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Second Generation P4P Community-Wide Diabetes and Asthma Care

Second Generation P4P Community-Wide Diabetes and Asthma Care. Thomas Foels, MD MMM drfoels@independenthealth.com. Agenda. General comments P4P Second generation Independent Health model Results of asthma and diabetes program. Courtesy 2004 MedVantage Survey.

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Second Generation P4P Community-Wide Diabetes and Asthma Care

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  1. Second Generation P4P Community-Wide Diabetes and Asthma Care Thomas Foels, MD MMM drfoels@independenthealth.com

  2. Agenda • General comments P4P • Second generation Independent Health model • Results of asthma and diabetes program

  3. Courtesy 2004 MedVantage Survey Growth of Pay-for-Performance Year 2004 84 programs (39 M lives) Year 2006 160 programs Pioneers Early Majority Late Majority Laggards Aetna Health Partners BCBS-Hi BCBS-Md IHA-WNY Highmark IHA (CA-6 plans) Bridges to Excellence Other healthplans CMS (federal) TPA Medicaid (state)

  4. First Generation Second Generation PCP SCP & PCP HMO PPO, HSA, non-gatekeeper Component Composite (Uni-dimensional) (Multi-dimensional) Secondary Source Primary source (Claims) (Medical record)

  5. First Generation Second Generation Focus on Simple Utilization & Satisfaction Satisfaction, Clinical “Process” (early HEDIS) Clinical “Outcome” (late HEDIS) Hybrid with Efficiency Index

  6. First Generation Second Generation “Social Darwinism” “Social Democrats” • learning objectives • improvement literacy • member-specific profiling

  7. “Improvement Equation” Physician Profiles + Incentives + Improvement Literacy

  8. Practice Excellence Program

  9. 400,000 members 30% market share 2,100 physicians

  10. Chronic Conditions Family Practice / Internal Medicine Diabetes Cardiovascular risk Pediatric Asthma

  11. “Improvement Equation” Physician Profiles + Incentives + Improvement Literacy

  12. Unique features: Profiles Self-directed chart review Physician-specific Sampling, not registry Target “active” patients Composite scoring methodology

  13. Asthma Process Measures Clinical Decision Four components history Correct Severity Severity Assessment Right med for severity Office PFT Review of PFT history Influenza vaccine Action Plan Maximum patient score = 10

  14. Diabetes Process Measures Outcome Measures A1C test #1 and #2 A1C < 7.0 LDL test LDL < 100 BP test BP sys < 130 DRE dia < 80 Lower extremity exam Nephropathy GFR Maximum patient score = 10

  15. CV Risk Process Measures Outcome Measures Family history Smoke history LDL at goal Exercise history HDL at goal BMI BP at goal Established goals Waist circ (NC) Maximum patient score = 10

  16. Independent Health Def populations Random sampling Chart Review 93-97% participation Physician Office

  17. Independent Health Def populations Random sampling Data Analysis Report Generation Chart Review Physician Office

  18. Independent Health Def populations Random sampling Data Analysis Report Generation Chart Review Results Physician Office

  19. “Improvement Equation” Physician Profiles + Incentives + Improvement Literacy

  20. Unique features: Incentives Participation (not Performance) based CME (20 hrs) Board re-certification

  21. Overall $2.40 pmpm Diabetes / asthma $0.70 pmpm CV risk $0.80 pmpm 500 members = $4,200 per component

  22. “Improvement Equation” Physician Profiles + Incentives + Improvement Literacy

  23. Unique features: Improvement Literacy Actionable reporting Interactive web site for data submission Physician account executive (PAE) outreach

  24. 5 Minute Tip Sheet 6 1 3 4 2 5 Incomplete history ? Did you assign a severity rating ? Does your assigned severity match the patient’s clinical history (calculated severity) ? Do all available medications match the patient’s disease severity ? Did the patient receive needed services ? Patients with lowest adherence scores have the greatest need for services and management. 1 2 3 4 5 6

  25. What is Improvement Literacy ? Identify system flaws “bad systems, not bad doctors” Motivation / engagement of physicians and staff Create a culture of mutual learning and discovery Foster idea diffusion / consensus building

  26. Data Analysis and Trends Asthma

  27. Patient's Adherence Scores to Asthma Guidelines Baseline Following Intervention 35% 8%

  28. Variation by Medical Office Site Highest Scoring Office Lowest Scoring Office

  29. Asthma Outcomes 20032004 ER Utilization 3.71 2.92 p<0.01 Hosp rate 0.83 0.81 HEDIS preferred pharmacy age 5-9 74% 81% p<0.05 age 10-17 68% 76% p<0.01

  30. Data Analysis and Trends Diabetes

  31. 5% meet all criteria

  32. Variation by Medical Office Site Highest Scoring Office Lowest Scoring Office

  33. Diabetes Outcomes Seven diabetes HEDIS measures: Statistically significant improvement in 2/3rd (all LOB)

  34. Diabetics with co-morbid conditions (20%) Had higher adherence scores (esp outcome measures)

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