISS, MVP/Taconic IPA, CareFirst, BCBST
Level 4 - Electronic Patient Registries, Systems for Rx/Tests, EMR, Health Plan Connectivity (lab, chart results, Rx)
Non-P4P: BCBS-AL, Group Health Cooperative, Kaiser
Source: Bridges to Excellence.© 2005 Med-Vantage Inc. All Rights Reserved. www.medvantageinc.com
8
“If interoperability is not solidified and built into EMRs, a generation of investment will be lost, as will an opportunity for fundamental improvement in care delivery?”
David Brailer, MD February 17, 2005 speech to HIMSS
But remember, the magic is in not bi-lateral connectivity – it’s in community exchange
9
PurchasersPayers RHIO
Hospitals &
Physicians
Gain Sharing
Enrollment Fee
Community Pool
Participation Fee
RHIO - Aligning Health Resources with Community Goals
Savings
©2004 Jeff Rose, HealthAlliant. All Rights Reserved
10
Financial Barriers to Physician Participation Financial Barriers to Physician Participation
• $30,000 - $50,000 -- Client / Server
• $1,000 per physician per month - ASP model
• Practice productivity loss
• Financial ROI favors the payers over providers
SOLUTION: Sustainable model built on core funding for the exchange plus financial incentives for physician practice participation
11
PharmaciesPharmaciesHospitalsHospitals ReferenceReference
LaboratoriesLaboratories
TRANSLATORTRANSLATOR
CLINICAL CLINICAL DATA DATA
REPOSITORYREPOSITORY
E-E-ResultsResults
E RxE Rx
MedAllies Portal
EMR 1EMR 1
EMR 2EMR 2
MASTER PATIENT INDEX
PAYORSPAYORS
PAY-4-PERFORMANCE
PMSPMS
PHYSICIANSPHYSICIANS
PATIENTSPATIENTS
Physician Physician PracticePractice
Source: A. John Blair III, MD, Taconic IPA
13
Incentives for Physician IT Adoption Incentives for Physician IT Adoption
“Financial incentives of the approximate range of $3 to $6 per patient visit or $0.50 to $1.00 per member per month appear to be a sufficient starting point to encourage wide-spread adoption of basic EMR technologies by small, ambulatory primary care practices.”
Work Group on Financial, Legal, and Organizational Stability
Connecting for Health…A Public-Private Collaborative
June 23, 2004
© 2005 Med-Vantage Inc. All Rights Reserved. www.medvantageinc.com
14
Hudson Valley THINC – Flow of ITAdoption Incentive $Hudson Valley THINC – Flow of ITAdoption Incentive $
MD MD MD MD MD MD
BTEEmployer A
Self-FundedEmployer B
Health Plan C
Health Plan D
CertificationOf
Performance$$
$
$
Health Plan ASO
$
Federal/StateGovernment ?
$
15
The Case for Payer Participation in a Collaborative RHIO Incentive ModelThe Case for Payer Participation in a Collaborative RHIO Incentive Model
• In most markets, no one payer has enough market share to drive change alone
• A small investment can produce a large return
• The broader the participation, the fewer “free riders”
• Most “e” benefits accrue to the payer
• Some payers could fund physician incentives with Rx savings
© 2005 Med-Vantage, Inc. All rights reserved. Proprietary and confidential. May not be reproduced without permission
16
There is a Strong Payer ROI in e-RxThere is a Strong Payer ROI in e-Rx
Savings By Stakeholder Group
Physicians Pharmacies Payers Gov. Payer
Copyright © 2004 Healthvision, Inc.
65%
29%
3%3%
17
. . . and an ROI in EMR Adoption. . . and an ROI in EMR Adoption
Decreased Billing Errors
Increased Billing Capture
Radiology Savings
Lab SavingsDrug Savings
Adverse Drug Events Prevention
Transcription Savings
Chart Pull Savings
EMR Benefits
Source: Partners Health Care experience based on 2500 patients and providers. “Cost and Benefit Analysis for electronic medical records in primary care.” The American Journal of Medicine 2003;114:397-403
15%
14%
13%
5%5%
15%
29%
4%
18
Physician P4P Model: From 100% IT to 100% Outcomes
Phase IYears 1-2
Phase IIYears 3-4
Phase IIIYear 5 on
Key Type of P4P P4I(Pay for Infrastructure)
P4U(Pay for Use)
P4O(Pay for Outcomes)
Desired Behavior Establish & use patient registriesAdopt & use eRx system
Adopt & use full EMR Perform at EBM best practice levels
Key Performance Indicators
Use of registriesUse of eRx with decision support
Use of full EMRClinical metrics – screening/levels
Clinical metrics - HbA1c, LDL levels;
smoking cessation; obesity, hypertension management
Weighting IT ( pat. reg. & eRx) – 70%Generic Rx – 30%
IT (EMR) – 50%Clinical – 50%
(screening/levels)
Clinical – 100%Levels + performance based
on chart data
Data Sources Self-report - registryeRx system reports
Clinical – admin data
EMR system reportsClinical – admin & lab data
Admin. & lab data, plus patient data from EMR
Incentive Formula Yes-No: registryTwo tiers for eRx % use
Two tiers for EMR useTwo tiers for clinical
Two tiers for clinicalYes-No: smoking, obesity
management
Incentive Pay-out Up to 10% bonuspmpm or visit add-on
Up to 10% bonus pmpm or visit add-on
Up to 10% bonuspmpm or visit add-on
© 2005 Med-Vantage, Inc. All Rights Reserved. May not be reproduced without permission.
20
Do this …Do this …
© 2004 Med-Vantage, Inc. All Rights Reserved. May not be reproduced without permission.
“Do the right thing. It will gratify some people and astonish the rest.”
Mark Twain
© 2005 Med-Vantage, Inc. All rights reserved. Proprietary and confidential. May not be reproduced without permission
21
For More Information…For More Information…
Beau CarterSenior Health Policy & Strategy Consultant
Med-Vantage, Inc.1 California Street, Suite 2800
San Francisco, CA 94111(415) 765-7103
www.medvantageinc.com
2003 - 2004 National P4P Study – now available50 + page White Paper – call 415-765-7106
Executive Summary – on the web site