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The Cost-Quality Connection in Southeast Michigan

The Cost-Quality Connection in Southeast Michigan. A Call for Consistency in Performance-Based Differential Reimbursement. John E. Billi, MD University of Michigan jbilli@umich.edu June 2004, GDAHC Annual Meeting. Relationships Among Cost, Quality, and Safety.

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The Cost-Quality Connection in Southeast Michigan

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  1. The Cost-Quality Connection in Southeast Michigan A Call for Consistency in Performance-Based Differential Reimbursement John E. Billi, MD University of Michigan jbilli@umich.edu June 2004, GDAHC Annual Meeting

  2. Relationships Among Cost, Quality, and Safety • Poor quality and safety problems increase costs: • complications, hospital acquired infections, longer LOS, extra ER visits, re-admissions, re-operations, extra office visits, extra drugs • Problems in cost, quality, & safety have similar root causes. • One cause is inappropriate variation in clinical practice (clinicians, pharmacists, hospitals…) • Problems in cost, quality, & safety have similar a solution: evidence-based medicine • eliminate variation through evidence-based practice guidelines nested in a continuous quality improvement model. • Can help underuse, overuse, and misuse • In Lean language, it is the endless pursuit of waste and its transformation into value for patients and those who fund care

  3. A Brief History of Performance Based Contracting in Southeast Michigan • None • Several • Many • ?Too many • Variable diseases • Variable guidelines and measures • Variable financial impact • Need to move to one coordinated model: performance-based differential reimbursement

  4. IOM: Crossing the Quality Chasm • Agenda for Redesigning 21st Century Healthcare System • All constituencies commit: • Policymakers, purchasers, regulators, health professionals, trustees, management, consumers, educators • HHS identify first priority conditions and provide resources to stimulate change • Organizations support change • Constituents foster and reward improvement • Create infrastructure to support evidence-based medicine • Facilitate use of information technology • Align payment incentives • Prepare workforce

  5. Challenges to Community-Wide Quality Improvement • Dueling Guidelines: from payers & national orgs. • Dueling Profiles: from many payers • Dueling QI Interventions: payers, MPRO, group practices, health systems • Dueling Formularies: payers/PBMs, employers, Caid • Disease of the Month: new QI initiatives every month distract physicians, hospitals, systems • Limits of claims data: my patients are different • Dueling incentive programs, each without critical mass – easier to ignore than to develop systems to comply

  6. Current State of Performance-based Differential Reimbursement • Medicaid: Qualified Health Plan incentives • Medicare Hospital Incentive Program • BCBSM • Hospital Incentive Program • Multihospital QI programs • BMC2 - percutaneous coronary intervention • Pharmacy incentive program • Physician Group Incentive Program • NBCH RFI for Health Plans • Health Plan-specific incentives • DM, asthma, immunizations, lead levels, beta blockers, • MCARE, HAP, Care Choices, HPM… some overlap, many differences • CMS Medicare Demonstration and Pilot Projects

  7. A Prototype for Performance-Based Differential Reimbursement • Blue Cross of Michigan Cardiac Consortium (BMC2) • Multihospital, evidence-based, data driven QI • Funded through BCBSM PPO hospital payments • All cath lab data collected reliably and accurately • Analyzed, blinded, reviewed together by cath lab heads • Interventions and re-measurement • Most common complication from cath was reduced – no longer the most common! • More clinical conditions can be managed this way • Breast, CABG, surgery quality…

  8. Coordinated Quality Improvement • Employers, payers, hospitals and physicians agree to pursue • Common diseases (MI, diabetes) • Common evidence-based guidelines (GAP, NQF, MQIC) • Common metrics (beta blocker, retinal screening) • Common measurement process (claims, definitions…) • Common all-payer profiles • Actionable, doctor-specific, patient-specific reports • Coordinated quality improvement efforts (MQIC, MPRO) • Consistent differential reimbursement for measurement and performance – for the same diseases and metrics • Physicians and hospitals can focus to do it once, right!

  9. Next steps • GDAHC endorse the Future Directions Initiative • Employers and health plans commit to back: • coordinated quality improvement • coordinated incentive programs • Employers, insurers, hospitals and physicians agree on medical conditions, guidelines, measures, and overall incentive model • Invite other stakeholders (Medicaid, State, Medicare) • Add/emphasize appropriateness, not just quality

  10. Quality Initiatives in SEM - The Panel • Tom Simmer, MD, BCBSM • Greg Pane, MD, HFHS • Edward Working, Detroit Regional Chamber • Discussion

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