Dr. Anne Docimo Improving Healthcare payer provider collaboration final


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Dr. Anne Docimo, Chief Medical Officer, UPMC Health Plan.
Presentation at 2011 National Healthcare Conference in Dublin

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  • Executive presenter: Speaks about how they personally support the mission of UPMC
  • UPMC is named regularly to the prestigious U.S. News & World Report Honor Roll in the annual “America’s Best Hospitals” survey. UPMC is ranked one of 14 hospitals nationwide that made the Honor Role of the “nation’s best” in the 2010 survey. UPMC ranked 13th out of more than 5,000 eligible hospital nationwide. UPMC is ranked among the nation’s best in 15 of 16 clinical specialties by U.S. News & World Report, including top 10 rankings in seven specialties.UPMC’s ranked specialties are: Ear, nose and throat, 3rd; gynecology, 6th; respiratory disorders, 7th; geriatric care, 8th; orthopaedics, 8th; psychiatry, 9th; rheumatology, 9th; digestive disorders, 11th; rehabilitation, 15th; kidney disorders, 17th; neurology and neurosurgery, 17th; urology, 20th; heart and heart surgery, 22nd; diabetes and endocrinology, 30th; and two rankings in cancer, 31st for UPMC Presbyterian Shadyside and 42nd for Magee-Women’s Hospital of UPMC.
  • Prevalence of Key Chronic Conditions
  • Dr. Anne Docimo Improving Healthcare payer provider collaboration final

    1. 1. Improving Healthcare: Payer-Provider Collaboration<br />Anne Boland Docimo, MD, MBA <br />
    2. 2. UPMC Today<br /><ul><li>One of the nation’s largest Integrated Delivery Systems
    3. 3. 5th in NIH funding, affiliated University of Pittsburgh
    4. 4. $8.0 billion in Annual Revenue
    5. 5. 50,000Employees
    6. 6. 2,700 employed physicians and 2,500 affiliated physicians
    7. 7. 21 hospitals and 43 regional cancer centers
    8. 8. 400+ service locations; home care; rehab, urgent care
    9. 9. 1.5million members in Insurance Division programs
    10. 10. 20,000+ contracted network providers
    11. 11. Global and Commercial Enterprise (UK; Italy)
    12. 12. $1 billion+/five years investment in technology </li></ul>2<br />
    13. 13. Vision of UPMC<br />UPMC will create a new economic future for western Pennsylvania — a future built on new ways of thinking about health care and sparked by leveraging the uniqueness of the integrated health enterprise. By exporting excellence nationally and internationally, and fueling the development of new businesses that emerge from UPMC’s intellectual capital, core capabilities, and management expertise, UPMC will catalyze a regional economic renaissance. At the same time, UPMC will remain steadfastly committed to providing premier health care services to our region and contributing to this community. <br />3<br />
    14. 14. UPMC Organizational Structure<br />International <br />and<br /> Commercial <br />Services<br />Hospital<br />and <br />Community<br /> Services<br />Insurance<br />Services<br />Physician<br />Services<br />4<br />
    15. 15. UPMC named to 2010 U.S. News & World Report Honor Roll as one of “America’s Best Hospitals” for the 11th time<br />Ranked in 15 of 16 clinical specialties; in the top 10 in seven of them<br />UPMC Insurance Companies highly ranked with NCQA “Excellence” status<br />Our Record of Success<br />5<br />
    16. 16. Goal of Accountable Care: Improve Value<br />Population Health<br />Patient Centered Care<br />Per Capita Costs<br />Experience of Care<br />Good Science<br />Public Health Orientation<br />Meaningful Information<br />The Right Incentives<br />Seamless Systems of Care<br />Outcomes<br />Based Care<br />Healthy <br />Communities<br />Payment Aligned<br />With Value<br />Smart <br />Systems<br />Patient<br />Centered<br />Best in Class Administrative Infrastructure<br />6<br />
    17. 17. Standard Claims Mapping: Clinical/Financial Integration<br />Financial and clinical integration<br />Financial and quality modeling<br />Standard reporting<br />Governmental<br />Employer<br />Provider contracting<br />Intervention design<br />Member benefit design<br />7<br />
    18. 18. Identifying Health Conditions by Data Source<br />8<br />
    19. 19. 75% of Healthcare Costs Driven by Chronic Disease<br />9<br />Medicare Key Chronic Conditions<br />Prevalence and PMPM<br />Hypertension<br />CAD<br />Arthritis<br />Diabetes<br />Neoplasm<br />CHF<br />
    20. 20. Escalating <br />Costs<br />Population <br />Health<br />10<br />
    21. 21. Medicare HMO CY 2009 Distribution of Healthcare Expenses by Membership<br />11<br />5% members = 40% costs<br />
    22. 22. Approaches<br />Coordinated care teams<br />Population Management<br />Supportive care<br />Patient-Centered Medical Home<br />Readmission/transitionprograms<br />Inpatient manager/Hospitalist<br />12<br />
    23. 23. Evidenced Based Guidelines<br />Inpatient Manager<br />Transitional Approach<br />Traditional UM<br />Accountable Care<br />Discharge Advocate + Ongoing Coordination with Care Team<br />13<br />
    24. 24. Payer-Provider Collaboration<br />Create Value: Accountable Care Organization<br />Evidence-based Clinical Pathways <br />Right care, Right time, Right setting, Right price<br />Common outcome metrics define value<br />Process measures: Following pathway<br />Clinical outcomes: Quality and Safety<br />Utilization of Resources <br />Admissions, Length of stay, Readmissions<br />Diagnostics, Specialty Care, Pharmaceuticals<br />Financial Outcomes<br />14<br />
    25. 25. Partners in Excellence – Patient Centered Medical Home<br />Transitional approach to utilization management<br />Project RED – transitions program<br />Wound Care – Telemedicine<br />Anticoagulation – multidisciplinary<br />Heart Failure – multidisciplinary<br />Doula Maternity<br />Connected Care<br />Going Home Program<br />Pharmacy quality initiatives<br />Member engagement strategy<br />Payer-Provider Collaboration: Seamless Systems of Care<br />15<br />
    26. 26. Medical Home<br />16<br /><ul><li>Practice Coaches </li></ul> (Process Improvement <br /> for Workflow)<br /><ul><li>Patient Outreach </li></ul> Education<br /><ul><li>Virtual Extender </li></ul> Team at Health Plan <br /> including Health <br /> Coaches for Lifestyle<br /><ul><li>Practice based Clinical Care Managers at selected sites
    27. 27. Provided Disease Registries; Predictive Modeling and Patient Risk Profiles
    28. 28. Timely Data: Emergency Inpatient, Pharmacy, Specialty and Care Gaps Data</li></li></ul><li>Quarterly Acute Inpatient Admits per 1,000 Exponential Trends (July 1, 2007 - December 31, 2010)<br />17<br />
    29. 29. Rate of Rehospitalization within 30 Days<br />Source: NEJM, April 2009, S. Jencks.<br />18<br />
    30. 30.  Shared Goals<br />Improve quality of care<br />Decrease readmission rates<br />Decrease adverse events after discharge<br />Increase follow-up activity with the PCPs and specialists<br /> Elements of Complete Transition Home<br />Medication reconciliation<br />Compare discharge plan against national guidelines and clinical pathways<br />Schedule follow-up appointments<br />Review post discharge instructions<br />Provider written discharge plan  After Hospital Care Plan  <br />Symptom Response Plan<br />Patient Education<br />Discharge Summary to the PCP<br />19<br />Improving Care Transitions<br />
    31. 31. Physician<br /><ul><li>Works with team on </li></ul> admission to start <br /> discharge planning <br /><ul><li> Completes medication </li></ul> reconciliation on <br /> admission and <br />discharge<br /><ul><li>Transition to post-acute</li></ul> team<br />Discharge Advocate <br /><ul><li>Education on admission,</li></ul> during stay, and at discharge<br /><ul><li> Care coordination with </li></ul> home care and DME<br /><ul><li> Makes follow-up </li></ul> appointments<br /><ul><li> Calls patient 48 hrs after discharge
    32. 32. Connect to HP Care Management Team</li></ul>Team Work <br /> and <br />Collaborations<br />Collaboration<br />Patient/Member<br />Health Plan Pharmacist<br /><ul><li>Assist with discharge </li></ul> planning<br /><ul><li> Comprehensive </li></ul> medication review on <br /> post hospital call<br />Bedside Nurse<br /><ul><li>Shares patient needs </li></ul> with care team<br /><ul><li> Provides patient </li></ul>education<br />20<br />
    33. 33. The UPMC Safe Discharge Hand-Off Initiative provides organized clinical information to both our patients and providers on discharge or transfer from the hospital<br /><ul><li>current problem list
    34. 34. vital sign trends
    35. 35. major tests and procedures
    36. 36. safety risks
    37. 37. vaccines and immunizations
    38. 38. tests results not available at time of DC (for follow-up)
    39. 39. communication process to access the hospital/unit and provider </li></ul>UPMC Safe Hand-Off<br />21<br />My UPMC Safe Discharge Reports include: <br />
    40. 40. UPMC Safe Discharge Hand-Off<br />Skilled Facilities<br />Sharing the clinical information with downstream providers<br />Rehabilitation<br />Creating tools for safe hand-off communication during care transitions<br />Engaging the patient in the process with enhancements for self-management<br />Home Health<br />Post-DC Office Visit<br />22<br />
    41. 41. UPMC Safe Discharge Hand-Off Outcomes Implemented October 2010<br />% of physicians who agreed or strongly agreed <br />80<br />Report was timely to follow-up on DC needs<br />% of Safe Hand-Off Reports Transmitted to PCPs <br />Content assisted with transition of care<br />55<br />33,715<br />Delivery method was suitable for work flow<br />75<br />The # of Safe Discharge Reports Transmitted<br />23<br />
    42. 42. MC: 30 Day Any DRG Readmission Rate Trend<br />24<br />
    43. 43. All LOB: 30 Day Any DRG Readmission Rate Trend<br />25<br />
    44. 44. Components of Readmission Survey<br /><ul><li> Is this a planned readmission?
    45. 45. Is this a related readmission?
    46. 46. What may have led to this readmission? </li></ul> (check all that apply)?<br /><ul><li> Medication related
    47. 47. No PCP or specialist visit since last hospitalization
    48. 48. Complication related to original stay
    49. 49. Unrelated causes
    50. 50. Discharge planning
    51. 51. Care giver support
    52. 52. Unable to determine
    53. 53. Could this admission have been avoided with alternate care plan?
    54. 54. Did patient receive discharge instructions?</li></ul>26<br />
    55. 55. Collaborative Care Plans <br />27<br />Patients with complex needs require comprehensive, coordination of care: <br />Frequent use of ED services<br />Frequent hospital admissions <br />Use of multiple hospitals<br />Seeing multiple physicians <br />Non-compliance with care in outpatient setting<br />Patients with known narcotic seeking behavior<br />Complex psychosocial issues<br />Patients in top 5% use 40% of resources <br />
    56. 56. Care Plan Committee<br />28<br />Identify key individuals to participate: <br />Patient’s Clinical Care Team<br />Primary Care Provider<br />Key Specialists relevant to patient’s clinical needs<br />Hospital Care Management (RN and SW)<br />Behavioral Health Liaison<br />Chronic Pain Service <br />UPMC Health Plan Care Management Team<br />
    57. 57. Creation of Care Plans <br />29<br />Template for Care Plans<br />Emergency Department: <br />Text-page/ email alerts to clinical and CM team on registration <br />Worklist alert in HealthPlaNET Care Management system<br />Clinical care plan, discharge care plan, follow-up instructions<br />Hospital Care<br />Establish criteria for admission<br />Admission team: Consistent Care givers: hospitalist team, key specialists<br />Compliance to clinical treatment plan, medications, behavior<br />Transition to Community Caregivers /Outpatient Care Management<br />Communication: <br />Care Plan in e-record, CM system updated on each admission and as needed<br />
    58. 58. Collaborative Care Plan<br />Results of FY2010 compared to FY2009 for patients in <br />Collaborative Care Plan Pilot:<br />Number of ED visits  7%<br />Number of hospital admissions 40%<br />Number of outpatient visits  17%<br />30<br />Total Cost of Care  24%<br />
    59. 59. Complex Care Plan Case Study:Chronic Pain Patient <br />31<br />
    60. 60. Pharmacy Programs<br />Drug therapy optimization<br />Intelligent Formulary Design<br />Promote safe, appropriate drug use<br />Evidence-based algorithms<br />Promote generic utilization<br />Medication therapy management<br />Provider partnerships<br />Pharmacist as virtual team member<br />Combine algorithms with real life clinical practice<br />Pharmacy Initiatives<br />32<br />
    61. 61. Provider Partnership Strategy: Rx for Success<br />33<br />
    62. 62. Generic Fill Rates<br />34<br />66.2%<br />74%<br />68.7%<br />62.8%<br />79.3%<br />72.9%<br />68.4%<br />76.7%<br />73.8%<br />63.9%<br />67.7%<br />
    63. 63. Clinical Management of Oxycontin Improving Quality and Cost<br />-<br />Oxycontin vs. Opana <br />Medicaid Utilization 2008 <br />Total Prescriptions<br />OXYCONTIN<br />OPANA IR<br />OPANA ER<br />Nearly $1 million in<br />annual savings and 16% walk aways<br />1000<br />900<br />800<br />700<br />600<br />500<br />400<br />300<br />200<br />100<br />0<br />JAN<br />FEB<br />MAR<br />APR<br />MAY<br />JUN<br />JUL<br />AUG<br />SEPT<br />OCT<br />NOV<br />DEC<br />2008<br />35<br />
    64. 64. Clinical Management of Designer Narcotics Improving Quality and Cost <br />A narcotic painkiller that looks like a lollipop -- designed for quick pain relief to cancer patients. <br />Narcotic painkiller Actiq, is ONLY FDA-approved for use in treating cancer pain. <br />The Wall Street Journal published these findings in 2006:<br />Oncologists accounted for only 1 percent of the 187,076 Actiq prescriptions in the first 6 months of 2006.<br />More than 80% of patients receiving Actiq had no cancer diagnosis. <br />Two children died after confusing the drug for candy.<br />UPMC Health Plan has always required clinical approval of Actiq based on FDA label in order to ensure safe, on-label use and mitigate abuse potential. <br />2010 UPMC HP: 18 members out of 535,000 lives = 0.0034% of total population.<br />Other designer narcotics with potential for abuse are also clinically managed include: Avinza, Kadian and Magnacet<br />
    65. 65. Specialty Drug Cost Drivers - More Drugs, More Uses, More Patients<br />Exploding pipeline - Oncology dominates<br />Currently half of all new drug approvals are specialty drugs<br />Expanding uses for existing products<br />Orals changing the landscape – becoming maintenance therapy<br />Management requires Evidence Based Guidelines developed with Clinical Experts.<br />Over 633 Biologics In Development<br />37<br />
    66. 66. Move to Accountable Care<br />Create Value<br />Defined by common metrics across payer-provider tracking clinical and financial outcomes<br />Position of strength moving forward: <br />Build sustainable programs that will deliver quality and use resources efficiently. <br />What next?<br />38<br />
    67. 67. “Prediction is very hard”<br />“Especially about the future.”<br />Yogi Berra<br />Source: Susan Dentzer, Editor-in-Chief, Health Affairs at theGrand Rounds, Department of Orthopedics, University of Pittsburgh Medical Center, October 21, 2009.<br />39<br />
    68. 68. Thank You<br />40<br />