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Using Patient Registries and Evidence-Based Guidelines to Overcome Declining Visit Trends

Steve HatkinChief Financial OfficerMankato Clinic

Presentation ObjectivesUnderstand the importance of effective care coordination in improving patient compliance and outcomesIdentify gaps in patient care using registries and evidence-based guidelines Improve profitability while achieving key aspects of population health management

AgendaAbout Mankato ClinicImproving Quality Patients are not receiving recommended care Optimizing the physician-patient relationshipImplementing Proactive Patient OutreachEngaging patients for recommended careImproved compliance to evidence-based guidelinesImpact on Revenue / ROISummary

OverviewAbout Mankato ClinicOne of Minnesota's largest physician owned, multi-specialty regional group practices and represents the most comprehensive array of high-quality, professional health-care services in the area.

121 providersMulti-specialty10 locations

There is solid and convincing evidence in numerous well received studies that quantify the occurrence of patients not receiving recommended care between 45% and 55%!

Even at the low end of the range it represents a potentially enormous problem in terms of outcomes based health improvement initiatives and evaluation of such based on population health methodology, or looked at another way an enormous opportunity to reach out and engage patients to book appointments to get the care that has been recommended to them.4OverviewOur Locations

5OverviewMankato Clinic Excellence 2010 Minnesota Bridges to Excellence award winner by the Buyers Health Care Action Group (BHCAG)

Three-year term of accreditation in Ultrasound as the result of a recent survey by the American College of Radiology (ACR).

Mankato DIAMOND participant (Depression Improvement Across Minnesota), is a new model for treating patients with depression in primary care by taking a team approach. It was developed in 2008 by the Institute of Clinical Systems Improvement (ICSI)

6Background:Patients Are Not Receiving Recommended CareMcGlynn et al The Quality of Health Care Delivered to Adults in the United States NEJM June 26, 2003Health Study by the RAND Corporation (supported by the Robert Wood Johnson Foundation and the Veterans Affairs Health Administration);

New England Journal found only 45% of patients are compliant following their physicians care guidelinesRAND researchers found that patients received 55% of the recommended care.Patients with asthma received about 67% of the care recommended for routine management and only 48% when their condition worsened

7McGlynn et al The Quality of Health Care Delivered to Adults in the United States NEJM June 26, 2003

Background:Patients Are Not Receiving Recommended Care8Research:Quality of Preventive Care for DiabetesEffects of Visit Frequency and Competing DemandsFenton et al Quality of Preventive Care for Diabetes: Effects of visit Frequency and Competing Demands Annals of Family Medicine, Jan/Feb 2006

Patients with low frequency office visits receive substandard preventive care for diabetes

Patients with more frequent visits for low priority illnesses are also likely to receive substandard care because the doctors attention is being spent on that care rather than the quality care for their diabetes.

9Research:Missed Appointments and Poor Glycemic ControlAn Opportunity to Identify High-Risk Diabetic PatientsFrom the Division of Research, Kaiser Permanente, Oakland, California.2004 Andrew J. Karter, PhD, The Division of Research, Kaiser Permanente,Analyzed 84,040 patients that had specific criteria, one outpatient visit, continuous enrollment, medical drug plan, and at least 1 A1C test, using these for the study.

Concluded that those patients who frequently miss appointments for diabetes care had substantially poorer glycemic control

10Research:The Effect of Advanced Access Implementation on Quality of Diabetes CareThe Effect of Advanced Access Implementation on Quality of Diabetes Care; Dr. JoAnn Sperl-Hillen, MD, et all; January 2008Just providing access to diabetics, any physician and convenient locations did not improve diabetes care.

What did improve diabetes care was continuity of care, coming into the office for the visits and being seen by their physician.

The study used a composite of measures for outcomes.

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Solution:Improving Quality Through Automated OutreachIdentify Patients that Need Recommended Care

Motivate Patients to Reconnect with their Providers

Improving Health and Outcomes12Implementing Automated OutreachProactive Protocols Across Several Key AreasAsthmaDiabetesHigh CholesterolHypertension Wellness

13Primary Care Protocol Set*Appointment Reminders/Missed Appointment F/UPrevention/Screening:Annual Preventive Medicine VisitsBreast CancerCervical CancerImmunizations:InfluenzaPneumoniaHPVMammographyOsteoporosisProstate CancerWelcome to Medicare VisitsDisease Management:Congestive Heart Failure:F/U Visit FrequencyACE/ARB/Beta Blocker Therapy Coronary Artery Disease:F/U Visit FrequencyAnti-platelet Therapy ________________________________________*Provided all data-points currently coded. PQRI CPT II Coding Required Non-PMS data point(s) required.

Diabetes:F/U Visit FrequencyHemoglobin A1c Frequency Hemoglobin A1c Level Control Hyperlipidemia:F/U Visit FrequencyLDL-C Frequency LDL-C Level Control Hypertension:F/U Visit FrequencySystolic/Diastolic Frequency Systolic/Diastolic Level Control Asthma:F/U Visit Frequency Appropriate Pharmacologic Therapy Thyroid DiseaseF/U Visit FrequencyCOPDF/U Visit FrequencyPractice Development Campaigns:Back to School Physical ExaminationsTravel ExaminationsChildhood ImmunizationsNew Providers/Services14Methodology OverviewTwo AnalysesHistograms of patient response to Outreach CallsMeasured speed with which patients scheduled billed E&M visits following Phytel Outreach communications.Monthly trends of E&M visits for Outreach subscribers.January 2008 to August 2010.

In the next four slides, well be reviewing outcomes generated by the Outreach program.

There are really two fundamental questions were concerned with:Is Outreach driving a patient response?If so, does that response affect our visit volumes for our providers who utilize the Outreach product.

To better understand the patient response to Outreach, we used histograms.

We analyzed monthly E&M visit volumes to get at the second question.15Patients Respond Fast to OutreachTrend line indicates patients respond quickly to Phytel Outreach by scheduling and then having E&M visits directly related to the call reason.

In the 90-day Histogram, 27% of patients responded within 5 days of the call and 50% within 15 days.This is the first of two histogram slides. It measures how quickly patients respond to Outreach calls by scheduling visits that are billed with codes that are directly related to the call reason. For example, if a patient is called because he or she is in need of treatment related to diabetes, the patient has a visit billed with an ICD-9 code for diabetes.

If there were no response to the Outreach calls, patients would be as likely to have a visit 90 days after the call than they are at 5 days. Their response would look something like the dotted red line, which is flat over the entire time period.

Instead, theres a large volume of appointments booked right after the Outreach call. This histogram measures patient response over a 90-day period. Within 5 days of the call, 27% of the patients book an appointment. That number jumps to almost 50% at 15 days. This means that of all the patients who scheduled an appointment directly related to the call reason within 90 days of the call, 50% of them did so within 15 days.

When you turn on the Outreach product, patients will start calling your office to schedule appointments. 16Outreach Motivates Patients to Reconnect With Their ProvidersPatients additionally respond by scheduling visits where the billing reason is different than the call reason. Trend lines also indicate a fast response for these visits, indicating that Phytel is motivating patients to re-engage with their providers.

This second histogram measures patient response where the visit is ultimately billed for a code that is different than the call reason. For example, the patient was called for hypertension, but instead had a visit related to some other reason.

While the patient response is not as pronounced as it is for visits that are directly related to the call reason, theres still a downward slope. The act of generating a targeted phone call to a patient population drives a residual response as well as a direct response.

The main point of the histogram slides is that Outreach is going to both bring patients back into the office for reasons directly related to the call, and drive a residual effect in which patients are motivated to simply reconnect with their physician.

17Outpatient Visits and Primary Care PhysiciansIn August 2009, Mankato transitioned to a hospitalist model. Formerly, Mankato PCPs spent an hour each day seeing patients in the hospital. Following the change, PCPs had an additional hour each day available for outpatient visits.

[Good place for Steve to add insights into how Mankato operationalized the extra hour of office visit time for PCPs]18Outreach Response Improves E&M Trends

Red bar is start of the initiative to add an extra hour of office visit time.Green bar is start of Phytel Outreach. E&M visits increase by 22% afterward.E&M trends increase significantly after the implementation of Phytel Outreach. This slide trends monthly E&M visits between January of 2008 and August of 2010 for Mankato providers who subscribe to Phytel Outreach.

The red bar indicates the time when the initiative to add an extra hour of office visit time for Mankato PCPs went live. There is an uptick in office visits from August to September, but the most significant change happens after Outreach went live. The average monthly visits in the period from January to August 2010 is 22% higher than the average from August to December 2009.

Notice the big increase in office visits in the spring of 2009. That was the result of the H1N1 pandemic. We actually had to call patients to tell them to stay home. Even with that spike, the average monthly E&M visits in the January to August 2010 time period the time after Outreach went live are still 14% higher than the same time period in 2009. And theyre 22% higher than the same time period in 2008.

This is to say that from our experience there are two pieces to increasing visit capacity. First, operational processes need to support the goal of seeing more patients Mankato addressed this through the initiative to add an extra hour of office visit time for PCPs. And next, a program to proactively bring patients in need of care into the office is important to filling that capacity.

19SummaryOutreach is in alignment with our quality initiativesRelatively effortless implementationImmediate impact on patients in need of careVery quick win with a near term ROIQuestions?21