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Oregon Health Leadership Council: High Value Patient Centered Care Model The Clinical Performance Improvement Network


September 19, 2012 Oregon Health Leadership Council: High Value Patient Centered Care Model The Clinical Performance Improvement Network Denise L. Honzel – PowerPoint PPT presentation

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Title: Oregon Health Leadership Council: High Value Patient Centered Care Model The Clinical Performance Improvement Network

Oregon Health Leadership CouncilHigh Value
Patient Centered Care ModelThe Clinical
Performance Improvement Network
September 19, 2012
  • Denise L. Honzel
  • Executive Director

Oregon Health Leadership Council--History
  • Commissioned by the business community in the
    summer of 2008
  • PurposeDevelop solutions and actions to keep
    health care costs and premium increases closer to
    the CPI
  • Incorporated as a 501(c) 6, statewide membership
    organization in 2010
  • 14 member Board of Directors
  • 29 Council members 7 major medical groups 8
    hospitals/health systems 12 local/national
    health plans Oregon Assoc. of Hospitals and
    Health System and Oregon Medical Assoc.
  • Director of Oregon Health Authority (ex-officio)
  • Quarterly reporting back to the business

Areas of focus for the Council
  • Initially, four committees to oversee work
  • Value Based Benefits
  • Evidence Based Best Practicehigh cost imaging
    low back pain elective deliveries before 39
  • Administration Simplificationsingle sign on
    standardized EDI for claims, eligibility best
    practicesplan websites, pre-authorization,
  • Reimbursement and Payment Reformmedical home
  • In 2011 began work on a major effort focused on
    re-designing care delivery and financing for the
    Medicaid and uninsured populations--now moving
    forward as Community Care Organizations (CCOs)

High Value Patient Centered Care
  • In early 2009, the Payment Reform group
    recommends a multi-payer medical home
    initiative focused on high risk adult population
  • Reviewed the successful model of Boeing that
    delivered lower costs (up to 20), higher quality
    and patient satisfaction, improved employee
    productivity with results beginning within 12
  • In fall of 2009, hired Dr. Pranav Kothari,
    Renaissance Health with a goal to launch the
    initiative within a year, learn along the way
  • Convened medical group and health plan advisory
    committees to develop the care and financing

Hypothesis Care Model and Outcomes
  • Focus on the to 10 highest risk patients
  • Intensive care management with RN Care Manager in
    the medical office, following a defined care
    model would produce the greatest impact on
  • At the end of the 2 year demonstration, results
    would show
  • Lower overall costs compared to a matched control
    group with reduced ED visits, reduced inpatient
    admits/days and initial increase in PCP visits
  • High quality health outcomes, high levels or
    member and provider experience

Hypothesis Process Needs
  • Multiple payers to get the size
  • Common model of care
  • Common payment model and standard contract for
    all plans to use
  • Committed medical groups
  • Scientific approach to the evaluation
  • Collective funding to support infrastructure
  • Common set of health plans policies and practices
    to implement

Common Care Model Components
  • Access
  • Dedicated care manager for each patient
  • 24/7 access for urgent care
  • Access to care team via email/phone
  • Facilitate access for non-MD services, integrated
  • Care Delivery Elements
  • Rules-based, care planning and management
  • Intentional, integrated care coordination
  • Recognition of social and behavioral health needs
  • Information
  • EHR, registries, quarterly feedback for the team
  • Movement towards broader data transparency

Common Care Model Components
  • Coordination
  • Care transition management (post ED, hospital)
  • Medical neighborhood of specialists, service
  • Care giver and social support systems
  • Intensive Care Management
  • Motivational interviewing, readiness assessment
  • Team based pre-visit planning, systematic Rx
  • Team huddles, group visits
  • Advanced directives, end-of-life care programs
  • StaffingRN as a team lead with support from the
    care team one RN for 200 patients enrolled

Consistent Payment Approach
  • All payers use the same methodology same
  • Upfront PMPM for participating patients to pay
    for the RN care coordinator
  • Standard fee-for-service for medical care
  • Shared savings between the medical groups and
    payers for achieving savings and quality metrics,
    paid at the end of the demonstration
  • Quality measuresmaintain or improve and achieve
    Quality Compass at 50th percentile for diabetes,
    hypertension, cholesterol management measures
    patient satisfaction administer pre, post
  • Cost savings50 share up to specified limit
    based on difference over difference of
    intervention group vs. tightly matched control

Rolling Out the Demonstration
  • Early 2010, 8 health plans and state expressed
  • Plans identified 25 medical groups statewide that
    they felt could deliver on the model
  • OHLC issued an RFP
  • Staff interviewed each group
  • Fourteen medical groups selected a 15th group
    met qualifications except not the volume needed
  • Due to volume or challenges with data, 5 health
    plans and state agree to move forward

Medical Groups Selected

Adventist (Portland) High Lakes (Bend)
Legacy (NW Port./Tualatin Medford Medical (Medford)
NW Primary Care (Portland) No. Bend Med. Ctr. (Coos Bay)
OHSU (Portland) Oregon Med. Group (Eugene)
PeaceHealth (Eugene) Portland Clinic (Portland)
Portland Family Practice (Portland) Providence (Portland/Newberg)
Tuality (Hillsboro) Westside Internal Medicine (Beaverton)
Health Plans and State Groups
Health Net ODS
PacificSource Providence
Regence PEBB (State employees)
OEBB (School employees) OMIP (High risk pool)
DMAP (Medicaid FFS)
  • July 2010, each health plan began negotiating
    with each medical group30 day target, finished
    within 45 days
  • During that time, plans began identifying
    patients to be invited into the demonstration,
    using plan predictive risk models
  • Top 10-15 highest risk adult patients
  • All complex and chronic included
  • Asked plans to exclude patients with ESRD,
    transplants, OB, Trauma with no other co-mordity
  • In September 2010, medical groups hired 23 RNs
  • In October 2010, 23 RNs participate in a four
    day training

  • Beginning October 1, 2010, using the lists
    provided by the plan, nurses start to invite
    patients to participate-- original goal to have
    all enrolled by end of December, extended until
    early March 2011
  • Intake visits and care plans completed early in
  • Baseline quality measures for each patient
  • LDLs, A1c and blood pressure reported
  • Patient satisfaction surveys (modified national
    survey) completed
  • Early 2011, began quarterly meetings on the
    medical group and health plan project managers
    and care managers

Where we are now
  • 3,600 patients voluntarily enrolled
  • In July 2011 began, reporting quarterly
    utilization reports to medical groups, from
    claims data
  • ED of visits, avoidable rates, diagnosis, by
    day of week, by member
  • Inpatient of admissions, by DRG,
    discharge/admission day of week, by member, LOS
  • Rx Drugs filled, Imaging, Lab
  • Working with Oregon HealthCare Quality Corp and
    Milliman to refine the medical group reporting
  • Producing summary utilization reports for OHLC
    and demonstration participants

Where we are now
  • Additional 1.5 day training for the care managers
    in Sept. 2011
  • Agreed to extend the program through Feb. 2013 to
    allow for input from physicians on patient
    selection minimize churning
  • Second enrollment period occurred Jan.-March 2012
    to address attrition
  • Plans provided new lists nurses more selective
    in choosing those to invite
  • Contracted with Dr. John McConnell, OHSU for the
    shared cost savings evaluation Dr. Meredith
    Rosenthal, Harvard University, Dr. Kothari,
    Renaissance Health will be advisors.
  • In February 2012, weekly Office Hours with care
  • Working on a sustainable model, post

Results to date
  • While promising, its too early to make
    conclusions not comparing to a control group,
    some enrollment data need reconciliation
  • Looking at utilization data through March 2012,
    compared to the pre-intervention time period, we
    are seeing
  • Downward trends in emergency room visits,
    inpatient admits and inpatient days/1000
  • Office visits for primary and specialty care
    initially stayed flat or increased slightly then
    decreased (phone/email not included
  • Reduced use of RX for chronic conditions
  • Slight downward trends in imaging
  • Final cost savings wont be available until the
    end of the demonstration and analysisfall 2013

Learnings Medical Group-Plan Partnership
  • Medical groups and Plans able to move beyond
    contracts and work creatively togetherfor data,
    care delivery
  • Medical groups and Plans appreciate personal
    interactions, in person meetings
  • Medical groups appreciate requests for input
  • Communication beyond direct participants involved
    has been uneven for all parties sometimes leading
    to confusion, complications and eroding
  • Medical groups and Plans challenged to manage new
    billing processes
  • Study design (control group, enrollment, etc)
    limits real-time adjustments to care model and
    patient selection

Learnings Data Transparency/Exchange
  • Exchanging accurate, timely data between plans
    and medical groups can impact care decisionsneed
    timely ED and hospital admit/discharge data
  • Challenge in the data exchange accuracy, timing,
    capabilities to manage/use data
  • Risk models are a good starting point to
    identifying risk need mechanisms to include
    clinical intelligence not all the right
  • Attribution capabilities uneven
  • Need for more real-time assessment of
    progressclaims lag not suited for dynamic

Learnings Medical Group Culture/Readiness
  • Some medical groups fully engaged others less so
    difference in readiness not small vs. large
    group, but cultural
  • Front-line MD compensations still almost entirely
    productivity based these efforts largely
    perceived as noise by physicians
  • Physicians appreciate care manager support,
    especially after seeing patient improvement
  • Support for care managers varies, depending on
    clinic buy in

Learnings Care Model
  • Patients appreciate care management from their MD
    team very high engagement when advocated by PCP,
    well-accepted by clinic
  • Non-visit based care (especially email) critical
    to serving this population needs and for care
    manager panel management
  • Early, regular communication with patients
    surface unique needs
  • Initial intake assessments yielded deep patient
    discussions, revelations around barriers
    although difficult to schedule
  • Workforce needs skill building to engage patients
  • Health Plan disease management can be helpful
    partner with medical group care management
  • Gap around education resources for patients,
    behavioral health, pharmacy, community resources

Next Steps
  • As demonstration continues, further work on the
    processes to support the model of care
  • Continue collaboratives to share best practices
    and learning's
  • Complete work on a sustainable model for the long
    term - care model, roles/responsibilities,
    reimbursement models
  • Measure results

For further information
  • Denise Honzel, Oregon Health Leadership Council
  • Denise_at_orhealthleadershipcouncil.org
  • Dr. Pranav Kothari, Renaissance Health
  • pk_at_renhealth.net
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