Dealing With Payers With Physician Driven Cost And


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This is a presentation I just did for MGMA Alabama on how providers should develop their own cost and quality data. Thanks to RealTime Medical Data for their support.

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Dealing With Payers With Physician Driven Cost And

  1. 1. Dealing with Payers with Physician Driven Cost and Quality Data<br />Hilton Sandestin Beach & Golf Resort, Destin<br />August 2, 2011<br />William F. (Bill) Cockrell, FACMPE<br />
  2. 2. What’s the Next “Big” Option<br />“Accountable Care Organizations (ACOs), Why They Will Fail and What We Will Need to Learn From the Experience”<br />The main ingredients (who can argue with these?)<br />Cost Effective <br />Quality<br />Because<br />In 2014 we have Healthcare Exchanges<br />
  3. 3. Healthcare Exchanges<br />The 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. <br />
  4. 4. Essential Elements of a Healthcare Exchange *<br />offering the essential benefit package (to be determined in regulations later this year); <br />adhering to cost-sharing limits; <br />being licensed and in good standing to offer health insurance; <br />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; <br />offering at least one qualified health plan at the silver and gold benefit levels; <br />
  5. 5. Status of State Legislation to Establish Exchanges,<br />as of July 2011<br />AK<br />NH<br />WA<br />ME<br />VT<br />MT<br />ND<br />MN<br />OR<br />NY<br />ID<br />WIWI<br />MA<br />SD<br />RI<br />WY<br />MI<br />CT<br />PA<br />IA<br />NJ<br />OH<br />NE<br />NV<br />DE<br />IN<br />IL<br />MD<br />UT<br /> WV<br />IA<br />VA<br />CO<br />DC<br />CA<br />KS<br />MO<br />KY<br />IL<br />NC<br /> WV<br />VA<br />TN<br />SC<br />OK<br />AZ<br />AR<br />NM<br />GA<br />AL<br />MS<br />LA<br />HI<br />TX<br />FL<br />State exchange in existence prior to passage of ACA<br />Legislation pending in one or both houses<br />Legislation signed into law post passage of ACA<br />Pending legislation failed<br />Legislation signed: intent to establish an <br />exchange, creation of study panel, <br />creates an appropriation<br />Governors have pursued/considering <br />non-legislative options<br />Governor veto or decision not<br /> to establish exchange<br />Legislation passed one or both houses<br />Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database.; Commonwealth Fund Analysis. <br />
  6. 6. What are Our Options<br />We can run<br />We can hide<br />We can retire<br />We can complain<br />But – There will be changes in the Healthcare Delivery System<br />
  7. 7. Here’s an Option<br />What 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.” <br />July 4, 2011 Birmingham News<br />Froma Harrop is a member of The Providence (R.I.)Journal’s editorial board and a syndicated columnist.<br />
  8. 8. Can an Enlightened, Well Intentioned, Elite Group Design One Plan to Fit All? <br />
  9. 9. 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?<br />
  10. 10. “The barrier to change is not too little caring; it is too much complexity.”<br /> -Bill Gates<br />
  11. 11. Medicare Cost Data<br />
  12. 12. 2007 Medicare Beneficiary Cost and Readmission Rate<br />Louisiana - $9,500 and 22 day readmission rate<br />West Virginia - $7,600 and 23 day readmission rate<br />Alabama - $7,600 and 17.5 readmission rate<br />Vermont - $7,400 and 14.5 readmission rate<br />Oregon - $6,100 and 13 day readmission rate<br />Rhode Island - $8,600 and 18.5 day readmission rate<br />
  13. 13. Cost and Readmission Rate Ranges<br />Louisiana $9,500<br />West Virginia 23 day readmission rate<br />Oregon $6,100<br />Oregon 13 day readmission rate<br />
  14. 14. The Usual, but Real, Data<br />
  15. 15.
  16. 16.
  17. 17.
  18. 18. Achieving Savings<br />There are three basic ways to reduce Medicare and Medicaid spending: <br /><ul><li>cutting eligibility or benefits—that is, reducing the number of people, the range of services, or the share of spending covered by the programs;
  19. 19. trimming payments by reducing the prices paid for covered services; or reducing utilization of services.
  20. 20. 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</li></li></ul><li>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 andquality.<br />
  21. 21. Option Three Depends on Real Data that Requires a Number of Sources and Results in Some Providers Changing, or Being Left Out<br />
  22. 22. The Financial Issues<br />Define cost effective<br />Comparison to the current fee for service / transaction based model?<br />This is the initial policy under the ACO model<br />Long term model?<br />How do you find out<br />Payers<br />BCBS and others have great information but difficulties in accessing it in a usable form<br />Data sources<br />Independent sources have data but it is blinded by individual patient name<br />
  23. 23. The Quality Issues<br />The Accountable Care Organization (ACO) Quality Performance Measures<br />Initial 65 quality measures<br />The measures are divided by five “domains” that are weighted equally:<br />Patient/Caregiver Experience (7 measures)<br />Care Coordination (16 measures, including transitions of care and HIT)<br />Patient safety<br />Preventative Health<br />At Risk Population/Frail elderly Health (31 measures) on the following<br />Diabetes, Heart Failure, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease, Frail Elderly<br />
  24. 24. Scoring of Quality Performance<br />Providers are scored on their overall achievement relative to a national or other benchmark<br />Quality performance standards will be issued in future rulemaking<br />Performance Scoring<br />CMS sets benchmarks at beginning of each reporting year using FFS, Medicare Advantage or data it has modeled<br />Points are assigned to each measure (and summed by domain) based on performance related to the national benchmark.<br />There is a maximum of 2 points per measure, with a maximum of 130 points for 65 measures<br />Domain scores are determined by dividing the actual points by the maximum potential points to determine a % of performance<br />The 5 domain scores are averaged to determine the overall score<br />
  25. 25. So, If We See Traction on Alternative Delivery Systems, and We Will, We Are Going to Be Faced with Getting from Here:<br />
  26. 26. Medical Treatment<br />Cath<br />Sample Referral Decision Tree <br />Diagnostics<br />Hospital A<br />Hospital B<br />CT Surgeon<br />Cath<br />Cardiologist<br />CT Surgeon<br />Hospital C<br />PCP <br />Interpreter A<br />Mobile Diagnostics<br />Interpreter B<br />
  27. 27. To Here:<br />
  28. 28. Medical Treatment<br />Hospital A<br />Cath<br />Sample Referral Decision Tree - Modified<br />Hospital B<br />Diagnostics<br />Hospital C<br />CT Surgeon<br />Cath<br />Cardiologist<br />CT Surgeon<br />PCP <br />Interpreter A<br />Mobile Diagnostics<br />Interpreter B<br />
  29. 29. And the New Decision Tree Must be Based On:<br />Cost<br />Quality<br />
  30. 30. What do Providers Need<br />Information<br />Keeping track of the rules<br />Understanding models<br />Organization<br />Systems<br />EMR’s<br />Real medical record data sharing<br />Reality<br />There will be those who don’t get to participate<br />
  31. 31. What’s Out there now for Patients, Payers and Providers<br />
  32. 32. Robert Woods Johnson Foundation<br />Comparative Healthcare Quality: A National Directory<br />June 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.”<br />“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.<br />
  33. 33. Data Research Results<br /><br />
  34. 34. Other Information Sources<br /><br /><br /><br />
  35. 35. Sample Using Real Data<br />A hospital in Alabama<br />25 primary care physicians<br />Referral to cardiologists based on top diagnoses<br />Medicare data used available through Freedom of Information Act<br />HPI information scrubbed<br />
  36. 36. BCBS Patient Satisfaction and Quality Measures for Selected Cardiologists<br />
  37. 37. Healthgrades Patient Satisfaction Measures for Selected Cardiologists<br />
  38. 38. What about the Financial Side of Things<br />
  39. 39.
  40. 40. ICD9 Diagnosis Codes<br />Effective Year: 2010(5)<br />Category: (CUSTOM) TOP FIVE CARDIOLOGY DIAGNOSES(5)<br />4011 - Essential hypertension, benign<br />41400 - Coronary atherosclerosis of unspecified type of vessel, native or graft<br />41401 - Coronary atherosclerosis of native coronary artery<br />42731 - Atrial fibrillation<br />78650 - Chest pain, unspecified<br />7/26/2011 ©RealTime Medical Data (205) 941-1211 [] 00:00:09.1553124 Page 1 of 1 The Source for Timely and AccuratePaid Medicare Claims Data™<br />
  41. 41. 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<br />
  42. 42. Coronary Atherosclerosis of Native Coronary Artery<br />
  43. 43. Ranking system<br />5 to 1 point(s) for high to low volume<br />5 to 1 point(s) for low to high LOS<br />5 to 1 point(s) for high to low CMI<br />5 to 1 point(s) for low to high cost<br />5 to 1 point(s) for high to low BCBS Patient Satisfaction<br />Points totaled and physicians ranked high to low<br />
  44. 44. Coronary Atherosclerosis of Native Coronary Artery Ranking<br />
  45. 45. Atrial Fibrillation<br />
  46. 46. Atrial Fibrillation Ranking<br />
  47. 47. Now What<br />If I’m a specialist and highly ranked, I find the way to get the word out to referring doctors and payers<br />If I’m a specialist and ranked low, I find out why and work to change or get better information<br />If I'm primary care, I let the specialists know I need this information in the future<br />
  48. 48. What can we (Providers) Do Today?<br />Start gathering data internally<br />As Primary Care Physicians ask for quality and cost data from our specialists<br />As Specialists, be proactive in gathering the necessary data and providing it to our PCP’s<br />As organizations, find out data sources, communicate this information to our members and help our members understand the information (MASA, MGMA research?)<br />Work with payers when the opportunity presents itself for meaningful analysis of information<br />
  49. 49. The Role of Electronic Records<br />In 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.<br />
  50. 50. The Role of Electronic Records<br />Reality, we cannot get the information we need through paper charts<br />We have to have discrete, searchable data elements<br />We have to have dashboards<br />We have to efficiently communicated reports and data<br />We have to share information, appropriately<br />
  51. 51. Questions?<br />Cockrell and Associates, LLC<br />(205) 999-8064<br /><br /><br />