spreading the adoption of electronic consultation ... · health metrics number of patients who had...

BluePath Health Inc.; Client Proprietary and Business Confidential 1

March 21, 2016

spreading the adoption of electronic consultation (eConsult)

in California's healthcare safety net

Presenter:Rachel WickProgram Officer, Health Care and Coverage

blueshieldcafoundation.org


eConsult spread strategy

51%

innovating with relationships

policyshared measurement

SFGH/UCSFSafety Net Institute (PRIME)

Center for Connected Health PolicyBluePath Health

Institute for High Quality Care

BSCF grant $, funding partnership with CHCF, and wisdom from 2014 expert stakeholder convening

YOU! Leadership, commitment and local partnerships

leveraging technology


eConsult evaluation overview

Goal: spread innovation that works

Learn from: early adopters

Demonstrate value through: Quadruple Aim framing

Inform and be informed by: policy environment

Build grantee consensus around: shared measurement and metrics

Collect & submit data to: UCSF/SFGH

UCSF/SFGH aggregates data for: field and Foundation impact


stages of planning & implementation

Should/could we do it?How do we do it? Let’s

do it and learn.How (quickly) do we scale

up?

How do we improve/innovate

further?

Contra CostaSan Joaquin

KernMontereySan Diego

San Bernardino CCASBC San Bernardino IEHP

AlamedaSanta ClaraSan Mateo

Los Angeles-LA Care

Los Angeles – LAC DHSSan Francisco

FeasibilityPlanning &

PilotingSpread &

Scale

CQI & Innovation

BSCF Interviews & UCSF/SFGH Survey

Build consensus on metrics

Collect and aggregate data

UCSF eReferral TA Team

Delphine Tuot, MDCM, MASNwando Olayiwola, MD, MPH, FAAFPIguehi James, MPHAlice Chen, MD, MPHElizabeth Murphy, MD, DPhil

Evaluation Framework: Impact of eConsult


Evaluation Framework: Impact of eConsult (1)Arm of the Quadruple

Aim

Informs Reimburse

ment

Directly related to

GPP

Directly related to PRIME

Measure Ascertainment DefinitionWhy measure

this?

CORE METRICS

Financial X X# specialty

touches/population served

eCR platform & health system

metrics

in-person specialty visits + eConsults (all back-and-forth included in one

eConsult)/empaneled primary care population

indirect measure for business case; access to specialty

care; look at trends and

whether supply induces demand

for consults

Population Health

X

Time to third next available new in-person appt for

eConsult specialties

health system metrics

third next available new patient appointment

access to specialty care; direct

measure of impact

XDemographics of the

population servedhealth system

metrics

race/ethnicity breakdown, insurance status of entire empaneled primary care

populationgeneralizability

XDemographics of

patients who received an eConsult

eCR platform & health metrics

race/ethnicity breakdown, insurance status of patients who received at least one

eConsult Program reach;

impact on equity

X X X% of patients who received specialty

expertise via eConsult


number of patients who had an eConsult (regardless of management strategy)/total

empaneled primary care patientsProgram reach

XPCP ability to manage

eConsult specialty conditions

PCP survey

% of PCPs who complete eConsult satisfaction survey question, including

question about educational implications of eConsult

effectiveness of eConsult; indirect

measure of program impact

X X X eConsult management eCR platform

% of eConsults that result in in-person visit/total eConsults (per specialty); % of eConsult that are never scheduled/total

eConsults (per specialty)

effectiveness of eConsult; direct

measure of impact



Aim

Informs Reimburse

ment

Directly related to

GPP

Directly related to

PRIMEMeasure Ascertainment Definition

Why measure this?

Population Health

X# of specialties offering eConsult and what they are

eCR platform raw number of specialties offering eConsultAccess to specialty care; direct measure of impact

X X Unclosed loop by PCP

eCR platform

# of specialist responses that are not read by PCP/total number of specialist responses via eConsult

patient safety; unanticipated impact

XUnclosed loop by specialist

eCR platform

# of eConsults that did not receive a specialist response/total number of eConsults


X XAverage time to eConsult response

eCR platform

average lapsed number of hours between time eConsult was generated and time specialist responded

Access to specialty care

Care team experience

XPCP satisfaction/dissatisfaction

survey

% of PCPs who have high satisfaction with process on survey (topics include questions about work flow, eConsult process, educational materials, eConsult templates)

program sustainability

XSpecialist satisfaction/dissatisfaction

survey

% of specialists who have high satisfaction with process on survey (survey topics include questions about work flow, eConsult process, educational materials, eConsult templates)


X

MEA/RN/referral coordinator satisfaction/dissatisfaction survey

% of non-MD team primary care team members who have high satisfaction on survey(survey topics include: eConsult work flow, process, eConsult templates)


SUPPLEMENTARY METRICS

Patient experience

X XSatisfaction with access to specialty care

focus groups patient self-report GeneralizabilityAcceptability/concerns related to eConsult

XTravel/time saved by patients for avoided clinic visits


DHCS Waiver Programs Supporting eConsult

David Lown, MDChief Medical OfficerCalifornia Health Care Safety Net Institute


The DHCS Medi-Cal 2020 waiver supports the expansion of eConsult through 3 programs

Public Hospital Redesign in Medi-Cal (PRIME) - $3.73b

— Builds on programs improving care delivery in designated public hospital (DPH) systems

DPH: 12 public (county run) health care systems and 5 UC medical centers

— Incentive payments earned based on achievement of targets based on specified benchmarks

— Requires aggregate DPH achievement of targets demonstrating increasing adoption of Alternative Payment Methodology(APM)

Global Payment Program (GPP) – PY1: $1.14b

— Care for the post-ACA remaining uninsured by public health care systems (PHS)

—Movement away from cost-based payment to point based payment structure with an overall global budgets

— Emphasizes ambulatory care with inclusion of previously unpaid-for services such as…electronic consultations

Whole Person Care Pilots (WPC) $1.5b

— Provide options to integrate care for beneficiaries who are high risk, high utilizers

— Pilot sites will share data between systems and coordinate their care in real time

http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/Waiver_Webinar_012516.pdf

http://www.dhcs.ca.gov/provgovpart/Documents/Waiver Renewal/Waiver_Webinar_012516.pdf


PRIME incorporates eConsult to increase access to specialty care through non face-to-face encounters

Program Overview

Goal: Improve the quality and value of care provided by CA’s safety net hospitals and health systems, including increasing access

to outpatient specialty care.

Population: ≥2 primary care encounters (independent of coverage) or Medi-Cal Manage Care assigned lives for Primary Care

Entities: All DPHs and most District and Municipal Hospitals (DMPHs)

Funding: Federal Funds and non-federal share from DPH & DMPH

Effective: July 1, 2015 through June 30, 2020

eConsult-Related Goals and Objectives Reimbursement Model

• Partner with PCMH to improve health outcomes in

acute and chronic disease

• Increase patient and provider access to high quality,

effective specialty expertise – delivered in the most

effective means to meet the need.

• Implement alternatives to face-to-face patient-provider

encounters, including the use of telehealth solutions

• Provide resources to increase PCP capacity to care for

complex patients

Payments made based on mid-year and annual reporting of metric

target achievement.

First report due September 2016.

Project Metrics include:

• Referral reply turnaround rate

• Specialty Care Touches: Specialty expertise requests managed

via non-face to face specialty encounters

• Closing the referral loop: receipt of specialist report (CMS50v3)

Measure stewards include:

• Los Angeles County Department of Health Services (LACDHS)

• San Francisco Health Network (SFHN)

• UC Davis Medical Center (UCDMC)

PRIME measures align with BSCF eConsult pilot measures to incentivize alternative specialty care touches


Global Payment: Supporting uninsured patients, increasing timely access to services through eConsult

Overview Point Value Establishment Criteria

Goal: Support public health care systems in providing services to the uninsured and to promote the delivery of more cost-effective and higher-value care

Population: Uninsured

Entities: Public health care systems and their affiliated and contracted providers

Funding: Disproportionate Share Hospital (DSH) and UncompensatedCare Pool (UC Pool). Incorporates DSH cuts. UC Pool TBD for PY 2-5. Payments for services

Effective: July 1, 2015 through June 30, 2020.

i. Service Cost

ii. Timeliness and convenience of service to patient

iii. Increased access to care

iv. Earlier intervention

v. Appropriate resource use for a given outcome

vi. Health and wellness services

vii. Potential to mitigate future costs

viii. Preventive services

Service Categories (Examples)

Category 2: Complementary Patient Support and Care Services: non-traditional outpatient encounters, where care is provided by non-traditional providers or in nontraditional settings., including:

• Panel Manager; Group Visits; Paramedicine Treat & Release

Category 3: Technology-Based Outpatient – This category includes technology-based outpatient encounters that rely mainly on technology to provide care:

• RN Call line

• Telephone and email consultations between provider and patient

• Provider-to-provider eConsults for specialty care

• Real Time Telehealth (provider - provider)

Encourages DPHs to provide non-traditional and technology based services to provide greater primary and preventive services – higher value care as compared to the high cost care of avoidable ER/acute inpatient care


Whole Person Care: coordinating health, behavioral health and social services to increase access to care, incorporating eConsult

Overview Required Participants

Goal: Coordination of health, behavioral health, and social services, in a patient-centered manner with goals of improved beneficiary health and well being through a more efficient and effective use of resources.

Population: Medi-Cal, high utilizers of multiple systems

Funding: $300m/yr in fed funds. Payments for infrastructure.

Lead Entity: County agency, designated public hospital, or district municipal public hospital

Schedule: Applications due to DHCS July 1, 2016

• Medi-Cal managed care health plan,

• Specialty mental health agencies,

• Other public agency (may include county alcohol and substance , criminal justice/probation, and housing authorities, human services agencies, public health departments) and

• (2) Community partners- physician groups, clinics, hospitals, and community-based organizations

Strategies

WPC Pilots shall include specific strategies to:

• Increase integration among county agencies, health plans, and providers, and other entities within the participating county or counties that serve high-risk, high-utilizing beneficiaries and develop an infrastructure that will ensure local collaboration among the entities participating in the WPC Pilots over the long term;

• Increase coordination and appropriate access to care for the most vulnerable Medi-Cal beneficiaries;

• Reduce inappropriate emergency and inpatient utilization; and

• Improve data collection and sharing amongst local entities to support ongoing case management, monitoring, and strategic program improvements in a sustainable fashion

BSCF pilot/CAPH member DPHs are participating in the application process for this cross-county program encouraging collaboration, coordination and reduction of unnecessary ER/inpatient utilization



Aim

Informs Reimburse

ment

Directly related to

GPP

Directly related to PRIME

Measure Ascertainment DefinitionWhy measure

this?

CORE METRICS

Financial X X# specialty

touches/population served

eCR platform & health system

metrics

in-person specialty visits + eConsults (all back-and-forth included in one

eConsult)/empaneled primary care population

indirect measure for business case; access to specialty

care; look at trends and

whether supply induces demand

for consults

Population Health

X





access to specialty care; direct

measure of impact

XDemographics of the

population servedhealth system

metrics

race/ethnicity breakdown, insurance status of entire empaneled primary care

populationgeneralizability

XDemographics of

patients who received an eConsult


race/ethnicity breakdown, insurance status of patients who received at least one

eConsult Program reach;

impact on equity

X X X% of patients who received specialty

expertise via eConsult


number of patients who had an eConsult (regardless of management strategy)/total

empaneled primary care patientsProgram reach

XPCP ability to manage

eConsult specialty conditions

PCP survey

% of PCPs who complete eConsult satisfaction survey question, including

question about educational implications of eConsult

effectiveness of eConsult; indirect

measure of program impact

X X X eConsult management eCR platform

% of eConsults that result in in-person visit/total eConsults (per specialty); % of eConsult that are never scheduled/total

eConsults (per specialty)

effectiveness of eConsult; direct

measure of impact


Drilling down on two examples….

Arm of the Quadruple

Aim

Directly related to

PRIMEMeasure Ascertainment Definition Why measure this?

Financial X

# specialty touches/

population served

eCR platform & health system metrics

in-person specialty visits + eConsults (all back-and-forth

included in one eConsult)/empaneled primary

care population

indirect measure for business case; access to specialty care;

look at trends and whether supply induces demand for

consults

• Feasibility: align with PRIME• Numerator

• eConsult definition?• Denominator

• Empaneled primary care population• Specialty care population


Drilling down on two examples….

• Ultimate goal of eConsult programs is to improve access to care• Not directly aligned with DHCS waiver programs• TNAA is a commonly used measure for access, but very dynamic• Is this feasible and meaningful? What might be a more meaningful

measure of access?

Arm of the Quadruple

AimMeasure Ascertainment Definition Why measure this?

Population Health





access to specialty care; direct measure of impact



Aim

Informs Reimburse

ment

Directly related to

GPP

Directly related to

PRIMEMeasure Ascertainment Definition

Why measure this?

Population Health

X# of specialties offering eConsult and what they are

eCR platform raw number of specialties offering eConsultAccess to specialty care; direct measure of impact

X X Unclosed loop by PCP

eCR platform

# of specialist responses that are not read by PCP/total number of specialist responses via eConsult


X Unclosed loop by specialisteCR platform

# of eConsults that did not receive a specialist response/total number of eConsults


X XAverage time to eConsult response

eCR platform

average lapsed number of hours between time eConsult was generated and time specialist responded

Access to specialty care

Care team experience

XPCP satisfaction/dissatisfaction

survey

% of PCPs who have high satisfaction with process on survey (topics include questions about work flow, eConsult process, educational materials, eConsult templates)


XSpecialist satisfaction/dissatisfaction

survey

% of specialists who have high satisfaction with process on survey (survey topics include questions about work flow, eConsult process, educational materials, eConsult templates)


XMEA/RN/referral coordinator satisfaction/dissatisfaction

survey

% of non-MD team primary care team members who have high satisfaction onsurvey (survey topics include: eConsultwork flow, process, eConsult templates)


SUPPLEMENTARY METRICS

Patient experience

X XSatisfaction with access to specialty care

focus groups patient self-report GeneralizabilityAcceptability/concerns related to eConsult

XTravel/time saved by patients for avoided clinic visits


Example: PCP Satisfaction Question

Since the start of eConsult, how satisfied were you with your ability to get specialists appointments for your patients in:

Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied

eConsult clinics 5 4 3 2 1

Non- eConsult clinics 5 4 3 2 1


Example: Specialist Satisfaction Question

How satisfied are you with the ease of the eConsult process?

Very Satisfied Satisfied Neutral Dissatisfied Very dissatisfied

Overall 5 4 3 2 1

Reviewing consults 5 4 3 2 1

Responding to consults 5 4 3 2 1

Tracking consult requests 5 4 3 2 1

Integrating with workflow 5 4 3 2 1

Reimbursement/ work credit 5 4 3 2 1

Your ability to communicate withthe referring provider regarding patient

5 4 3 2 1


Timeline: Expected Deliverables PRIME & eConsult

APRIL PRIME: 4/4/16 – 5-Year Project Plan Due eConsult:

Which metrics are feasible? What numerator and denominator makes sense?

May PRIME: April – May refinement of PRIME Metric specs (see below) eConsult: finalize shared metrics for impact evaluation with definitions & survey edits

June PRIME: 6/3/16 DHCS approves or disapproves each Plan PRIME: 6/30/16 payment of 25% of DY11 $$ for approved Plan

July eConsult (est): administration of on-line satisfaction surveys

September PRIME: 9/30/16 Baseline data due on all project metrics eConsult: submit baseline data to UCSF/SFGH

October PRIME: 10/31/16 (est.) payment of 75% of DY11 $$ for reporting all baselines