Bridges To Excellence Rewarding Quality Accelerating IT Adoption in Healthcare

1. Bridges To ExcellenceRewarding QualityAccelerating IT Adoption in Healthcare HIT Summit West San Francisco, CA March 8, 2005 Jeff Hanson, MPH Regional Healthcare Manager, Verizon Communications Board President, Bridges to Excellence

2. AGENDA • Quality Imperative – Employer’s View • Program Structure • Results • Consumer Engagement • Lessons Learned

3. Employer Perspective: “Change is Necessary” • Compelling Stats • 280,000 people will get the wrong advice today in a doctor’s office • 2,800 people will be harmed today by a medication error • Equivalent of 390 fully-loaded 747’s will die this year in the hospital from a preventable medical mistake – >1 747/day • Many of these will be our employees

4. What Problems are we Trying to Solve? • Big Gap Between “What we Know” and “What We Do” • American adults, on average, receive the healthcare recommended for their conditions only 54.9% of the time • Nearly one-third of patients with congestive heart failure are discharged from the hospital without being given ACE inhibitors, even though it’s been known for a decade that these drugs provide life-saving benefits • Translation of medical research into practice is slow—average of 17 years

5. Quality: Missing the Mark Source: NEJM 2003 348:2635-45

6. Employer Perspective – Potential for Cost Savings Time to change focus … without losing sight of reality

7. Employer Perspective: Improved Effectiveness Leads to Cost Savings Greater Effectiveness Healthier Patients Cost Savings Incentives $ Preventive Screening Disease Management Clinical Information Systems Fewer Complications Fewer Medical Errors Reduced Health Care Costs Increased Productivity

8. WASHINGTON - The Bridges to Excellence (BTE) coalition, a group of large employers that collectively support various physician pay-for-performance efforts around the country, today announced its largest bonus payout to date: more than $800,000 to 35 medical groups in the Boston area. The incentive payments reward physician practices that have implemented systems and which leverage available information technology to track and educate patients, maintain medical records, prescribe medicines and ensure appropriate follow up. Such systems have been shown to dramatically improve patient care and prevent mistakes. December 3,2004

9. BTE – What is Bridges To Excellence? • Multi-stakeholder approach to creating incentives for quality • Employers, health plans, consumers, physicians and group practices • Mission: • Improve quality of care through rewards and incentives that • encourage providers to deliver optimal care, and • encourage patients to seek evidence-based care and self-manage their conditions • Focus: • Re-engineer office practices by adopting better systems of care • Demonstrate the reengineering is working through better outcomes for patients with chronic conditions, starting with diabetes and cardio-vascular diseases • Program costs paid by participating employers

10. BTE: Rewarding Outpatient Care • Bridges to Excellence is a program designed to create significant leaps in the quality of care by recognizing and rewarding health care providers who demonstrate that they have implemented comprehensive solutions in the management of patients and deliver safe, timely, effective, efficient, equitable and patient-centered care. • Quality is measured uniformly using nationally accepted standards, collected by an independent third party – NCQA • Quality measures are focused on actuarially sound performance criteria that provide an opportunity for a positive ROI for payers in a fee-for-service environment What we’re after is a significant reengineering in the processes of care.

11. BTE: Overall Concept • Employers Commit • Within Market • Collaboration • Critical Mass • Health Plans • Supply Data • Patient Counts per Physician • Physicians • Notified • Reward Potential • Next Steps • Practices • Apply • NCQA Web site • Application Fees • Practices • Recognized • NCQA • 3-yr • Practices • Rewarded • Rewards Based on Patient Counts • Fees Reimbursed

12. NCQA BTE uses nationally recognized physician recognition programs Structure (PPC): • Patient safety – e-prescribing • Guideline-driven care – EHRs • Focus on high-cost patients – Care coordination • Improved compliance – Patient education & support Process & Outcomes (DPRP & HSRP): • HbA1Cs tested and controlled • LDLs tested and controlled • BP tested and controlled • Eye, Foot and Urine exams • LDLs tested and controlled • BP tested and controlled • Use of aspirin • Smoking cessation advice

13. The process for recognition and rewards is straightforward • Physicians apply for recognition with NCQA • NCQA send notify of physician being recognized to Medstat • Medstat looks up physician/patient attribution by BTE Participant & Invoices for rewards • BTE Participant pays reward to Medstat • Medstat bundles Participant payments and pays physician

14. PPC – HIT Adoption PPC identifies and highlights doctors and medical groups that use information and systems to make patient care better. Patient registries, online prescribing and electronic medical records are among the many processes that may qualify for recognition and, in some cases, rewards.

15. We have three programs that are operational now

16. Physician Office Link (PPC) Measures Summary of Performance Measures Req. % of Patients Achieving Measure Cardiac Care Link Measures # Blood Pressure Testing in last 12 mos 80% Proportion < 140/90 mm Hg 75% LDL <100 mg/dl 50% # Lipid Profiles Done in last 12 mos 80% Patients with aspirin or other antithrombotics use 80% Smoking status & cessation advice 80%

17. BTE Incentives A top scoring practice can earn up to $20K per doc/year

18. The rewards are designed to encourage adoption AND use of better systems • 3 PCP Practice with 1000 patients covered by the program: • 3.5% are diabetic patients • 2.5% are cardiac patients • Practice receives total of $54,800: • $40 * 1000 = $40,000 for meeting PPC measures (POL) • $80 * 60 + $10 * 1000 = $14,800 for meeting DPRP & HSRP measures (DCL & CCL) • Purchaser saves a total of $55,000 less program costs ($6 pmpy)

19. BTE is live in four markets

20. We’ve made great progress in all our pilot markets already

21. Results to Date

22. We’re continuing a rigorous evaluation, but we’ve learned a lot • What we know: • DPRP docs are more efficient, by ~15% when looking at diabetes costs alone, by ~5% when looking at overall costs • What we don’t know: • Are POL docs more efficient? We’re getting the answer from two sources: • Ingenix working with Tufts • CFP since they have aggregated data in MA • Are DPRP docs more efficient over time? We’re also getting the answer from two sources: • Ingenix & CFP

23. And they also have lower costs of care, whether episodes or total costs

24. Why BTE – Employer Perspective Financial • DPRP savings est. 15% or ~$1,000 pppy (medical only) • ROI >10% members see DPRP doctors • Verizon – est. 50,000 diabetic members • 5,000 x $1000 = $5M annual savings (breakeven) • If 50% DPRP, savings = $25M annually (medical only) • If 100% DPRP, savings = $50M annually (medical only) Quality • Quality does not mean higher cost • Realign provider incentives • HIT adoption; implications beyond diabetes

25. Rewarding Active Consumers: CareRewards • Four-step process • Create a profile to establish baseline • Use CareGuide with doctor to set long term goals • Use CareJournal to track progress • Earn CareRewards by answering the self-care questions Employer specific content • Links to: • MD search to find recognized MD’s • Leapfrog Website for hospital safety data • Newsletters, news, clinical trials and additional health info Bridges To Excellence, Proprietary & Confidential

26. Earning and Redeeming Points Rewards Customizable by Employer Bridges To Excellence, Proprietary & Confidential

27. Consumers are also engaged through our physician report card web site • High-level roll-up of physician’s overall performance • Distinguishes relative performance of physicians within each level Bridges To Excellence, Proprietary & Confidential

28. Effectiveness results come from NCQA, patient experience of care from employees Bridges To Excellence, Proprietary & Confidential

29. Lessons Learned/Challenges/Opportunities • Provider report cards are disliked by almost all providers • BTE’s stance has been to tie incentives to public disclosure of performance measures using tested tools • Providers are emphatic that patient incentives be aligned with provider incentives • Having the Diabetes/Cardiac Care Rewards program has been a significant contribution to the positive feedback by providers regarding BTE • Employer communications to employees and other covered members is critical to success of initiatives • But employers need plug & play toolkits to implement the campaigns • Engaging consumers adds complexity to an already complex program • Need to source vendors, create specs and test consumer tools in addition to setting up all processes and operations on provider performance measures and rewards

30. Key lessons learned are applied to all markets to improve performance • Moving docs to reengineer faces numerous barriers – cost, privacy, interoperability – all surmountable • Physician certification process is resource intensive • Getting multiple purchasers to coordinate activities is tough, especially when they are used to plans doing everything for them • You have to be nimble and quick to adapt to succeed in changing the market

31. Program Success Factors • Critical mass re: employer participation (covered lives) in specific markets • Active employer and health plan participation in each market • Prompt execution of data agreements • Buy-in by physician community Bridges To Excellence, Proprietary & Confidential

32. There are 13 additional markets that have actively expressed interest in BTE • 4 UHC markets • 2 Employer specific • 3 BCBS Plans • Remainder – Coalition based BTE Markets BTE Interest

33. Market expansion & strategic alliances • Plan Licensing: • BTE & UHG – initially 10 markets including Omaha, South & Central Florida, St. Louis • CareFirst BCBS rolling out POL 1/18/2005 • CMS: • MCMP demonstration program set to be launched, with first cooperative market being MA • Leapfrog: • BTE & Leapfrog can cooperate to help regional coalitions implement the new Leapfrog Hospital Rewards Program • NBCH: • Currently four coalition members ready to start one or more BTE programs

34. We need to add critical clinical areas every year to get to the bulk of our spend

35. We’re going to continue building programs to cover most specialties • 2005 • 2006 • 2007 PPC version 2.0 + All Docs Patient Experience of Care PCPs (IM, FP, Gyn, Ped, etc.) PCP Recognition Program Endo DPRP Cardio & Neuro HSRP Ortho & Rheum MSK RP Oncologists Cancer RP

36. BTE Summary • Focused on physician care reengineering • Processes of care that are assessed include health information technology (i.e. fully functional & interoperable EHR), patient education and care management • Program launched and operated in four markets. Health information technology being rewarded now in two markets (MA & NY) • NCQA assesses if practices meet the BTE criteria through the PPC program, which is being revised into Version 2.0, adding in MCMP requirements Bridges To Excellence, Proprietary & Confidential

37. Resources • Bridges to Excellence. www.bridgestoexcellence.org • National Committee for Quality Assurance. www.ncqa.org • The MEDSTAT Group. bridgestoexcellence@medstat.com • Web MD.www.webmdhealth.com • National Business Coalition on Health www.nbch.org