Better care at lower cost - How to set up a quality incentive programme

www.uk.gdit.com/health
Better care at less cost – a ‘how to’
for commissioners & providers
William E. Golden, MD, MACP
Nena Sanchez, MS, PMP
Ben Breeze

Introduction
Ben Breeze
UK Healthcare Director
General Dynamics Health Solutions

Yesterday
Similarreform initiatives over
many years in UK and US
Costs increasing year on year
Need for a ‘self reforming’ system
Incentivising quality, reduce cost
and improve outcomes
GDIT Proprietary3 | www.uk.gdit.com/health
We talked about the ‘WHAT’

Today
Quick recap
How to approach a quality
incentive programme
Setting up and running the
programme
Results
Applying this to the UK
Is about ‘HOW’

Programme Overview
William E. Golden, MD, MACP, Medical Director
Arkansas Department of Human Services
Division of Medical Services

Same challenge
Improving the experience of
care
Improving the health of
populations
Reducing the per capita
costs of healthcare
Triple Aim Five Year Forward View



Care and quality gap
Health and wellbeing gap
Funding and efficiency gap




Similarities of public healthcare
Providers Providers
NHS
England
Wales
Scotland
NI
CCGs
Patients Patients
Everyone
Over 65
Registereddisabled
Children
Low income
State
Medicaid
State
Medicare
Center for Medicare & Medicaid
£
T
a
x
e
s
$
T
a
x
e
s
Department of Health &
Human Services
Department of Health

Perspective: grading a physician’s value

Measure attributes
Reliable
Low Burden
Actionable
FeasibleMeaningful
(importance)

Outcomes & Lessons
Stretch the Providers Who…
Provide Programme Feedback…
That Modifies Requirements/Analytics…
Which Support Practice Transformation…
And Starts New Cycle of Dialogue
Learning System

The need for a ‘self reforming’ system
GDIT Proprietary
Efficiencies at the price of lost
funding or downsizing the
organisation are a ‘hard sell’
Incentivising the right
behaviours does lead to
change, e.g. QOF programme
for UK GPs
Positive change in the clear
interests of the organisation
happens much faster
The financial system must
support clinical priorities, or
at least not be in direct conflict
Rewarding quality leads to
higher quality
11 | www.uk.gdit.com/health

Terminology
Same as episode in the UK, however these were developed as part
of the payment improvement initiative.
GDIT Proprietary12 | www.gdit.com/health
Episode
Medicare
Medicaid
PaP
Payer
PCMH
Provider
Publicly funded care for the over 65s and registered disabled (20%
of overall health spend).
Publicly funded care for those on low incomes (15% of overall health
spend). A high percentage of recipients are children. The Arkansas
Health Care Payment Improvement Initiative focuses on Medicaid.
Primary Accountable Provider, read as Provider.
Insurer (public or private) who funds the treatment being given.
Similar to a CCG or Social Services in the UK.
Patient Centred Medical Home; a delivery model where care is
coordinated by the primary care physician supported by technology.
Same as UK, organisation delivering the care.

Episodes
Episodes have the potential to …
As in the UK, episodes were used to
organise the delivery of care
Avoid complications, reduce errors and redundancy
Deliver coordinated, evidence-basedcare
Focus on high-quality outcomes
Improve patient-focus and experience
Incentivise cost-efficientcare
This new approach
enhanced the existing ‘fee for
service’ model

Pay for results to control costs and improve quality
Eliminate coverage of expensive services, or eligibility
Pass growing costs on to consumers through higher
premiums, deductibles and co-pays (private payers), or
higher taxes (Medicaid)
Intensifypayer intervention in clinical decisions
to manage use of expensive services (e.g. through prior
authorisations) based on prescriptive clinical guidelines
Reducepayment levels for all providers regardless of
their quality of care or efficiency in managing costs
Transition to system that financially rewards value and
patient outcomes and encourages coordinated care





Three domains of care
Patient populations
within scope (examples) Care/paymentmodels
Population-based:
medical homes responsible for
care coordination, rewarded for
quality, utilisation and savings
against total cost of care
Episode-based:
retrospective risk sharing with
one or more providers, rewarded
for quality and savings relative to
benchmark cost per episode
Combination of population-
and episode-based:
health homes responsible
for care coordination; episode-
based payment for supportive
care services
Healthy, at-risk
Chronic
(Diabetes)
Acute medical
(Pneumonia)
Acute procedural
(hip replacement)
Developmental disabilities
Severe and Persistent
mental illness
Acute and
post-acute care
Prevention
screening,
chronic care
Supportive
care

Episodes designed in collaboration with providers
Cliniciansareintegraltotheepisodedesignprocess
Research
around national guidelines
and standards of care
Clinical Advisors
provide inputfor localisationof
practice patternsand informthe
process about the patient
journey
Programmers
and Coders
create algorithmsand logic to
implementdesignelements

How episodes work for patients and providers
seek care
& select
providers as
they do today
submit claims as
they do today
reimburse for all
services as they
do today
Patients seek
and providers
deliver care
exactlyas
today
(performance
period)
Patients CommissionersProviders

Shared savings
Shared costs
No change
Low
High
Individual providers in order from highest to lowest average cost
Acceptable
Commendable
Gain
sharing limit
Pay portion of
excess costs
No change in payment
to providers
Receive additional payment
as shared savings
Quality standards and average costs share in savings
GDIT Proprietary
+
-

Mechanics, Technology &
Data Reporting
Nena Sanchez, MS, PMP
Senior Director of Programs
General Dynamics Health Solutions

Operationalize plan – data-to-episode outputs
InputData
Files
EOC Engine
(ReportCalculations)
Report Engine
(ReportProduction)
Payment
Providers Reports
Call Centre Reports
Statistical Reports
Episode Based Payment System (EBPS)
follows a modular designthat is maintained in such a manner that it will align business, architecture anddata

Providers given tools to measure & improve care
Example of provider reports
Reports provide
performance information
for provider episode(s):
Overview of quality acrossa provider’s
episodes
Overview of cost effectiveness:
how a provider is doing relative to cost
thresholds and relative to other providers
Overview of utilisation and drivers
of a provider’saverage episode cost
6
10,625
433
1,062
1,400
1,251
2,260
944
1,321
1,307
1,237
3,409
3,865
9,492
643
Cost detail – Pharyngitis
Care
category
All providersYou
51%
49%
3%
5%
5%
7%
11%
9%
77%
79%
97%
95%
52%
48%
81
51
59
2,500
3,000
600
500
1,062
179
62
1,400
81
194
69
Medicaid Little Rock Clinic 123456789 July 2012
Total episodes included = 233
Outpatient
professional
Emergency
department
Pharmacy
Outpatient
radiology /
procedures
Outpatient
lab
Outpatient
surgery
Other
89
77
221
184
21
16
12
# and % of episodes
with claims in care
category
Total cost in care
category, $
Average cost per
episode when care
category utilized, $
5
Quality and utilization detail – Pharyngitis
5025
Percentile
Metric You 25th
Metric with a minimum quality requirement
You did not meet the minimum acceptable quality requirements
Metric 25th 50th
50th 75th
You 75th 5025
Percentile
You
Percentile
Percentile
0
0
100
100
Minimum quality requirement
30% 5%
% of episodes that had a strep
test when an anti-biotic was filled
% of episodes with at least one
antibiotic filled
64% 44%
% of episodes with multiple
courses of antibiotics filled
6% 3%
81%
60%
10%
99%
75%
20%
Average number of visits per
episode
1.1 1.31.7 2.3
-
-
-
Quality metrics: Performance compared to provider distribution
Utilization metrics: Performance compared to provider distribution
75
75
4
Summary – Pharyngitis
Quality summary
1823
45
80
292315
100
50
>$115$100-
$115
$85-
$100
$70–
$85
$55–
$70
$40-
$55
$40
You
(adjusted)
20,150
You (non-
adjusted)
25,480
80
60
40
8184
All providersYou
Cost summary
Your total cost overview, $
Distribution of provider average episode cost
Your episode cost distribution
Average cost overview, $
Not acceptableAcceptableCommendableYou
Minimum quality requirement
All providers
Key utilization metrics
Overview
Total episodes: 262 Total episodes included: 233 Total episodes excluded: 29
Does not meet minimum quality requirements
You did not meet the minimum quality requirements Your average cost is acceptable
You are not eligible for gain sharing
 Quality requirements: Not met
 Average episode cost: Acceptable
#episodesCost,$
You All providers
Commendable Not acceptableAcceptable
$0
% episodes with
strep test when
antibiotic filled
48%
Quality metrics – linked to gain sharing
66%
58%
10%
6%
64%
Quality metrics – not linked to gain sharing
% episodes with
multiple courses
of antibiotics filled
% episodes with
at least one
antibiotic filled
1.11.7
30%
64%
Avg number of visits per episode % episodes with antibiotics
Cost of care compared to other providers
You
Percentile
Gain/Risk share
All provider
average
< $70 > $100$70 to $100
3
Upper Respiratory Infection –
Pharyngitis
Quality of service
requirements: Not met
Sinusitis
Average episode cost:
Commendable
Quality of service
requirements: N/A
You are not eligible
for gain sharing
Your gain/risk share
You will receive gain
sharing
Non-specific URI
Not acceptable
Quality of service
requirements: N/A
You are subject to
risk sharing
Perinatal
Acceptable
Quality of service
requirements: Met
You will not receive
gain or risk sharing
Acceptable
Attention Deficit/
Hyperactivity Disorder (ADHD)
Acceptable
Quality of service
requirements: N/A
You will not receive
gain or risk sharing
$0
$x $0
$0
$x
Performance summary (Informational)
* Episode and health home model for adult DD population in development. Tools and reports still to be defined.
Example provider reports

Cost Categories: Provider vs. Peer

Provider portal
Accessible to all providers
– Login with existing username/ password
– New users follow enrollment process detailed
online
Key components of the portal are
to provide a way for providers to:
– Enter additional quality metrics for select
episodes (Hip, Knee, CHF and ADHD with
potential for other episodes in the future)
– Access current and past performance reports
for all payers where designated
Provider Portal
allows providers to enter qualitymetrics for certain episodes and access their provider reports

Example data entry

Provider Report
Displays provider-level reports for each time period that they were sent. Display supports
Health administrators and APII call center staff

Reporting
Reporting
Health Officials and support staff use an application tool to view
provider reports and episode level statistical reports
meet & exceed
informational needs
assist in interactions
with the Health officials and GP
community

Configurable elements
Configurable Elements
Allows approved administrators to update algorithm specific modules
and allows Health officials to perform “what if” analysis by changing values for certain variables
Working example:
 EOC Engine provides ability
to see the impact of
changing acceptable
threshold
 Hip replacement costs
reduced from $12K (£7.8K)
to $10K (£6.5K)
 Reports can be generated to
see the impact of the change

Data system – design feedback loop
RefinepreliminaryEpisode of Care (EOC)
algorithmsby feedbackand investigation
Focusedimprovementbasedon relevantdata and
Businessprocess.
Call Centre Provider
Relations
Data
Research
Provider
Engagement
EOC Refinement Practice Pattern
Goal
Focused
Research
Findings
EOC Refinement
Practice Pattern
Billing Issues
Identified the need for
portal entry of QMs
Length of stay analysis
showed providers with
greater than 3 days due to
C-section births

Now that the programme is established,
it’s time to measure the results.
EOC programme details
Since the initial release of the EOC programe in 2012:
 14 quarterly EOC runs have been completed
 6 payment runs have been completed, including generation of gain/risk
share payments
 The Episode Engine has identified approximately 2,000 PAPs
 The Episode Engine has processedover 456.4m Medicaid claims
and generated over 3.3m episodes
 The Reporting Engine has generated over 26,000 PAP Reports

EOC dashboard
Highlights
 Includes all data for the history of the EOC programme
 Data is presented through various visualisations including:
– Trending graphs (line, bubble, bar, etc.)- provide “clear and actionable” information
– Charts
– Pivot Tables
– State-based Geomapping
 Multiple views to the data in print and export-ready formats
 Drill-down, action-linked functionality for over 60 quality and utilisation metrics
 Data files representing all of the hundreds of thousands of data points presented in the
dashboard are available for download for the purpose of performing ad-hoc analysis on
the data using any desired analytic tool
 Provides detailed documentation explaining all of the measurements, instructions on
using the dashboard, descriptions of changes to the EOCs over time, and other analytic
information in order to fully inform dashboard users

EOC dashboard
Layout
Tab navigation Time period selector
Export
link
Slider to select ranges
for each grouping
Chart type selector
View data in
tabular format

Geomapping
% of episodes excluded by country and quarter

EOC dashboard
Example
Trending: Quality metric results
URI-Nonspecific: Episodes with an antibiotic claim

EOC dashboard
Example
Provider Engagement
PAP Report view counts by day per month and by provider

EOC dashboard
Example
Information: Variety of definitions, user guideand analytic notes
Episode Changes Over Time documentation providesinformationon changes made to the
EOC algorithms to assist with explainingtrends in the data

EOC dashboard
Example
Trending
Gain share, Risk share by quarter (programme level)

Results: Quality of care

Results: Cost savings

UK application
Whatdataisavailablenow?
GDIT Proprietary40 | www.gdit.com/health
Whatlevelofcostingcandifferentiateepisodes?
What data can be extracted
from source systems?
What are your
local priorities?
Whatarethemajorlessonsfromthe
programme?
What opportunities
does the National Tariff System bring?
What are the limitations
of current tariffs/HRGs?

Questions?
William E. Golden, MD, MACP
MedicalDirector
Arkansas Departmentof Human
Services Divisionof MedicalServices
Nena Sanchez,MS,PMP
Senior Directorof Programs
GeneralDynamicsHealthSolutions
GDIT Proprietary
Please rate our workshop using the app!
For more information
Ben Breeze
UK HealthcareDirector
GeneralDynamicsHealthSolutions
Ben.Breeze@gdit.com
www.uk.gdit.com/health

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Better care at lower cost - How to set up a quality incentive programme

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Better care at lower cost - How to set up a quality incentive programme