Date post: | 13-Jan-2015 |
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Anne Boland Docimo, MD, MBA
Improving Healthcare: Payer-Provider Collaboration
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• One of the nation’s largest Integrated Delivery Systems
• 5th in NIH funding, affiliated University of Pittsburgh
• $8.0 billion in Annual Revenue
• 50,000 Employees
• 2,700 employed physicians and 2,500 affiliated physicians
• 21 hospitals and 43 regional cancer centers
• 400+ service locations; home care; rehab, urgent care
• 1.5million members in Insurance Division programs
• 20,000+ contracted network providers
• Global and Commercial Enterprise (UK; Italy)
• $1 billion+/five years investment in technology
UPMC Today
Vision of UPMC
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.
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Hospital and
Community Services
InsuranceServices
International and
Commercial Services
UPMC Organizational Structure
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PhysicianServices
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• UPMC named to 2010 U.S. News & World Report Honor Roll as one of “America’s Best Hospitals” for the 11th time
• Ranked in 15 of 16 clinical specialties; in the top 10 in seven of them
• UPMC Insurance Companies highly ranked with NCQA “Excellence” status
Our Record of Success
Population Health
Per Capita Costs
Experience of Care
Patient Centered
Care
Good Science
The Right Incentives
Meaningful Information
Seamless Systems of Care
Public Health
Orientation
OutcomesBased Care
Payment AlignedWith Value
Smart Systems
PatientCentered
Healthy Communities
Goal of Accountable Care: Improve Value
6Best in Class Administrative Infrastructure
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Standard Claims Mapping: Clinical/Financial Integration
Financial and clinical integrationFinancial and quality modelingStandard reporting
GovernmentalEmployerProvider contractingIntervention designMember benefit design
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Data Source (Incremental)N = 31,204
Condition Claims Only Claims & RxClaims, Rx &
HRAClaims, Rx, HRA & Screenings/Labs
Diabetes 1,596 1,994 2,197 2,344
Hyperlipidemia 4,086 5,698 5,698 6,774
Hypertension 4,324 6,588 6,588 7,658
Asthma 982 2,715 2,715 2,715
Depression 2,200 6,366 7,597 7,597
Low Back Pain 2,738 2,738 2,738 2,738
Smoking 1,442 5,721 6,119
Obesity 132 132 8,593 8,878
All Conditions 11,795 16,036 21,005 21,913
Identifying Health Conditions by Data Source
75% of Healthcare Costs Driven by Chronic Disease
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Medicare Key Chronic ConditionsPrevalence and PMPM
Hypertension
CADNeoplasm
Arthritis
CHF
Diabetes
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Chronic Care
Costs 75%
Acute Care Costs25%
Escalating
Costs
Population
Health
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
50%
7%
30%
19%
10%
18%
5%
17%
4%
24%
1%
15%
% of Members % of Expenditures
$135,465,6902,349 MembersMER = 271%
$92,562,2702,936 MembersMER = 199%
$100,457,5205,872 MembersMER = 124%
$108,665,60917,616 MembersMER = 55%
$39,153,95629,361 MembersMER = 19%
$81,550,410587 MembersMER = 446%
Medicare HMO CY 2009 Distribution of Healthcare Expenses by Membership
5% members = 40% costs
Inpatient manager/Hospitalist
Readmission/transition programs
Coordinated care teams
Patient-Centered Medical Home
Supportive care
Population Management
Approaches
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Pre-Admission
Review
Concurrent Review
Discharge Planning
Evidenced Based
Guidelines
Inpatient Manager
Discharge Advocate + Ongoing
Coordination with Care Team
Traditional UM Accountable Care
Transitional Approach
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Payer-Provider Collaboration
• Create Value: Accountable Care Organization– Evidence-based Clinical Pathways – Right care, Right time, Right setting, Right price
• Common outcome metrics define value– Process measures: Following pathway– Clinical outcomes: Quality and Safety– Utilization of Resources
• Admissions, Length of stay, Readmissions• Diagnostics, Specialty Care, Pharmaceuticals
– Financial Outcomes
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• Partners in Excellence – Patient Centered Medical Home• Transitional approach to utilization management• Project RED – transitions program• Wound Care – Telemedicine• Anticoagulation – multidisciplinary• Heart Failure – multidisciplinary• Doula Maternity• Connected Care• Going Home Program• Pharmacy quality initiatives• Member engagement strategy
Payer-Provider Collaboration: Seamless Systems of Care
Medical Home
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Practice based Clinical Care Managers at selected sites
Provided Disease Registries; Predictive Modeling and Patient Risk Profiles
Timely Data: Emergency Inpatient, Pharmacy, Specialty and Care Gaps Data
Practice Coaches (Process Improvement for Workflow)
Patient Outreach Education
Virtual Extender Team at Health Plan including Health Coaches for Lifestyle
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Quarterly Acute Inpatient Admits per 1,000 Exponential Trends (July 1, 2007 - December 31, 2010)
July
2007
August 2007
September
2007
October
2007
November
2007
December
2007
January
2008
February 2008
March 2008
April 2008
May 2008
June 2008
July
2008
August 2008
September
2008
October
2008
November
2008
December
2008
January
2009
February 2009
March 2009
April 2009
May 2009
June 2009
July
2009
August 2009
September
2009
October
2009
November
2009
December
2009
January
2010
February 2010
March 2010
April 2010
May 2010
June 2010
July
2010
August 2010
September
2010
October
2010
November
2010
December
2010
40.00
44.00
48.00
52.00
56.00
Commercial Admits / 1,000
CommercialExponential (Commercial)
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Source: NEJM, April 2009, S. Jencks.
Rate of Rehospitalization within 30 Days
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Shared Goals• Improve quality of care• Decrease readmission rates• Decrease adverse events after discharge• Increase follow-up activity with the PCPs and specialists
Elements of Complete Transition Home• Medication reconciliation• Compare discharge plan against national guidelines and
clinical pathways• Schedule follow-up appointments• Review post discharge instructions• Provider written discharge plan After Hospital Care Plan • Symptom Response Plan• Patient Education• Discharge Summary to the PCP
Improving Care Transitions
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Physician• Works with team on admission to start discharge planning • Completes medication reconciliation on admission and discharge• Transition to post-acute team
Bedside Nurse• Shares patient needs with care team• Provides patient education
Health Plan Pharmacist• Assist with
discharge planning• Comprehensive medication review on post hospital call
Team Work and
Collaborations
Collaboration
Discharge Advocate
Physician
Health Plan Pharmacist
Bedside Nurse Patient/Member
Discharge Advocate • Education on admission, during stay, and at discharge• Care coordination with home care and DME• Makes follow-up appointments• Calls patient 48 hrs after
discharge• Connect to HP Care
Management Team
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The UPMC Safe Discharge Hand-Off Initiative provides organized clinical information to both our patients and
providers on discharge or transfer from the hospital
current problem list vital sign trends major tests and procedures safety risks vaccines and immunizations tests results not available at time of
DC (for follow-up) communication process to access
the hospital/unit and provider
UPMC Safe Hand-Off
My UPMC Safe Discharge Reports include:
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Post-DC Office Visit
Skilled Facilities
Rehabilitation
Home HealthCreating tools for safe hand-off communication
during care transitions
Engaging the patient in the process with
enhancements for self-management
Sharing the clinical
information with
downstream providers
UPMC Safe Discharge Hand-Off
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October November December January February0
102030405060708090
100
% of Safe Hand-Off Reports Transmitted to PCPs
33,715The # of Safe
Discharge Reports Transmitted
80
% of physicians
who agreed or strongly agreed
Report was timely to follow-up on DC needs
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75
Content assisted with transition of care
Delivery method was suitable for work flow
UPMC Safe Discharge Hand-Off Outcomes Implemented October 2010
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2008/11
2008/12
2009/01
2009/02
2009/03
2009/04
2009/05
2009/06
2009/07
2009/08
2009/09
2009/10
2009/11
2009/12
2010/01
2010/02
2010/03
2010/04
2010/05
2010/06
2010/07
2010/08
2010/09
2010/10
15.0%
15.5%
16.0%
16.5%
17.0%
17.5%
18.0%
18.5%
19.0%
19.5%
20.0%
MC: 30 Day Any DRG Readmission Rate Trend
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2008/11
2008/12
2009/01
2009/02
2009/03
2009/04
2009/05
2009/06
2009/07
2009/08
2009/09
2009/10
2009/11
2009/12
2010/01
2010/02
2010/03
2010/04
2010/05
2010/06
2010/07
2010/08
2010/09
2010/10
14.0%
14.5%
15.0%
15.5%
16.0%
16.5%
17.0%
17.5%
18.0%
All LOB: 30 Day Any DRG Readmission Rate Trend
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Components of Readmission Survey
• Is this a planned readmission?• Is this a related readmission?• What may have led to this readmission? (check all that apply)?
Medication related No PCP or specialist visit since last hospitalization Complication related to original stay Unrelated causes Discharge planning Care giver support Unable to determine
• Could this admission have been avoided with alternate care plan?
• Did patient receive discharge instructions?
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Collaborative Care Plans
• Patients with complex needs require comprehensive, coordination of care: – Frequent use of ED services– Frequent hospital admissions – Use of multiple hospitals– Seeing multiple physicians – Non-compliance with care in outpatient setting– Patients with known narcotic seeking behavior– Complex psychosocial issues– Patients in top 5% use 40% of resources
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Care Plan Committee
• Identify key individuals to participate: – Patient’s Clinical Care Team
• Primary Care Provider• Key Specialists relevant to patient’s clinical needs
– Hospital Care Management (RN and SW)– Behavioral Health Liaison– Chronic Pain Service – UPMC Health Plan Care Management Team
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Creation of Care Plans
• Template for Care Plans– Emergency Department:
• Text-page/ email alerts to clinical and CM team on registration • Worklist alert in HealthPlaNET Care Management system• Clinical care plan, discharge care plan, follow-up instructions
– Hospital Care• Establish criteria for admission• Admission team: Consistent Care givers: hospitalist team, key
specialists• Compliance to clinical treatment plan, medications, behavior
– Transition to Community Caregivers /Outpatient Care Management
• Communication: – Care Plan in e-record, CM system updated on each admission and
as needed
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Results of FY2010 compared to FY2009 for patients in
Collaborative Care Plan Pilot:
• Number of ED visits 7%
• Number of hospital admissions 40%
• Number of outpatient visits 17%
Collaborative Care Plan
Total Cost of Care 24%
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Complex Care Plan Case Study:Chronic Pain Patient
Outpt Visits
ED Visits
Hospitalizations
0 5 10 15 20 25 30 35 40
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13
5
13
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15
20092010
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• Pharmacy Programs– Drug therapy optimization
• Intelligent Formulary Design• Promote safe, appropriate drug use• Evidence-based algorithms• Promote generic utilization
– Medication therapy management– Provider partnerships
• Pharmacist as virtual team member• Combine algorithms with real life clinical practice
Pharmacy Initiatives
Right Practice- Strong
Administrator
- High Volume/ in P4P
- Generic Utilization
Right Rx Data: Prescribing
Profiles- Provider, Practice and Network Level
- Visual Chart versus Peers
- Correlate to QIRP/P4P
Right Clinical Data: Provider Education
- Objective Clinical Evidence
- Prove Patient Outcomes &/or
Savings
- Patient Education
Provider Partnership Strategy: Rx for Success
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Generic Fill Rates
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63.9
%
67.7
%
73.8
%
68.4
%
72.9
%
76.7
%
79.3
%
62.8
%
66.2
%
68.7
%
74%
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Clinical Management of Oxycontin Improving Quality and Cost
0
100
200
300
400
500
600
700
800900
1000
JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC
Total Prescriptions
2008
Oxycontin vs. Opana -Medicaid Utilization 2008
OXYCONTIN OPANA IR OPANA ER
Nearly $1 million inannual savings and 16%
walk aways
Clinical Management of Designer Narcotics Improving Quality and Cost
• A narcotic painkiller that looks like a lollipop -- designed for quick pain relief to cancer patients.
• Narcotic painkiller Actiq, is ONLY FDA-approved for use in treating cancer pain.
• The Wall Street Journal published these findings in 2006:– Oncologists accounted for only 1 percent of the 187,076 Actiq
prescriptions in the first 6 months of 2006.– More than 80% of patients receiving Actiq had no cancer
diagnosis. – Two children died after confusing the drug for candy.
• 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.
• 2010 UPMC HP: 18 members out of 535,000 lives = 0.0034% of total population.
• Other designer narcotics with potential for abuse are also clinically managed include: Avinza, Kadian and Magnacet
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Over 633 Biologics In Development
• Exploding pipeline - Oncology dominates
• Currently half of all new drug approvals are specialty drugs
• Expanding uses for existing products
• Orals changing the landscape – becoming maintenance therapy
• Management requires Evidence Based Guidelines developed with Clinical Experts.
Specialty Drug Cost Drivers - More Drugs, More Uses, More Patients
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Move to Accountable Care
• Create Value– Defined by common metrics across payer-provider tracking clinical
and financial outcomes
• Position of strength moving forward: – Build sustainable programs that will deliver quality and use
resources efficiently.
• What next?
“Prediction is very hard”
“Especially about the future.”
Yogi Berra
Source: Susan Dentzer, Editor-in-Chief, Health Affairs at the Grand Rounds, Department of Orthopedics, University of Pittsburgh Medical Center, October 21, 2009.
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Thank You40