P4P Success Story- MN BTE - Global Health Care

P4P Success Story- MN BTE Barry Bershow, M.D. Medical Director Quality & Informatics Fairview Health Services (Minneapolis) [email protected] 612.672.2022 Fairview Health Services 20,000 Employers 7 Hospitals 31 Primary care clinics- 300 physicians 28 Specialty clinics 24 Institute for Athletic Medicine locations 5 Urgent care centers 5 Fairview Hand Center locations 8 Orthotics & prosthetics clinics 8 Fairview Counseling Centers 20 Senior housing facilities 5 long-term care facilities 24 Retail pharmacies Two Level View

1. Influence across the state since 1st awards in 2006 2. Influence within a delivery system Difference in Lake Wobegon State participation starting 2007, both Department of Employee Relations (DOER) and state Medicaid program. Added many lives to BTE and really helped it gather respect and attention Data collection having the trust of the medical community- MNCM Granular level reporting capability due to DDS Skipped right over the POL step due to the penetration of EMRs in the state already Alignment of Initiatives Starting to be agreement around common measures in the state and a common data set to support this. BCBS (with one small exception in 2008) agrees to use the same data definitions as BTE/MNCM

Culture of Quality in the state One group submitted data for diabetes and asked to be reported publicly even though their percentage of patients in optimal control was zero MN not interested in working with NCQA thresholds because we felt they werent high enough Roll-up pass rules are very difficult to achieve, which is why we like them 2007 Health Care Quality Report Presented November 1, 2007 MN Community Measurement Overview Improving health through public reporting A community effort of providers, purchasers and health plans Report results on health care quality measures Provide information for consumers to make better

health care decisions Provide information to help providers improve care Increase efficiency of reporting MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. BTE/MNCM Direct Data Submission Pilot Optimal Diabetes Care measure Bridges to Excellence recognition in June 2007 Posted on Web site in July 2007 Optimal CAD Care measure Data collection complete, validation underway Bridges to Excellence recognition in Dec. 2007 Posted on Web site in Jan. 2008 MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. BTE/MNCM Direct Data Submission Benefits Efficient Aligned methods to meet multiple needs

Useful More representative data Shorter reporting cycle better supports QI cycles & puts reward closer to performance Clinic-level reporting better supports consumer decision-making & brings rewards to those deserving MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. Year in Review Engaging Consumers Example: Enables consumers to compare clinics by geography MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. Methodology Direct Data Submission Medical groups submit data on patient results

using MNCM specifications Data must be submitted on all sites of care, patients attributed to sites by the medical group Samples can be used, but whole populations preferred Results audited by MNCM staff Only model eligible for BTE rewards in 2008 Participating Medical Groups MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. FV Leads state in DM results 2007 DOS revealed at conference Three Year Improvements with Optimal Diabetes Care 25.00% 20.00% 19.60% 18.60%

17.40% 15.81% 15.00% 12.64% 11.13% 10.00% 8.63% 7.53% 6.05% 5.00% 2.97% 0.54% 0.00% 2005 0.00% 2006 Fairview Health Services

Neighborhood Health Care Netw ork MeritCare State Average 2007 Park Nicollet Health Services MN Community Measurement. All rights reserved. May be used by participating medical groups as outlined in the Guidelines for Use Agreement. BTE & other P4P programs redirect organizational culture 2004- Fairview below average in state for diabetes outcomes as reported by Minnesota Community Measurement 2005- average 2006- above average, but in the pack 2007- BTE in place. FV now #1 in state. Named as setting the benchmark in MN for DM care

P4P/BTE Lessons P4P is a powerful tool in producing improved quality outcomes Ongoing P4P continues to improve patient results Withdrawal of P4P leads to erosion of gains Rewards programs redirect conversation towards what really matters. QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. QuickTime and a

decompressor are needed to see this picture. QuickTime and a decompressor are needed to see this picture. Improve the Center- Reduce the Spread Mean Outliers Normalized Curve of Chlamydia Screening Pediatric Patients 2006 & Q3 2007 3.5 key 2006 Q3 2007 3.0

Mean StDev N 15.50 5.853 5 39.02 16.68 6 Frequency 2.5 2.0 1.5 1.0 0.5 0.0 0 10 20 30 40 50 60 70 Percent of Eligible Patients Who Were Screened

Normalized Curve of Chlamydia Screening OBGYN Patients 2006 & Q3 2007 5 key 2006 Q3 2007 Frequency 4 Mean StDev N 81.22 7.107 12 87.74 5.690 13 3 2 1

0 65 70 75 80 85 90 95 100 Percent of Eligible Patients Who Were Screened Diabetes Histogram Fairview Clinics 2006 & Q3 2007 10 key 2006 Q3 2007 Frequency

8 Mean StDev N 0.2196 0.06572 27 0.2719 0.1079 29 6 4 2 0 0.00 0.12 0.24 0.36 0.48 0.60 Percent of Patients Who Acheived All Treatment Goals

Diabetes Histogram (Fairview Clinics = Q3 2007) (Other MN Clinics = 2006 dates of services) 50 Mean StDev N 0.2719 0.1079 29 0.1208 0.06769 163 Frequency 40 30 20 10 0

key Fairview Other MN Clinics 0.0 0.1 0.2 0.3 0.4 0.5 0.6 Percent of Patients Who Acheived All Treatment Goals Diabetes Histogram (Fairview Clinics = Q3 2007) (Other MN Clinics = 2006 dates of services) Frequency Minnesota 50th Percentile 10

0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 Percent of Patients Who Acheived All Treatment Goals key Fairview Mean StDev N 0.2719 0.1079 29 0.1208 0.06769 163 There is still room to improveUnwarranted variation (ala Jack Wennberg) exists Diabetes Management Fairview Family Practice, I nternal Medicine, and I M/Peds Providers

3rd Quarter 2007 (Patients Seen J uly 1 to Sept 30) Cedar Ridge Chisago Crosstown Eagan Eden Center Elk River Hiawatha Highland Park Hugo Jonathan Lakeville Lino Maple Grove Milaca Northbranch Northeast Oxboro Princeton FP Princeton I M Ridges RidgeValley Rush City

Uptown Wyoming FP Wyoming I M Zimmerman Zimmerman I M 0 Patients = 5,921 Providers = 151 Overall Score = 28.6 5 10 15 20 25 30 Median = 26.3 35

40 45 50 55 60 65 Targets: Baseline = 22.8, Max = 38.8 70 % Patients with Diabetes Optimally Managed Samples with < 10 patients are not displayed Composite Cancer Screening Fairview OB/GYN Providers 2007 YTD October # Providers = 28 # Patients = 12,610 Overall Score = 84.7 Targets: Baseline = 80.0, Maximum = 92.0 Median = 86.9 CM MW CM OB

Lakes OB Northland OB SW&MV OB 75 78 81 84 87 90 93 % Patients Up to Date for Cancer Screening 96 Childhood Immunizations

Fairview Pediatric Providers 2007 YTD September # Patients = 1,323 # Providers = 25 Overall Score = 73.2 Targets: Baseline = 72.0, Maximum = 94.8 Median = 76.2 Elk River Peds Fairview Childrens Hugo Peds Lino Peds Oxboro Peds Ridges Peds Wyoming Peds 32 40 48

56 64 72 80 % Patients Up to Date on Immunizations by 2nd Birthday Fairview Ambulatory Clinical Quality Initiative Results Asthma - FP/IM/IMPEDS 2005 2006 2007 1Q 2007 2Q 2007 3Q 100.0%

92.3% % Patients with Asthma Managed 91% 90.0% 87% 85.7% 83% 83.8% 83% 80.0% 88% 87%

81.2% 81% 78.9% 77% 75% 73% 70.8% 70.0% 67% 66% 61.6% 60.0% 52% 50.0%

Central Metro Southwest Minnesota Northland Metro Valley Lakes Maple Grove Total Fairview Ambulatory Clinical Quality Initiative Results Chlamydia Screening - FP/IM/IMPEDS 2007 1Q 2007 2Q 2007 3Q 80.0% % Patients Screened

70.0% 60.0% 53.9% 50.0% 44.9% 45.0% 42% 45% 40% 40.0% 41.5% 40.8% 36% 39%

32% 30.8% 30.0% 44.3% 26% 20.0% 10.0% Central Metro Southwest Metro Minnesota Valley Northland

Lakes Maple Grove Total Fairview Ambulatory Clinical Quality Initiative Results Composite Cancer Screening - FP/IM/IMPEDS 2006 2007 1Q 2007 2Q 2007 3Q 80.0% 2007 Maximum Threshold = 72% % Patients Screened 70.0% 58.1% 60.0% 57.4% 55.2%

58.6% 55.6% 50.8% 50.0% 47% 46% 47% 44% 43% 40.0% 38% 36.1% 30.0% 24%

20.0% 10.0% Central Metro Southwest Metro Minnesota Valley Northland Lakes Maple Grove Total Fairview Ambulatory Clinical Quality Initiative Results Diabetes Management

% Patients with Diabetes Managed (7 criteria) 2006 2007 1Q 2007 2Q 2007 3Q 40.0% 35.0% 33.4% 30.0% 2007 Maximum Threshold = 38.8% 33.9% 28.6% 26.8%26%

25.0% 26.6% 22% 20.0% 18% 20% 20.0% 15% 17% 15.0% 13% 14.3%

10.0% 5.0% 0.0% Central Metro Southwest Minnesota Northland Metro Valley Lakes Maple Grove Total Fairview Ambulatory Clinical Quality Initiative Results Problem List - FP/IM/IMPEDS % Patients with Complete Problem List 2006

100.0% 95.0% 90.0% 2007 1Q 2007 2Q 2007 3Q 98% 98% 97% 96% 95% 92.7% 93.4%

97% 93.3% 94% 91.3% 89.7% 87.0% 85.0% 80.1% 80.0% 75.0% 70.0% Central Metro Southwest Minnesota Northland Metro Valley Lakes

Maple Grove Total 0% Total MG RG FP MG PY FP MG MC FP MG BL FP WY IM WY FP RC NB

LL HU CL ZMC IM/PED 40% ZMC PMC IM 2Q 2007 PMC FP MMC IM 2007 1Q

MMC FP EMC FP RI 2006 RV LV EAG CR OX JN EC CS

UP NE HP HW % Patients with Diabetes Managed (7 criteria) Fairview Ambulatory Clinical Quality Initiative Results Diabetes Management 3Q 2007 60% 50% Maximum Threshold = 38.8% 30%

20% 10% Fairview Ambulatory Clinical Quality Initiative Results Chlamydia Screening- OB/GYN 2006 2007 1Q 100.0% 2007 2Q 2007 3Q Maximum Threshold = 91.7% 95.0% 93.3% 90.0%

87.8% 87.7% % Patients Screened 85.5% 85.0% 80.0% 85% 83% 81.4% 80% 77% 75.0% 70.0% 66%

65.0% 60.0% 55.0% 50.0% Central Metro SW/MV Northland Lakes ALL OB/GYN Francois de Brantes Minnesota is doing it better than everywhere else. Were going to throw out those programs and change them to the MN model. Conclusions 1. P4P works if reward is high enough to get physicians attention

2. P4P outcomes lag if reward is withdrawn and refocused elsewhere before it is hard-wired into system 3. Having enough patients enrolled helps create a large enough critical mass, so state participation in MN was vital Conclusions, continued A trusted joint steering committee of clinicians, employers and health plans (BTE steering committee in our state) is critical in getting buy-in and promoting understanding of viewpoints and hurdles A trusted jointly operated measurement group (MNCM in our state) promotes confidence in data & suppresses noise about all that is wrong with P4P Direct data submission via electronic records fits in well with Dr. Bershows porpoise theory Rapid cycle feedback to providers is key in helping them understand where to improve. Therefore EMRs are part of the solution, not something to be rewarded in & of themselves Projections into the future

After a time, your high performers will reach an asymptote. Getting better outcomes after that requires system changes to move the laggards Redesign of compensation models will need to be made to extend concept of P4P out to the capillaries (R4R in our state) Further alignment of health plans P4P with BTE (& MNCM in our state) will increase signal strength and magnify improvement

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