university of michigan medical management center august, 2006

UNIVERSITY OF MICHIGAN

MEDICAL MANAGEMENT CENTER

August, 2006

Presentation Goals

Explain the role of the UMHS Medical Management Center (MMC)

Demonstrate MMC attempts to implement the Chronic Care Model within provider setting

Present outcomes Describe P4P programs supporting

MMC effortsCMS Physician Group Practice Demonstration ProjectBCBSM Physician Group Incentive Project

Discussion

UMHS Medical Management Center (MMC)

Created in 1996 to advance population-based medical and chronic disease mgt.

Focus on:Proactive case finding & outreachComplex care management Clinician-directed disease managementEvidence-based guidelines & provider feedbackPharmacy management Transitional care between inpatient/outpatientPatient centered care based on the Chronic Care ModelSystem integration

Align efforts with external funding opportunities

1996 GUIDES: Guideline development,

measurement & feedback

1997 BMC2

1998 Partnership Health (Ford Motor) & Medical Management Center

2001 Activecare (GM) joins MMC

2001 MMC adds MCARE HMO & Medicaid (~80,000 lives)

2002 MMC adds Washtenaw Health Plan

2003 JCAHO Disease-Specific Care Certification

─ 7 UMHS programs certified ─

2004 CMS Physician Group Practice Demonstration Project

2004 BCBS Physician Group Incentive Program

2004 Kids Connection

UMHS Medical Management Center (MMC)

Chronic Care Model

Resources and Policies

Community

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Health Care Organization

Informed,Activated

Patient

Prepared,Proactive

Practice TeamProductiveInteractions

Improved Outcomes

CC

Productive Interactions


CommunityResources and Policies

Community


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System



DecisionSupport

ClinicalInformation

Systems

Self-Management

Support


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System


Health System


CC

Informed,Activated

Patient

Prepared,Proactive

Practice Team

Improved Outcomes

Healthy Stable chronic diseaseor at riskAcutely ill

Hospitalized

Unstablechronic disease or high risk

Postdischarge

Application of the Chronic Care Model

TEAM APPROACH(Physicians, Nurse Practitioners, Social Work...)


Hospitalized


Postdischarge

GENERAL CAUSE VARIATION



Community


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System



DecisionSupport

ClinicalInformation

Systems

Self-Management

Support


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System


Health System


CC




Hospitalized


Postdischarge


•All-payer disease registries- claims data (BCBSM; MCARE HMO, CMS; internal billings)

- EMR + data warehouse (lab, text searches, etc.)

- pharmacy data (UMHS employees)

- sample reviews for validation of assignment algorithm

- diabetes (9,537), CHF (3,943), CAD(4,382), depression (3,768), asthma (?)




Hospitalized


Postdischarge


• All-payer disease registries

• Measure evidence-based outcomes

- 25 clinical guidelines reviewed & approved by UMHS physicians (http://www.med.umich.edu/i/oca/practiceguides/)




Hospitalized


Postdischarge


• All-payer disease registries• Measure evidence-based outcomes

• Feedback to providers (by site & clinician)

UMHS All Payor Diabetes Performance; By Health Center, Care Provider




Hospitalized


Postdischarge


• All-payer disease registries• Measure evidence-based outcomes• Feedback to providers (by site & clinician)

• Patient education & self-management

Self Management Goals

Develop patient friendly self-management form

Pilot form and reminder postcard or phone call

Report self management goals on Health Center leadership reports

Educate providers and staff regarding documentation of self management in Problem Summary List

Over the past 6 months, when receiving medical care for my chronic illness, I was: Almost

Never Generally

Not

Sometimes Most of

the Time Almost Always

1. Asked for my ideas when we made

a treatment plan.

1

2

3

4

5 2. Given choices about treatment to

think about.

1

2

3

4

5 3. Asked to talk about my goals in

caring for my illness.

1

2

3

4

5 4. Helped to set specific goals to

improve my eating or exercise.

1

2

3

4

5 5. Given a copy of my treatment plan. 1 2 3 4 5 6. Encouraged to go to a specific

group or class to help me cope with my chronic illness.

1

2

3

4

5 7. Sure that my doctor or nurse

thought about my values and my traditions when they recommended treatments to me.

1

2

3

4

5 8. Helped to make a treatment plan

that I could do in my daily life.

1

2

3

4

5 9. Helped to plan ahead so I could take

care of my illness even in hard times.

1

2

3

4

5 10. Helped to set a goal with my doctor

or health team member.

1

2

3

4

5 11. Given a form or book in which to

help me record the progress I am making on my goals.

1

2

3

4

5

Enter Self Management Goal or Health Maintenance Data in PSL

Click ‘Self management goal’’

Enter ‘Additional information’, the ‘date’, and click ‘Save’

*If the exact date is not known enter the month and year.




Hospitalized


Postdischarge


• All-payer disease registries• Measure evidence-based outcomes• Feedback to providers (by site & clinician)• Patient education & self-management

• Resources : Patients = Few : Many

• Emphasis: Improve quality for all

UMHS All Payor Diabetes Quality Indicators by provider type

Through 12/31/2005; compared to HEDIS 90th percentile as well as to previous time-point (June 30, 2004)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

PC Only (N=5,582) 91% 81% 50% 93% 81% 61% 66% 71% 80% 57% 66% 48%

Jointly Managed (N=1,640) 97% 83% 46% 95% 84% 65% 64% 92% 80% 81% 73% 54%

E&M Only (N=1,340) 95% 85% 47% 79% 70% 52% 52% 86% 71% 75% 39% 54%

HEDIS 90th (CY 2003) 92% 79% 95% 73% 50% 65% 66%

Total 6/30/2004 92% 79% 42% 88% 74% 52% 51% 68% 70% 53% 49%

Total 12/31/2005 (N=8,562) 93% 82% 49% 91% 80% 60% 64% 77% 79% 64% 63% 50%

A1CTest

A1C< 9%

A1C< 7%

LDL-CTest

LDLC < 130mg/dL

LDLC < 100mg/dL

On StatinMonitor for

Nephropathy

Proteinuria and on

ACE/ARB

FootExam

EyeExam

BP <135/80

CAD Outcomes

79% of pts. With LDL<100 in past 12 mos. (goal > 80%)

88% on anti-hyperlipidemic medication (goal >90%)

88% on platelet aggregation medication (goal > 90%)

1/3rd Totalcost

1%Severe &UniqueConditions

9% Chronic Conditions

90% Highfrequencycommonconditions

1/3rd TotalCost

1/3rd Totalcost

$1,200

$6,600

$71,600

From: Franklin Health, Chase H&O

Driving 1/3rd of Health Care Costs: The 80%:20% Rule

Average Annual Costs

50% of population

45% of

population

5% of population

3%of claims

37% of claims

60% of claims

(Todd,W., Nash,D., Disease Management: A Systems Approach to Improving Patient Outcomes, 1997)

3%of claims




Hospitalized


Postdischarge


• All-payer disease registries• Measure evidence-based outcomes• Feedback to providers• Patient education & self-mgt.• Resources : Patients = Few:Many• Emphasis = Improve quality for all

SPECIAL CAUSE VARIATION

•7 JCAHO certified disease management programs; specialty physician + nurse team:

AsthmaDiabetesDepressionHeart FailureCoronary Artery DiseaseStrokeSpine Pain



Hospitalized


Postdischarge




•7 JCAHO certified disease management programs

• Health Navigator RNs & Social Workers #1 complaint: “feeling lost in a

complicated system” Same-day MMC notification of

discharge or ED visit High-cost + High risk reports Transitional care

HEALTHAFFAIRS

January/February 2001 – Volume 20, Number 1

Interview:A Founder of Quality AssessmentEncounters A Troubled System Firsthand

“At the University of Michigan, the outpatient and inpatient teams are entirely separate…There are areas where no one takes responsibility, where planning is weak, where I am left on my own…The system is the problem…Things won’t improve until something is done about the design of the system…The system is the responsibility of the doctors and the hospital leadership.

…….tell the committee that Donabedian said they have a problem.”

By Fitzhugh Mullan, p137-141

Clinical Initiatives: Transitional Care Problems

Problem Example Consequence

AppointmentsTimely appointment not made

Patient unaware of appointment

Health deteriorates

Missed appointment

Contact Information

Discharge destination unknown Unable to contact patient

Dischargecounseling

Patient confused about medications Patient confused about tests

Does not take medicationsDoes not go to tests

SocialLacks transportation Cannot afford medications

Misses appointment

Does not take medications

Home care Visiting nurse not available Health deteriorates

“I want to express my appreciation and thanks to the Medical Management Center, especially Ms. Sue Smart (Health Navigator) who has been following my case. Ms. Smart has spent considerable time advising me of different options and providing valuable information, which she has attained from numerous independent sources. She has been an invaluable part of my treatment plan. Her advice will minimize extra medical appointments and missed work, which could save tens of thousands of dollars for my employer. Ms. Smart is the most informed, proactive and knowledgeable person I have experienced during my 15 years plus of dealing with ‘insurance companies’. She is absolutely fantastic and a gem!”

Transaction Costs: The ‘Health Navigator’



Hospitalized


Postdischarge




•7 JCAHO certified disease management programs• Health Navigator

• Patient self-monitoring trial for CHF

-Daily input by patient

-Manage ‘by exception’

-Evidence to date is uncertain



Hospitalized


Postdischarge



• 7 JCAHO certified disease management programs• Health Navigator• Patient self-monitoring trial for CHF

• Pharmacy management program under Pharmacy management program under MMCMMC

- University purchased contract for PBM services- University purchased contract for PBM services

- Provider-specific utilization feedback- Provider-specific utilization feedback

- Pharm D. participates to advise and assist with - Pharm D. participates to advise and assist with interventionintervention

- Cost savings of ~$500,000Cost savings of ~$500,000

- Funding additional Pharm D. & server space in 2006Funding additional Pharm D. & server space in 2006

Lipids: New anti-hyperlipidemic prescriptions by year

Increasing use of preferred drugs over time

0

250

500

750

1000

1998 1999 2000 2001

Preferred

Non-Preferred

60%

62%

69% 70%



Hospitalized


Postdischarge



• 7 JCAHO certified disease management programs• Health Navigator• Patient self-monitoring trial for CHF• Pharmacy management program under MMCPharmacy management program under MMC

• Resources:PatientsResources:Patients = Few:FewFew:Few•EmphasisEmphasis = Intensive Case = Intensive Case ManagementManagement

DISEASE MANAGEMENTVolume 9, Number 1, 2006© Mary Ann Liebert, Inc.

Population-Based Medical and Disease Management: An Evaluation of Cost and Quality

CHRISTOPHER G. WISE, Ph.D., M.H.A.,1 VINITA BAHL, D.M.D., M.P.P.,2 RITA MITCHELL,2 BRADY T. WEST, M.A.,3 and THOMAS CARLI, M.D.1ABSTRACT

Reports by the Institute of Medicine and the Health Care Financing Administration have emphasized that the integration of medical care delivery, evidence-based medicine, and chronic care disease management may play a significant role in improving the quality of care and reducing medical care costs. The specific aim of this project is to assess the impact of an integrated set of care coordination tools and chronic disease management interventions on utilization, cost, and quality of care for a population of beneficiaries who have complementary health coverage through a plan designed to apply proactive medical and disease management processes. The utilization of health care services by the study population was compared to another population from the same geographic service area and covered by a traditional feefor-service indemnity insurance plan that provided few medical or disease management services. Evaluation of the difference in utilization was based on the difference in the cost permember-per-month (PMPM) in a 1-year measurement period, after adjusting for differences in fee schedules, case-mix and healthcare benefit design. After adjustments for both case-mix and benefit differences, the study group is $63 PMPM less costly than the comparison population for all members. Cost differences are largest in the 55-64 and 65 and above age groups. The study group is $115 PMPM lower than the comparison population for the age category of 65 years and older, after adjustments for case-mix and benefits. Health Plan Employer and Data Information Set (HEDIS)–based quality outcomes are near the 90th percentile for most indications. The cost outcomes of a population served by proactive, population-based disease management and complex care management, compared to an unmanaged population, demonstrates the potential of coordinated medical and disease management programs. Further studies utilizing appropriate methodologies would be beneficial. (Disease Management 2006;9:44–55)

Cost Comparisons (PMPM)

Figure 4. Comparison of Per-Member-Per-Month (PMPM) Costs by Age Category

$436

$95

$247

$472

$626

$373

$77

$195

$372

$511

$410

$85

$214

$409

$562

$188

$88

$165

$289

$430

$0

$100

$200

$300

$400

$500

$600

$700

All Members Age<18 Age 18-54 Age 55-64 Age 65+

PMPM

Control Population

MMC Population; adjusted for case-mix & benefits

MMC Population; adjusted for case-mix only

MMC Population; unadjusted

(Wise CG, et.al., Disease Management 2006;9:44–55)

PROGRAMS SUPPORTING MMC EFFORTS

1. CMS “Physician Group Practice” Demonstration Project

2. Blue Cross / Blue Shield of Michigan “Physician Group Incentive Program”

CMS Physician Group Practice Demonstration Participants

Geisinger Clinic (PA)

Marshfield Clinic (WI)

The Everett Clinic (WA)

Forsyth Medical Group (NC)

St John’s Health System (MO)

Deaconess Billings Clinic (MT)

The University of Michigan (MI)

Dartmouth-Hitchcock Clinic (NH)

Park Nicollet Health Services (MN)

Integrated Resources for Middlesex (CN)

Pay-for-Performance: Calculating the return

If UM holds Medicare per-patient case-mix adjusted cost to 2% less than the growth in our regional comparison group, UM can “earn back” up to 80% of the savings over 2%

Amount of savings returned to UM is based on a combination of cost savings and quality

Year 1 = 70% cost savings / 30% quality Year 2 = 60% cost savings / 40% quality Year 3 = 50% cost savings / 50% quality

25% of earn-back withheld by CMS until end of project

PGP Clinical Quality Indicators:Weighting by difficulty of data collection

Diabetes Mellitus Congestive Heart Failure

Coronary Artery Disease

Preventive Care

1 HbA1c Test 4Left Ventricular (LV) Assessment

1 Antiplatelet Therapy 1Blood Pressure Measured

1

2 HbA1c < 9% 1LV EjectionFraction Testing

4Antihyperlipidemic Therapy

1Blood Pressure < 140/90

1

3Blood Pressure < 140/90

1 Weight Measured 1Beta-Blocker Therapy:Prior MI

1Care Plan if elevated BP

1

4 LDL Test 4Blood Pressure Measured

1Blood Pressure Measured

1Breast Cancer Screening

4

5 LDL < 130 1 Patient Education 1 Lipid Profile 4Colorectal Cancer Screening

1

6Urine Protein Testing

4 Beta-Blocker Therapy 1 LDL < 130 1

7 Eye Exam 4 ACE-I (inhibitor) Therapy 1ACE-I if diabetes or LV systolic dysfunction

1

8 Foot Exam 1Warfarin - atrial fibrillation

1

9Influenza Vaccination

1 Influenza Vaccination 1

10 Pneumonia Vaccine 1 Pneumonia Vaccination 1

TOTAL Points22

13

10

8

Clinical Initiatives: Complex care coordination solutions

Problem Provider Focus# of

patients

Coordination

Nurse navigatorSocial workerHealth navigator

Multiple comorbidities, clinically complexPsychosocial problems, frail elderlyOther

50/month70/month2000/mo.

Identification& monitoring

Data analystsCare managers

High risk and/or high cost patients by: real-time review admissions & discharges real time review emergency room visits establishing automated flags for

high use – high cost high risk – major diseases

Reporting Data Analysts Produce financial & clinical reportsProduce outcome reports

DeliriumProject

CMS Demo Core

Functions• Health Navigation• Disease Management• Transitional Care• Pharmacy Management• Evidence-based

Palliative Care

Clinical Care

Coordinators

Nurse Educators

Office of Clinical Affairs

Turner

Geriatrics

Michigan Visiting Nurses

BCBS

PGIP

DischargePlanning

EmergencyDept.

HospitalistProgram

MCIT

CQIP

Nursing Homes

BCBSM PGIP

Payments based on provider’s proportion of ambulatory activity (E & M codes)

Quarterly payments to provider groups for:‘All payer’ chronic disease registriesInnovative implementation strategiesMeasured outcomesCredit for working with other provider groupsAdvancing Wagner’s ‘Chronic Care Model’

Payments to MMC for advancing structure & processes; no risk arrangement

Opportunity to collaborate with payer-based programs

Hospitalized


Postdischarge


• All-payer registries• Measure evidence-based

outcomes• Feedback to providers• Patient ed. & self-mgt.• Resources : Patients = Few :

Many• Emphasis = Improve quality for

all


• 7 JCAHO cert. DM programs• Health Navigator• Patient self-monitoring trial for CHF• Pharmacy Management• Resources : Patients = Few : Few• Emphasis = Intensive case management




Community


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System



DecisionSupport

ClinicalInformation

Systems

Self-Management

Support


DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System


Health System


CC

THE END

university of michigan medical management center august, 2006

Documents

chronic care model resources

high risk post discharge

outcomes cc slide

nurse practitioners

umhs programs

social work

umhs physicians http

present outcomes