incenting quality improvement across 150 canadian (ontario) … · 2011-03-21 · incenting quality...

Large Scale P4PLarge Scale P4PIncenting Quality Improvement Across 150 Canadian (Ontario) Hospitals

. 1 .

Introductions

Joshua Lawson

•

Partner at SECOR Consulting

•

Head of the Health and Life Sciences practice

Joshua Lawson

•


•

Head of the Health and Life Sciences practice

Jonah Peranson

•

Manager at SECOR Consulting

Jonah Peranson

•


. 2 .

Vancouver

New York

MontréalToronto Paris

Québec

About SECOR

Over 35 years of experience advising companiesSECOR has become the largest international strategy boutique in Canada

Why SECOR?We integrate the organizational reality of companies and institutions into the development of action plans in order to help our clients achieve high performance.

A unique approach recognized for its impact on the growth and performance of our clients

1975

Montreal

1997

Paris

2000

Toronto

2010

Vancouver

Offices from Montreal to Vancouver, and New York, SECOR has grown significantly

2007

New York

. 3 .

Objectives

To discuss the use, design and implementation of a large-scale P4P

initiative in the Canadian context

To discuss the use, design and implementation of a large-scale P4P

initiative in the Canadian context

. 4 .

Agenda

The Context Brief overview of the Ontario health system

The Issue Hospital inpatient care

The Design Process and strategy for P4P program design

The Program Elements, results and evaluation of the program

. 5 .

Government Health Expenditures $50.2 billion

Patients 12.5 million

Physicians 24,000

Hospitals 170+

Hospital Discharges 1 million

Emergency Department Visits 5 million

Ontario OverviewOntario can be considered to one of the largest HMOs

in the

world

Source: MOHLTC, CIHI NHEX, 2010

. 6 .

Health Spending in Ontario

Total Health Spending$74.7 billion

Private Sector32.6%

Provincial Government62.8%

•

Vision Care•

Dental

•

Drugs (not seniors)•

Alternative medicine

•

Some long term care and home care

•

Physicians

•

Hospitals

•

Regional Health Authorities

Other Public Sector4.4%

•

Municipal

•

Federal Direct

•

Workers Comp

Source: CIHI NHEX, 2010

Roughly 70% of total health spending comes from public sources and this ratio has been steady over time

. 7 .

System Structure and AccountabilityOntarians receive universal health care coverage, delivered by independent institutions and providers in 14 regions

Provincial governments are strictly funders of the health care system

Each of the 14 planning regions has its own board of directors

Each of the 170+ hospitals has its own board of directors

The 24,000 physicians participate in the corporate practice of medicine – they are not “employees”

. 8 .

Physician Payment Models

General Practitioner/Family Physician

48%73%

Medical specialist

42%58%

Surgical specialist

62%82%

20071990

Source: 1990 to 2002 CMA Physician Resource Questionnaire; 2004 & 2007 National Physician Survey (CFPC, CMA, RCPSC)

In Ontario, 65% have blended capitation and many participate in Preventative Care Management P4P incentives

Also from salary, sessionals and service contracts

There is a mixed bag of payment models, with FFS still quite prevalent

Percent of Canadian physicians remunerated 90%+ by fee-for-service

. 9 .

Agenda





. 10 .

Every patient admitted to an Ontario hospital has a MRP

Physicians of any specialty with hospital privileges can be a MRP

MRPs play a key coordinating role of patient care in the hospital

Hospital Inpatient P4PThe Ontario government established a P4P incentive to improve the performance of Most Responsible Physician care in the hospital

Day 1

Illustrative example of patient stay in hospital

• Care Management• Bedside Care• Quality and System Improvement• Patient education, and other activities

MRP

Episode of Hospital Care

Consultant

• Diagnoses• Procedures• Other activities

Patient

Admission Day 3Day 1 Day n DischargeDay 2

. 11 .

Opportunity for ImprovementThe motivation for the P4P program was a realization that a small number of patients were using a huge proportion of system resources

69%69%72%73%74%77%77%77%78%78%81%81%84%85%

Planning Area

Average

NMLKJIHGFEDCBA

Source: DAD 2006/07 M7, Secor Analysis

These patients were 'stuck' in hospital because of a lack of coordinated care and they were contributing to ED wait times

Percentage of Alternate Level of Care Bed-days Occupied by High-needs Inpatients

. 12 .

Key Characteristics High-needs Inpatients

Non High-needs Inpatients

Age 75+ 53% 24%

Unattached to Primary Care Physician 52% 29%

MH/Add. co-morbidity 27% 7%

Medical diagnosis 70% 59%

As a group, these high-needs inpatients need general medical, non-specialized, coordinated care

High-needs Inpatient Characteristics

Source: DAD 2006/07 M7, Secor Analysis

. 13 .

By realizing small improvements in the utilization by high-needs inpatients, we free up resources for other patients

Reduction in Avg Bed Days for High-needs

Inpatients

Adjusted Avg LOS for High-

needs Inpatients

Freed Inpatient Days

# of Non High-needs Inpatients

(Assuming 6.3 Days per Patient)

0% 72.9 0 05% 69.3 5,104 809

10% 65.6 10,209 1,61915% 62.0 15,313 2,428

Reducing bed days used for high-needs

inpatients…

…results in freeing up beds for… …other patients

ILLUSTRATIVE

Potential Benefits

. 14 .

Agenda





. 15 .

P4P Framework

MeasuresQuality■Structure and

Infrastructure■Process and

management■Outcomes

Efficiency■Productivity■Cost savings

Basis for RewardMeasurement method■Absolute level of

measure■Change in measure■Relative ranking

RewardFinancial■Bonus payment

Non-financial■Publicize measures

and rankings

We approached the P4P design using the following framework

Source: Adapted from Dr. Richard Scheffler, UC Berkeley, 2010

. 16 .

The Ontario Government negotiated a $33 million P4P platform for MRP care with the Ontario Medical Association

MRP P4P Fund

An Expert Panel of hospital executives, physicians and researchers was established to make recommendations for implementing the fund

Measures –Key indicators: average length of stay, “may not require hospitalization”

rates, and readmission rates

–Effective management

of hospital inpatientsKey Terms of P4P Platform

–

$33 million of funding over 2 yearsReward

Basis for Reward –Paid to MRP Physician Groups

to meet targets 3

1

2

Source: 2008 Ontario Physician Services Agreement

. 17 .

Effective ManagementInstituting programmatic MRP care can improve efficiency without

negatively impacting health outcomes

5043

4032

29 291

847

Provider Satisfaction

Patient SatisfactionMortality

Readmission Rate

Length of Stay

Hospital Cost

000275

Improvement

No Change

Deterioration

*All studies not accounted for in the table above had either had inconclusive or no data for the relevant category

Operational Clinical Experiential

Num

ber of Studies*

57 peer-reviewed studies on effective inpatient care were analyzed

1

Source: SECOR analysis

Evaluative Framework

. 18 .

Effective Management - BenchmarkingBenchmarking was conducted to identify the state of programmatic

MRP care across Ontario

Service DeliveryGovernance Performance

The degree programmatic was evaluated across three dimensions: governance, service delivery and performance

WorkloadCoverageScope of practiceIntegration

Compensation and incentivesReview processesQuality improvement

Org structureLeadershipRoles and responsibilities

1

. 19 .

1 2 2

2

11

3 2 2

3

2 2

3 3

4

3 3

11

1

Hospital

Performance andIncentives (out of 4)

Service Delivery(out of 4)

Governance(out of 5)

20

12

4

5

19

11

4

4

18

9

1

4

17

9

3

3

16

9

3

3

15

8

2

4

14

7

2

3

13

7

3

1

12

7

1

4

11

6

1

3

10

6

3

9

6

2

3

8

6

1

4

7

6

2

2

6

32

5

31

4

31

3

3

1

1

2

21

1

2

1

Effective Management - FindingsThe benchmarking showed a substantial amount of variability in the state of programmatic care across Ontario

1

Source: MOHLTC

Results of Programmatic Care Benchmarking (out of 13)

. 20 .

Key IndicatorsGiven the variability and short time horizon, realizing progress

on

small needle metrics was more likely than on big needle metrics

ED Wait Times for Admitted Patients

Length of Stay

Readmission Rates

Patient Satisfaction

PerformanceMetrics



Length of StayLength of Stay

Readmission Rates

Readmission Rates



PerformanceMetrics

←Timely medical reconciliation

←Lack of coordination ←Lack of skills

←Cognitive←Financial←Social

←Risk assessment←Lack of optimal care paths←Lack of benchmarks

←Accurate←Timely

←Standardized←Complete

Example Small Needle Metrics for Readmission Rates

MRP P4P Big Needle Metrics

Population Mgmt

Information Mgmt

Care Mgmt Patient Self- Mgmt

2

. 21 .

A volume measure was used to define physician eligibility for groups

Number of MRP services

Num

ber o

f P

hysi

cian

s

Source: CHDB 2007/08 M7, Secor Analysis

1 to 249 250 to499

500 to749

750 to999

1,000 to 1,249

1,250 to 1,499

1,500 to 1,749

1,750 to 1,999

2,000 or more

0

500

1000

1500

2000

2500

8%20%

33%

46%54%

61% 66% 71%

100%

0%

50%

100%

Cum

ulative D

istribution of M

RP

Services

Defining MRP Groups

Using an eligibility criteria helped define terms of governance for MRP groups and increase average payout from the fund

BAR GPBAR SurgeryBAR OtherBAR General Internal MedicineBAR Other Internists

LEGEND

BAR Paediatrics

BAR GPBAR SurgeryBAR OtherBAR General Internal MedicineBAR Other Internists

LEGEND

BAR Paediatrics

3

EligibilityILLUSTRATIVE Distribution of MRP Service Volume

. 22 .

Key Principles for MRP P4P DesignThe MRP Expert Panel provided the following advice on the design

of the P4P program

A one size fits all approach will not work

for the P4P design

Try to achieve progress on small-needle metrics

Give local groups the flexibility

Performance metrics should align to areas that are within the physicians’control

Advice of MRP Expert Panel

Use volume targets to define eligibility and

funding levels at each hospital

Total funding to each group should proportional to the volume of MRP services provided at the hospital

31 2

. 23 .





Agenda

. 24 .

Core Program Elements

1.

Physicians voluntarily sign up for MRP Groups

(one group per hospital corporation) and appoint a leader

2.

Physician Groups commit to ensure 24/7/365 coverage

for

unscheduled inpatients

3.

Physician Groups review performance on key indicators

4.

Physician Groups develop and begin implementation of hospital approved quality improvement plans

1.

Physicians voluntarily sign up for MRP Groups

(one group per hospital corporation) and appoint a leader

2.

Physician Groups commit to ensure 24/7/365 coverage

for unscheduled inpatients

3.

Physician Groups review performance on key indicators

4.

Physician Groups develop and begin implementation of hospital approved quality improvement plans

MRP P4P ProgramThe final MRP P4P program design has 4 main elements

. 25 .

Timeline of Activities

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Year 1 Year 2

Appoint Lead

Sign up for Groups

Define and Review Performance Indicators

Develop Quality Improvement Plans

Implement Quality Improvement Plans

Report Progress to Ministry

Activity

MRP P4P High-Level Timeline

The P4P program is being rolled out over 18 months

The first year is focused on organization and planning, while the second year is focused on implementation and reporting

. 26 .

Results to date

Early ResultsData is still being compiled and is meant to be used for illustrative purposes only

The first year of the incentive is nearing completion – participation has been strong

More than 3600 physicians across 104 hospitals have voluntarily signed up to participate

97.3% of all eligible MRP services are covered by the Groups

$10.7 million will be distributed in year 1

Median MRP group allocation of $67,000 (range from $1000 to $470,000)

. 27 .

Potential Barriers and SupportA needs assessment was conducted to determine barriers and supports required for successful implementation

Stated Support Needs

Primary■Best practice care for specific

clinical conditions■ Identifying areas for

improvement

Secondary■Change management■Writing effective QIPs■ Lean process■ Leveraging data tools

Identified Barriers to Success

Primary■Time commitment required■Cooperation amongst multi-

disciplinary members of the group

Secondary■ Level of incentive■Cooperation of other hospital staff■Relationship with hospital

administration

. 28 .

Networking and coaching facilitate knowledge sharing

Leaders will be provided with basic QI Lean Training

Example QIPs were provided to provide guidance and to set standards for the QIP deliverable

Support Program

Support for MRP P4P Incentive

Peer Support

QI Resources

Theory & Primer

Measurement tools

QIP Templates

Objective

QIP Templates

Resources

Peer Support

Timelines

Owner

Activities Desired Outcomes

Best PracticesFocusedBroad

The Ministry is now developing a support program for this initiative

UN

DE

R D

ISC

US

SIO

N

. 29 .

Assessment Against Framework

Measures

Quality■QIP planning■24/7/365 coverage■Key indicator review

Efficiency

■

Volume-based eligibility criteria

Basis for Reward

Method of Measurement■

Approval of QIP

■

Reporting on performance review

Reward

Financial

Bonus payment distributed from allocation of $33 million over 2 years

Self- Evaluation

Areas for Improvement

Outcome metrics are not considered

Measurement is binary rather than relative

Funding is time- limited with no

guaranteed for continuation

Program Element

. 30 .

Next StepsThe Ministry is taking steps to spread MRP best practices across

the sector and formalize programmatic care for the future

TodayJuly 2011

Online Toolkit QIP Review Networking and Coaching

2012 Negotiation

•

Review the hospital-

approved MRP Group QIPs

•

Develop resource of tools, templates and best practice interventions

•

Facilitate forums for peer-

learning, collaboration and knowledge sharing

March 2012

November 2011

June 2011

•

Prepare recommendations for models of care and HHR strategy

. 31 .

Questions?

Joshua Lawson

•


•

[email protected]

Joshua Lawson

•


•

[email protected]

Jonah Peranson

•


•

[email protected]

Jonah Peranson

•


•

[email protected]

incenting quality improvement across 150 canadian (ontario) … · 2011-03-21 · incenting quality...

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