Community Partnerships in Quality-Based Purchasing

1. Community Partnerships in Quality-Based Purchasing Roy Plaeger-Brockway, MPA Senior Program Manager Health Services Analysis Washington State Labor & Industries Olympia, Washington

2. Objectives • Describe two Washington State pilots • Explain how pilots encourage community based quality improvement • Share results of pilots based on a University of Washington evaluation • Discuss lessons learned

3. Background • L&I is a state workers’ compensation insurer • Purchase $500 million of health care a year • Quality of care is a top priority • To improve care we engaged our customers in designing two community-based quality improvement pilots • Centers of Occupational Health & Education • 700 participating doctors • 20,000 patients a year

4. What was the problem? Difficult for purchaser to influence quality • Doctors with imperfect knowledge about work related conditions • No incentives for physicians to adopt occupational health best practices No infrastructure for community-wide disability prevention • Delivery system not organized to prevent disability • Lack of care coordination • No education or feedback for doctors • No information systems to track clinical data • Not using data for health care quality improvement

5. What was the solution? Develop a community-based infrastructure • Local centers and experts to provide education and support to community physicians • Health services coordinators Align payment incentives to support quality • Enhanced payment linked to quality indicators to encourage use of occupational health best practices Improved work force training • Free CME and individualized physician training and support More effective use of information technology • Patient tracking tool with reminders and alerts

6. Two providers chosen with RFP Inland Northwest Health Services St. Luke’s Rehab Institute Valley Medical Center

7. Community-based modelsupports use of best practices Customer Advisors State Insurer • Education & reminders • Patient tracking tools • Health services coordinators Health System Pilot Community Community • Payment linked to quality indicators Physicians

8. Design of quality measures • Review evidence • Develop seed measures (best practices) • Share with practicing physicians • Rank with physician leaders • Establish payment levels and billing codes • Develop quarterly reporting to track progress on measures based on billing codes

9. Best practices with incentives • Submit accident report within 2 days • Document worker’s physical status and limitations at each visit • Contact the worker’s employer about return to work options • Assess barriers to return to work at 4 weeks of lost time

10. Example of a best practice “Activity Prescription” • Use at patient visit • Script best practices • Document employment issues • Work status • Employer contact • Light duty accommodation • Set patient expectations

11. Increased adoption of best practice Percent of Claims Where Doctors Used Best Practice (Physical Status Form)

12. Evaluation of Western WA COHE • Disability outcomes • Incidence was 17.8% vs. 23.7% for control • Workers on time loss at 6 months was 15.1% vs. 18.9% • Workers on time loss at 12 months was 7.4% vs. 9.4% • Costs • Medical costs were $1,785 per claim vs. $2,167 • Disability costs were $711 per claim vs. $1,209 • Satisfaction • Patient satisfaction was equal to control group • Physicians reported greater willingness to work with injured workers Based on 10,000 claims

13. Evaluation of Eastern WA COHE • Disability outcomes • Incidence was 15.1% vs. 21.5% for control • Workers on time loss at 6 months was 20.5% vs. 20.4% • Workers on time loss at 12 months was 10.2% vs. 9.7% • Costs • Medical costs were $1,643 per claim vs. $2,138 • Disability costs were $610 per claim vs. $930 • Satisfaction • Patient satisfaction was equal to control group • Physicians reported greater willingness to work with injured workers Based on 10,000 claims

14. Overall results University of Washington evaluation shows: • Reduced incidence of disability • Improved patient outcomes • Lower medical and disability costs • High patient satisfaction • Improved physician satisfaction Overall savings • $441 per claim Western WA • $359 per claim Eastern WA

15. Lessons Learned • Community-based partnerships between purchaser and health care leaders help: • Create infrastructure needed to improve quality and outcomes • Foster physician support for solutions by involving local leaders in program design and development • Place responsibility for quality improvement within the local marketplace, which increases adoption

16. Lessons Learned • Physicians are willing and able to adopt best practices and improve quality when they have: • Local institutional support from clinical leaders • Incentives for use of best practices • Health services coordinators • Better information tools and education • Reduced administrative burden • Reminders and academic detailing

17. 2001 IOM Report: Crossing the Quality Chasm - Similarities