Post on 24-Dec-2015
transcript
The Maine Experience
In Pursuit of Value-Based Purchasing
August 4, 2009
Background
Self-insured POS plan of 34,000 (with additional 6,800 Medicare retirees)
Largest employer-sponsored plan in Maine Governed by State Employee Health
Commission, twenty-two member labor/management organization
Slightly older working population Higher incidence of chronic illness
The Path to Value-Based Purchasing Founding member of Maine Health Management
Coalition – multi-stakeholder organization of employers, hospitals, health plans, and physician groups
External factors Institute of Medicine reports Juran Institute report for MBGH NEJM study findings on treatment of chronic illness Dartmouth Atlas
Commission Adopts Value-Based Purchasing Strategy Growth in plan expenses is unsustainable Resisted traditional cost shifting tactics in
favor of value equation (quality, utilization, efficiency) – trying to change behavior
Gaps in care and unwarranted variation cannot be adequately addressed without changes in benefits and reimbursement
Phase I – TDES (1/1/05)
Telephonic Diabetes Education & Support program
Improve participation in self-management program and improve adherence to prescribed treatment
Partnership with TPA (Anthem) and non-profit Medical Care Development
Adapted traditional education and self-management model to telephonic pilot
TDES Basic Design
1st and 12th sessions require face-to-face encounter with nurse educator for pre/post assessment & biometric measures
Intervening 10 sessions are conducted via telephone at convenient times
Plan waives Rx copays for diabetic medications and supplies for duration of member’s participation
Results of TDES Pilot
Participants received recommended care evidenced by: physician visits, foot exams, retinal eye exams, HbA1c levels
Members participating in TDES had statistically significant improvement in adherence to oral diabetes medications
Compared to randomly selected control group TDES participants had an adjusted average cost $1,300 less than control group over 12-month follow-up
Phase II – Hospital Tiering (7/1/06)Goals & Objectives Encourage public disclosure of provider
performance Establish attainable performance benchmarks to
be incrementally adjusted Drive quality improvement Give members tools to make informed decisions Provide incentives to shape decision-making
Hospital Tiering Basic Design
Completion of Leapfrog safe practices survey Performance on Maine Health Management Coalition
medication survey indicating “has made good progress to implement recommended safe practices”
Met or exceeded national average on CMS clinical core measures
Services billed by “preferred hospital” exempt from annual deductible
All hospitals remain in the network Over 60 sessions conducted statewide to inform
members
What Happened?
Only 14 of 36 acute care hospitals met the criteria for preferred hospital
Members voiced concern to local hospital officials for failing to meet criteria
By 1/1/07 all Maine hospitals had completed the Leapfrog safe practices survey and the MHMC medication safety survey
Number of preferred hospitals jumped to 25 by 1/1/07
The Next Phase of Hospital Tiering
Providers became more engaged in process Agreement to use MHMC as “trusted” source of
measures and reporting State aligned with MHMC hospital ratings – blue
ribbon designations (7/1/07) Financial incentives for members become more
meaningful (10/1/08)
What Do We Know About Hospital Tiering? Design was quite benign and non-threatening but it
produced results Incremental approach helped ensure members were not
disenchanted Focus on quality and safety insulated initiative from
provider complaints Anecdotally, hospital QI staff and pharmacists told us the
initiative helped secure resources In first year there was 5% shift in outpatient services
from non-preferred to preferred hospitals
What Have We Learned?
There is strong evidence to support that initial objectives have been met
Individually and collectively hospital quality performance has improved – at least for dimensions of care we measure
Incentives do have some impact on both provider and enrollee behavior
What Do We Need To Know?
Is there a link between higher-performing hospitals and efficiency?
How do we design incentives to produce desired results?
Can we adapt this model to specific high-volume or high-risk procedures?
How do we demonstrate the continued effectiveness of this strategy?
Phase III – Primary Care Physician (PCP) Tiering Maine Health Management Coalition’s
Pathways to Excellence (PTE) developed metrics to measure management of patients with chronic conditions
Measures office systems, treatment of diabetes, treatment of heart disease, treatment of pediatric asthma and results of childhood immunizations
How Does PCP Tiering Work?
Preferred practices must be awarded two or three blue ribbons
Office visit copays to preferred practices are waived
Services billed by preferred practices not subject to deductible
Developments in PCP Tiering
From 2007 to 2008 35% increase in the number of practices with 3 blue ribbons and 20% increase in number of practices with 2 blue ribbons
By 2009 over 50% of the better than 400 primary care practices were preferred
MHMC moving to national measures – Bridges to Excellence and NCQA
Phase IV
Adapt TDES principle to asthma and congestive heart failure (7/1/09)
Centers of Excellence for bariatric surgery (7/1/09)
Health credit program (10/1/09)
Next Steps
Minimally invasive surgery Introduction of efficiency measures (to include
utilization) for PCPs, specialists and hospitals Shared decision-making for preference-sensitive
services Regional medical tourism Payment reform