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WHIO Symposium May 13, 2011

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Goals of WHIO To aggregate health care data from sources across Wisconsin to create a single reliable data source to be used by multiple stakeholders to examine variations in efficiency, quality, safety and cost To improve the quality, cost, safety and efficiency health care in Wisconsin by sharing the results with providers, purchasers and consumers To support provider quality improvement initiatives To encourage value-based health care choices by consumers

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WHIO Members and Subscribers The Alliance Anthem Blue Cross and Blue Shield of Wisconsin Greater Milwaukee Business Foundation on Health Humana United Healthcare of Wisconsin WEA Insurance Trust WPS Health Insurance Wisconsin Collaborative for Healthcare Quality Wisconsin Hospital Association Wisconsin Medical Society Wisconsin Department of Employee Trust Funds Wisconsin Department of Health Services Aspirus Aurora Health System Bellin Health Dean Health Plan Group Health Cooperative South Central Wisconsin Gundersen Lutheran Health Plan Health Tradition Health Plan/Mayo MercyCare Insurance Network Health Plan Physicians Plus Insurance Prevea Health Plan Security Health Plan ThedaCare Unity Health Plan UW Population Health Institute

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Using the Data: Wisconsin Payment Reform Initiative Launched with the premise that: Aligning the incentives of payers, providers, employers and patients, Measuring quality and cost of care at a granular level, and Publicly reporting outcomes Will: Improve the quality of care delivered and reduce its cost by rewarding those who reduce waste and develop more effective, efficient processes

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And This is Important Because Health care spending now tops 18% of US GDP Premium growth crowds out wage increases, is unsustainable for employers 1:6 (50+ million) Americans is enrolled in Medicaid 1:6.5 (47+ million) Americans is enrolled in Medicare 1:6 (50+ million) Americans is uninsured

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History of WPRI November 2009 WHIO creates WPRI Steering Committee April 2010 Steering Committee hosts WPRI Leadership Summit 170 C Level leaders from stakeholder organizations Agreed to form Acute, Chronic, Preventive Care Workgroups to develop pilot projects Hypothesis: The outcomes for patients treated for a specific condition will improve, and costly complications or exacerbations of the patients condition will be avoided, if the payment system fosters competition among providers at the level of the medical condition based on the quality of care delivered and the total cost of services.

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Pilot Conditions Acute Care chose total knee replacement Chronic Care chose adult diabetes Preventive Care chose composite measure of screenings for: Breast Cancer Cervical Cancer Colorectal Cancer

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Partnership for Healthcare Payment Reform Our Mission: The Partnership for Healthcare Payment Reform supports the voluntary engagement of Wisconsins diverse healthcare stakeholders in assessing, designing, testing and implementing innovative, comprehensive approaches to healthcare payment reform in order to improve the quality and affordability of healthcare in Wisconsin and advance the health status of Wisconsin residents.

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Guiding Principles/Values Collaboration: We rely on shared sense of purpose among participants Openness/Transparency: Communicate learnings, engage all parties. Patient Centeredness: Payment reform should enhance patient experience of care. Synergy: PHPR will provide relevant, Wisconsin-based leadership, building on national trends

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Guiding Principles/Values Evidence-based: Use data to select high value projects; assess promising practices Continuous Learning: Our understanding of what best supports value in healthcare continues to evolve Impact: Pilot approaches that are both replicable and scalable

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Why Are 60+ Organizations Participating in Design Efforts? Opportunity to align incentives among payers Maximize purchasing strategies Collaborative nature of the workbuilding on Wisconsins tradition and healthcare assets Shared learning Commitment to quality Opportunity to test what we know we have to do Sense of responsibility/duty to sustainable healthcare system

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Current Status: Acute Care Pilot Bundled payment for total knee replacement (single knee) Commercially insured patients ages 18 64 Includes 90 day warranty period to cover complications, device failure

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Why Pilot Bundled Payments? Bundled payments have been shown to improve quality and efficiency of care* Medicare scheduled to pilot episode of care bundled payments beginning January 1, 2013 Few multi-payer bundled payment efforts in the countryWisconsin can lead the way Participation in PHPR bundled payment pilot allows manageable testing of larger payment reforms to come *See, e.g., http://www.gao.gov/new.items/d11126r.pdf; Cromwell J, et al., Cost savings and physician responses to global bundled payments for Medicare heart bypass surgery. Health Care Financ Rev. 1997 Fall;19(1):41-57.http://www.gao.gov/new.items/d11126r.pdf 13

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Acute Care Pilot Overview What Services? Bundled payment for Total Knee Replacement (one knee) Episode period begins at admission and concludes 90 days from hospitalization Revision procedure performed during episode period resulting from patient complications or device failure Patient complications arising during anchor admission Treatment of complications related to either anchor or revision admission (any service setting) Readmission during the 90-day episode period for listed DRGs 14

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Acute Care Pilot Overview, contd. Whos Included? Patients presenting for the index procedure without: Clinical history that demonstrates a clinical condition of active cancer, HIV/AIDS, or End Stage Renal Disease Body Mass Index (BMI) of 40 or greater Over age 18 and under age 65 on the date of surgery Covered (as primary plan) by a participating employer and health plan at the time of admission 15

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Acute Care Pilot Overview, contd. How Will Bundled Payments Work? Bundler (hospital, IPA, PHO) negotiates bundled payment Provider bills upon patient discharge and at end of episode period Payer pays negotiated amount to bundler Bundler distributes payment to TKR bundle team members 16

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TKR Bundle Quality Measures MeasureWho Collects and Reports To Whom How Often SCIP Cardiology 2HospitalCMS/ PHPR Quarterly SCIP VTE 2HospitalCMS/ PHPR Quarterly Length of StayHospitalPHPRQuarterly Readmission/Revision Rates for TKRPayers/WHI O PHPR6 months Complications (infection rates, DVT, PE) Payers/WHI O PHPR6 months Patient SatisfactionHospitalHCAHP S/ PHPR Quarterly Outcomes Measure (WOMAC, KSS, KOOS, etc.) depending on what provider uses ProviderPHPRQuarterly Patient facility with activities of daily living pre-op vs. post-op (being developed) ProviderTBD 17

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Acute Care: Next Steps Expressions of interest requested by May 20 or as soon as feasible Targeting go-live of September 1, 2011 Workgroup meeting this afternoon open to potentially interested pilot participants

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Current Status: Chronic Care Pilot Project Adult diabetics covered by commercial plans WCHQ quality measures Begin with shared savings and transition to global payment over time Payers retain insurance risk; providers take clinical/performance risk Consider opportunities to work on local community engagement around nutrition, physical activity, obesity prevention/reduction 19

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Why Pilot Shared Savings/ Episode of Care Payments? Condition-based, episode of care payments are expected to improve quality and efficiency of care* Pilots propose to start with shared savings and transition to full global payment Participation in PHPR chronic care payment pilot allows manageable testing of larger payment reforms to come Few multi-payer episode of care payment efforts in the countryWisconsin can lead the way *See, e.g., http://www.ncbi.nlm.nih.gov/pmc/articles/PMC554918/; http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2008/Jun/Evidence- Informed-Case-Rates--Paying-for-Safer--More-Reliable-Care.html?doc_id=689893http://www.ncbi.nlm.nih.gov/pmc/articles/PMC554918/ http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2008/Jun/Evidence- Informed-Case-Rates--Paying-for-Safer--More-Reliable-Care.html?doc_id=689893 20

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Diabetic Services Bundle Adults 18-64 with diabetes Without HIV, cancer, suicide, ESRD, pregnancy Include the following ICD-9-CM codes: 250.xx, v45.85, v53.91, v58.67, v65.46 Establish outliers to exclude expensive surgical claims 21

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Chronic Care: Payment Model

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Diabetic Pilot Outcomes Measures MeasureWho Collects and Reports* To Whom How Often Good Control Hemoglobin A1C (target < 7.0% or