Dealing with Payers with Physician Driven Cost and Quality Data

Hilton Sandestin Beach & Golf Resort, Destin

August 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 Quality

Because

In 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;

TX

FL

NMGA

AZ

CA

WY

NV

AK

OK

MSLA

MT

TN

Status of State Legislation to Establish Exchanges,as of July 2011

Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis.

WA

ORID

SD

ND

MNWIWI

MI

IA

AR

IL

OH

WVVA

AL

PA

NY

ME

MA

NHVT

HI

Legislation signed into law post passage of ACA

Legislation passed one or both houses

Governors have pursued/considering non-legislative options

Legislation signed: intent to establish an exchange, creation of study panel, creates an appropriation

Legislation pending in one or both houses

UT CO

KS

NEIA

MO

ILIN

KY

WVVA

NC

SC

DC

MDDE

NJ

CTRI

Governor veto or decision not to establish exchange

State exchange in existence prior to passage of ACA

Pending legislation failed

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

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

Medicare Cost Data

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 rate

Rhode 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

The Usual, but Real, Data

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.5

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

Those 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 and quality.

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 effective

Comparison to the current fee for service / transaction based model? This is the initial policy under the ACO model

Long term model?How do you find out

Payers BCBS and others have great information but

difficulties in accessing it in a usable formData sources

Independent 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 safety Preventative Health At Risk Population/Frail elderly Health (31 measures) on the following

Diabetes, 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 Scoring

CMS sets benchmarks at beginning of each reporting year using FFS, Medicare Advantage or data it has modeled

Points 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 measures

Domain scores are determined by dividing the actual points by the maximum potential points to determine a % of performance

The 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:

Cardiologist

CT Surgeon

CT Surgeon

Hospital B

Hospital C

Hospital A

Mobile Diagnostics

Interpreter A

Interpreter B

PCP

Sample Referral Decision Tree

Diagnostics

Medical Treatment

Cath

Cath

To Here:

Cardiologist

CT Surgeon

CT Surgeon

Hospital B

Hospital C

Hospital A

Mobile Diagnostics

Interpreter A

Interpreter B

PCP

Sample Referral Decision Tree - Modified

Diagnostics

Medical Treatment

Cath

Cath

And the New Decision Tree Must be Based On:

CostQuality

What do Providers NeedInformation

Keeping track of the rulesUnderstanding modelsOrganization

SystemsEMR’sReal medical record data sharing

RealityThere 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 Results http://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

BCBS AlabamaPhysician Number

% of Patients Would Recommend

Patient Satisfaction Overall # Patients Rating Diabetes Management Heart Disease

1 76% 2 37 3 22 96% 3 26 3 33 97% 3 37 2 24 97% 3 59 2 25 94% 3 16 2 36 94% 3 51 3 37 85% 3 26 2 38 96% 3 26 2 29 100% 3 17 3 3

10 98% 3 40 2 211 87% 3 23 N/A N/A12 93% 3 27 3 213 100% 3 22 2 114 95% 3 42 3 315 92% 3 37 2 N/A16 90% 3 31 2 217 96% 3 23 2 2

Healthgrades Patient Satisfaction Measures for Selected Cardiologists

Healthgrades

Physician Number % of Patients Would Recommend HG Overall of 5 # Patients Rating

1 83% 4 5

2 100% 4.5 93 100% 4.5 5

4 100% 5 15 N/A 3 36 100% 5 17 100% 4.5 1

8 100% 5 2

9 86% 4.5 5

10 83% 4.5 6

11 100% 4.5 4

12 100% 5 213 100% 5 114 N/A N/A N/A

15 N/A 2.5 1

16 N/A N/A N/A17 100% 5 6

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

Discharge To:

Physician Number ALOS CMI Volume

Average Payment

Actual Payment

Home or Self Care Rehab

Home Health SNF Expired

1 1.94 2.342 17 $ 11,365 $ 193,034 15 1 1 0 0

2 1.58 1.733 12 $ 8,714 $ 104,562 12 0 0 0 0

3 1.75 2.109 12 $ 10,845 $ 130,140 12 0 0 0 0

4 3.45 2.622 11 $ 9,592 $ 105,507 10 1 0 0 0

5 3.55 2.783 11 $ 11,171 $ 122,877 10 0 1 0 0

6 4.9 3.422 10 $ 16,552 $ 165,517 8 1 1 0 0

7 2.78 2.79 9 $ 13,787 $ 124,084 8 0 2 0 0

8 1.25 1.776 8 $ 8,793 $ 70,340 8 0 0 0 0

9 2.38 2.277 8 $ 8,948 $ 71,585 7 0 0 1 0

10 2.25 2.455 8 $ 12,702 $ 101,616 8 0 0 0 0

11 5.29 2.963 7 $ 15,568 $ 108,978 6 0 1 0 0

12 4.57 3.03 7 $ 11,210 $ 78,469 6 1 0 0 0

13 6.83 3.941 6 $ 6,480 $ 38,878 6 0 0 0 0

14 4.25 1.578 4 $ 5,110 $ 20,441 4 0 0 0 0

15 6.75 4.941 4 $ 19,914 $ 79,655 3 0 1 0 0

16 14 9.937 3 $ 7,543 $ 22,629 2 0 0 0 1

17 2.33 1.573 3 $ 4,312 $ 12,935 3 0 0 0 0

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

Discharge To:

RankPhysician Number ALOS CMI Volume

Average Payment Actual Payment

Home or Self Care Rehab

Home Health SNF Expired

1 3 1.75 2.109 12 $ 10,845 $ 130,140 12 0 0 0 0

2 2 1.58 1.733 12 $ 8,714 $ 104,562 12 0 0 0 0

2 4 3.45 2.622 11 $ 9,592 $ 105,507 10 1 0 0 0

2 13 6.83 3.941 6 $ 6,480 $ 38,878 6 0 0 0 0

3 10 2.25 2.455 8 $ 12,702 $ 101,616 8 0 0 0 0

4 5 3.55 2.783 11 $ 11,171 $ 122,877 10 0 1 0 0

4 9 2.38 2.277 8 $ 8,948 $ 71,585 7 0 0 1 0

5 1 1.94 2.342 17 $ 11,365 $ 193,034 15 1 1 0 0

5 8 1.25 1.776 8 $ 8,793 $ 70,340 8 0 0 0 0

6 6 4.9 3.422 10 $ 16,552 $ 165,517 8 1 1 0 0

6 15 6.75 4.941 4 $ 19,914 $ 79,655 3 0 1 0 0

6 17 2.33 1.573 3 $ 4,312 $ 12,935 3 0 0 0 0

7 7 2.78 2.79 9 $ 13,787 $ 124,084 8 0 2 0 0

7 16 14 9.937 3 $ 7,543 $ 22,629 2 0 0 0 1

8 12 4.57 3.03 7 $ 11,210 $ 78,469 6 1 0 0 0

10 11 5.29 2.963 7 $ 15,568 $ 108,978 6 0 1 0 0

11 14 4.25 1.578 4 $ 5,110 $ 20,441 4 0 0 0 0

Atrial Fibrillation

Atrial Fibrillation Ranking

Now WhatIf I’m a specialist and highly ranked, I find

the way to get the word out to referring doctors and payers

If I’m a specialist and ranked low, I find out why and work to change or get better information

If 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

Questions?Cockrell and Associates, LLC

(205) 999-8064bcockrell@caahms.com

www.caahms.com