Improving the health of individuals, families and communities JJ Parsons Presbyterian Healthcare Services Vice President, Business Development & Contracting

Improving the health of individuals, families and communities

JJ ParsonsPresbyterian Healthcare ServicesVice President, Business Development & [email protected](505) 923-8512

Total Quality Management in Health Care MarketingHow the Market’s Demand for Quality is Changing!

mailto:[email protected]


Americans are more likely to want a new direction in health care even compared to the situation in Iraq!

Health care

Iraq

Immigration

Foreign policy in places other than Iraq

Family values issues

Global Warming

Trade

39%35%29%22%20%13%10%

Source: Public Opinion Strategies (2007)


Healthcare Needs a Quality Focus

• “The current healthcare system is economically unsustainable and negatively impacting our nation's ability to compete globally.” Craig Barrett, Intel Chairman, 2006.

• The Institute Of Medicine estimates that44,000-98,000 deaths occur annually in American Hospitals due to medical errors.


Market Implications:

1.National and local healthcare reform and legislation

2.Market transparency of quality outcomes

3.Changes in Reimbursement

4. Increase focus by regulators

5. Increased competition by healthcare travel companies

6.Healthcare corporations focused on balanced scorecards


Don’t Try this at Home

“Why are they always pushing quality on us?”


1. National & Local Healthcare Reform & Legislation

• Massachusetts – 2006 - First state to require health insurance

and provide universal coverage

• California– Governor introduced $12B universal coverage

plan, but failed in Legislature in 2008

• New Mexico– Governor Richardson seeking healthcare

coverage expansion but outlook in Legislature is uncertain


Insurance: National Scene

•Rising healthcare costs•Evolving consumer role & interests•Importance of technology•Increasing government

involvement•Increasing focus on quality &

customers •Consolidation



Insurance: New Mexico Market - Overall• Increasing role of government

including legislative bill and restrictions on profit levels of health plans

• Higher percentage of individuals covered under government programs; lower reimbursement for these programs increase rate for Commercial market


Physicians/100,000 Population: New Mexico

3858

3186

1954.601832.28

197.4

173.8

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2001 2006

Year

Nu

mb

er o

f A

ctiv

e P

atie

nt

Car

e P

hys

icia

ns

160.0

165.0

170.0

175.0

180.0

185.0

190.0

195.0

200.0

NM

Po

pu

lati

on

(in

0's

)

Number of Active Patient Care Physicians NM Population (in 0's) Physicians per 100,000 Population

Source: US Census Bureau & Center for Health Workforce Studies


2. Market transparency of quality outcomes Who are the audiences for health

performance information?

Consumers…use this information at various points of interaction with the health system, from the time they choose a health plan to the point of selecting a health care provider for a specific service.

Employers/Purchasers…want information to use in selecting from among various health plans, including the cost and outcomes of providers and quality standards.


Transparency (continued)

Health Plans…want to evaluate the price and quality of all physicians, hospitals, and other providers. May also want to benchmark their performance on service and quality measures to their competitors.

Providers…Hospitals, physicians, and other health care providers would benefit from more transparent price and quality information as a feedback loop for improved performance efficient or effective referrals.

Policymakers…Federal/state officials for oversight and monitoring of provider and health plan performance.



Quality in Healthcare: Performance Scores (continued)


Response: Demand for Increased Transparency

• Cost (IRS Form 990)– Collection practices– Community benefit– Tax-exempt status

• Quality– IHI: “5 Million Lives Campaign”– Leapfrog: 27 Safe Practices– Never Events– Regulatory


3. Changes in Reimbursement: CMS Halts Payments for Never Events

• CMS – “The right care, for every patient, every time.”

• October, 2007: 1st step toward preventing Medicare from paying hospitals for costs of treating a patient who acquires specific conditions during hospitalization.

• “Never Event” Examples:–Objects left in surgery–Catheter-associate urinary tract infections–Decubitus ulcers


4. Increased focus by regulators: Transparency of Patient Satisfaction Data

As stated by CMS and AHRQ:• “HCAHPS is a tool to be used for public reporting

of major areas of hospital performance to support consumer choice”

• “HCAHPS is not a stand-alone quality improvement tool”

HCAHPS presents the symptoms—additional measurement is needed to make a diagnosis and improve.

Hospital Consumer Assessment of Healthcare Providers and Systems


Transparency of Patient Satisfaction Data• Consumers will have access to the data

– Consumers will relate more easily to HCAHPS than to clinical data

– Some will use HCAHPS data to choose hospitals– Will have volume, revenue, and reputation

implications• HCAHPS will be in the public eye

– Media coverage– Promotion by hospitals themselves

• Reported for consumers on Hospital Compare Web site (www.hospitalcompare.hhs.gov)

• Typical public report data are shown as frequencies– Hospital performance frequencies– National and state average performance

frequencies

http://www.hospitalcompare.hhs.gov/


Transparency of Patient Satisfaction DataPublic reporting will include the following six

domains (March 2008):• Communication with Doctors• Communication with Nurses• Responsiveness of Hospital Staff• Pain Control• Communication about Medicines• Discharge InformationThe following four questions will also be

reported:• Cleanliness of Hospital Environment• Quietness of Hospital Environment• Overall Rating of Hospital• Recommend Hospital


Don’t Speak in “Quality-ese”

“It’s a vice-president thing, Berger.You wouldn’t understand.”


5. Increased competition by healthcare travel companiesMedical Tourism Plans Blossoming Around the country

• Why?– Reduced costs

• Ex: Open Heart Surgery in US: $100,000 Wockhardt, India: $7,500

- Way in which patient Treated• Care outside medical services includes: gourmet

meals; laundry services; quality of room; hotel suite like room

• Access to physician call phones

- Opportunity to see new part of the world: “vacation” - Access to procedures not yet approved by FDA Source: ForbesLife


Three Things

Growth & Mission

Staff Focus

Customer Loyalty

Clinical Outcomes

Financial Outcomes

National Excellence

• Commercial Sales• Throughput• Facilities/SM• Advanced Access

• Hire Right• Rounding• TYN• 30/90

• Customers First• Customer Loyalty Bundle• Advocate

• Medical Safety• Clinical Bundles• Comprehensive Diabetes Care

• MCR Management• Expense Control• PFS

• Customer Count• Time to 3rd next available

• Turnover• Employee Satisfaction

• PHP Satisfaction• PDS Satisfaction• PMG Satisfaction

• Mortality• Harm Rate• Diabetes AIC

• Operating Margin• Day’s Cash

6. Healthcare corporations focused on balanced scorecards


Baldrige Criteria Framework: A Systems Perspective


MBNQA Applicants by Stage

MBNQA

Award Category

ApplicantsStage 2

(Consensus)Stage 3

(Site Visits)Recipients Applicants

Stage 2 (Consensus)

Stage 3 (Site Visits)

RecipientsApplicants / Consensus

Stage 3 (Site Visits)

Recipients

Manufacturing 1 1 1 1 3 2 0 0 2 0 0

Service 6 3 1 1 4 2 1 1 4 0 0

Small Business 8 3 1 1 8 3 3 1 7 2 1

Healthcare 33 21 7 1 45 22 6 1 42 7 2

Education 16 8 3 2 16 10 3 0 16 1 0

Nonprofit NA NA NA NA 10 10 2 0 13 4 2

Total: 64 36 13 6 86 49 15 3 84 14 5

2005 2006 2007


Strategy: National Excellence Goals: 3 Things 1. Malcolm Baldrige Award 2. Top 10% in Patient Safety 3. “AA” Rating

Must Haves: How We Work

Employee Retention Bundle– Rounding– Thank You Notes– 30/90 Day Meetings

Hire Right Bundle– Behavioral Interviewing– Pre-Interview Assessment– Peer Interviewing

Customer Loyalty Bundle– Key Words at Key Times (AIDET)– Rounding on Customers– Pre, Post and Welcome Calls– Service Recovery (Advocate)

PresEssentials : Clinical Outcomes Financial Outcomes Customer Loyalty Staff Focus Growth and Mission

Results: PHS Board Measures

2007 Theme: Every Patient, Every Member, Every Time

2007 Vital Few Create process and information infrastructure changes to:Objectives: – Improve outcomes of the Patient Care Process (access, throughput, satisfaction, safety) – Reduce cost per member and cost per unit of service


Presbyterian serves to improve

the health of individuals,families and communities.

We value clinical and service excellencethrough:-- People helping people -- Stewardship -- Integrity -- Honest, caring relationships

-- Totality of health: body, mind and spirit.

Sense of Mission

Sense of Mission

To benefit patients and members,Presbyterian is dedicated to national excellence by theachievement of 3 Things:

C.A.R.E.S.

To earn from eachcommunity served:

Dear Pres byterian:You were born and ra is ed here because we neededa p lace for hea ling and car ing. A s we grew and changed, you have grown wi th us. Y ou s erv e each ind ividual and fami lywith compassion and sensi tivi ty . By your exam ple, you teach us to take better care of ourse lves. We are wil ling partner s wi th you in making our communi ties better p laces to l ive . You have met the cha llenge of m aking your ser vices ac cess ib le, affor dable, and accountable to the c omm unity. It’s no wonder you are r ecogn ized nationally fo r heal thcare excel lenc e. We are proud to cal l you our own.

Comm unities Throughout the S outhwest

1 . Malcolm Baldrige Quality Award - c ontinuously improv eprocesses to produce nationally excellen t c lin ic al, servic eand business res ul ts .

2 .Top 10% in Patient Safet y - create the safest poss ib le envi ronment for those who place thei r tr ust in us.

3 . “AA” Rating - control expenses while growing our business to sus ta in positiv e financia l

perform ance and to fund excellence.

Or iginal Board Ap proval 12 /9 5 3rd Revision Adopted 10/22/02

To benefit patients and members, Presbyterian

is dedicated to national excellence by the achievement of 3 Things:

1.Malcolm Baldrige Quality Award - continuously improve processes to produce nationally excellent clinical, service and business results.

2.Top 10% in Patient Safety - create the safest possible environment for those who place their trust in us.

3.“AA” Rating - control expenses while growing our business to sustain positive financial performance and to fund excellence.

To benefit patients and members, Presbyterian

is dedicated to national excellence by the achievement of 3 Things:

1.Malcolm Baldrige Quality Award - continuously improve processes to produce nationally excellent clinical, service and business results.

2.Top 10% in Patient Safety - create the safest possible environment for those who place their trust in us.

3.“AA” Rating - control expenses while growing our business to sustain positive financial performance and to fund excellence.


PHS Baldrige Journey Timeline

2006

Plan from self-assessment

Zia application completion

QNM Roadrunner Recipient

49 QNM Examiners

Achieve MBNQA Consensus Stage

NMQA Zia Award Recipient

40 QNM Examiners

One MBNQA Examiner

Training

Define customers and requirements

Key core process identification

Organizational Profile

Self Assessment

Four areas of focus

2002 2003 2004 2005

MBNQA Site Visit

25 QNM Examiners

One MBNQA Examiner

MBNQA Site Visit

Two MBNQA examiners: One senior

26 QNM Examiners

2007

Focused on Key Learnings

49 QNM Examiners

1 MBNQA Examiner


JanuaryMPR, QPR, ELF,

LDI, QEF

FebruaryMPR

MarchMPR

AprilMPR, QPR, ELF,

LDI, QEF

JuneMPR

MPR

December

MPR

November

MPR, QPR, ELF, QEF

OctoberMPR, LDI

September

MPR

August

MPR, QPR, ELF, LDI, QEF

July

MayMPR

Revision: 1/11/2008

4th QuarterPreparation

2nd QuarterPeople

Process link

3rd QuarterStrategy

Presbyterian Annual Rhythm

Start

Stop

•Staff reviews•Leadership evaluations•People summit

•Budget•Work Plan•Measures•Incentives•Theme

1st QuarterCelebration/Kickoff

•Annual Theme•Vital Few Objectives

LDI : Leadership Development Institute QPR: Quarterly Performance ReviewMPR: Monthly Performance Review QEF: Quarterly Employee ForumsELF : Extended Leader Forum

Performance Reviews:•Monthly Leadership (MPR)•Quarterly Leadership (QPR, LDI, ELF)•Quarterly All Employees (QEF)

•Project Prioritization•Strategic Plan•Tactical Plan•Capital Plan• IT Plan•Budget assumptions

Looking Ahead (The journey is challenging but we are better prepared)

PHP PDS

Operating Units

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S e n io r L ea d er

Customer Acquisition and Retention Process/Council

COB UNIT PROCESSING Detailed Process Map – Baseline State Process

PFS COB Unit

Verifies Primary Insurance is Eligible for

Dates of Service

PFS

Work Individual Denied Claims from Provided Denial Report

1 2

Verify Information on file is enough to file the claim

Online System Available?

Yes

PFS COB Unit

Updates Patient Accounting

System

PFS COB Unit

Verifies Timely Filing Period

PFS COB Unit

Validates Patient Eligibility and

Insurance Address

PatientEligible?

Yes

No

Within Timely Filing Period?

Yes

PFS COB Unit

Submits Electronic Claim

Electronic Submission?

Yes

No

PFS COB Unit

Mails ClaimNo

PFS COB Unit

Pulls PHP Denial

PFS COB Unit

Rebills/Void and Repost Claim to Correct Primary

Payor

PFS COB Unit

Waits 1 – 7 Days for Claim

Generation

PFS COB Unit

Attaches Denial and Claim

PFS COB Unit

Mails Claim

PFS COB Unit

Adds Account to TRAC for Next Day Follow-up

PFS COB Unit

Documents in TRAC for Further

Follow-up

PFS COB Unit

Adds QUIC Deficiency

PFS COB Unit

Adds Account to TRAC for Further

Follow-up

PFS COB Unit


PFS COB Unit

Adds Account to TRAC for Further

Follow-up

PFS COB Unit


PFS COB Unit

Waits 30 Day

PFS COB Unit

Check Account Status in PAC

Paid?

Non-COB Denied?

Unpaid?

PFS COB Unit

Contacts Payor for Claim Status

(Phone/Online)

Yes

PFS COB Unit

Documents in TRAC for Further

Follow-up

Yes

PFS COB Unit

Updates TRAC/QUIC Deficiency/

PAC

PFS

Paid Claim

Yes

PFS COB Unit

Updates TRAC/QUIC Deficiency/

PAC

No

No

3 4

A

A

11 12 13 14 15 16

PFS

Follow Appeal Process

B

B17

21

30

18 19 20

27 28 2924 25 262322

NoWeekly Decision Support Generated from PHP Denials – Eligibility information also included on the existing report

PFS COB Unit

Contact Insurance Payor who is

Primary

PFS COB Unit

Contacts Primary Insurance Payor

Patient Eligibile?

Yes

No

PFS COB Unit

Contacts PHP COB for

Investigation

PFS COB Unit

Determines Other Coverage

PFS COB Unit

PHP Provides Corrected

Information

Other Primary Coverage?

Yes 1

1

No

PFS COB Unit

PHP Updates and Adjudicates Claim

as Primary

PFS

Go to Secondary Coverage Collection

2

2

PFS COB Unit

Send to Denial Team for Appeal

No 1

5 6

7 8 9

10

31

PFS COB Unit

Downloads Weekly Automated PHP Denial Report

2

PHS Work System

Customer Service Process/Council

Selection & Engagement Process/Council

Customer Financial Experience/Council

Patient Care Process/Council

Employees and other

Stakeholders engaged at

each process step

Presbyterian Healthcare Services

EST and EOT

Each Employee

connects to PHS’

Purpose through the management

structure

Su

pp

ort

Annual Rhythm Process



HEDIS: Diabetes A1c Poor Control--Commercial

0%

10%

20%

30%

40%

50%

60%

70%

2003 2004 2005 2006 2007

Per

cent

in P

oor

Con

trol

90th Percentile National Average

Presbyterian Health Plan Best Competitor

Good


Presbyterian’s Commitment to Quality

• Earned two consecutive site visits from National Malcolm Baldrige Quality program. Earned QNM’s Zia in 2004.

• Health Plan one of 14 in nation with three“excellent” accreditations for managed care.

• Medical Group setting the benchmark for care of patients with diabetes.

• Investing millions in patient safety, reduced hospital medication errors by 80 percent.


Perspective on the Future

• Healthcare will continue to be front page news– It will be painful for those not prepared

• All stakeholder's of the healthcare arena will demand data to make decisions

• The value equation = quality over cost • Will under go many cycles of change

• Every service will be faster• Those who don’t accelerate on the technology

journey will not be around• Very soon there will be no payment for mistakes • Consumer will own their own healthcare data