wellmark blue cross blue shield 2006 1 collaboration on quality: a foundation built on trust michael...

Collaboration on Quality: A Foundation Built on Trust

Michael Pekas, M.D.Medical DirectorJoel HasenwinkelDirector, Clinical Collaboration

Wellmark Blue Cross Blue Shield 2006

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Wellmark at a GlanceWellmark Blue Cross Blue Shield of Iowa, an Iowa Mutual Insurance CompanyWellmark Blue Cross Blue Shield of South Dakota, a South Dakota Insurance CompanyWellmark Health Plan of Iowa, Inc., an Iowa HMO owned by Wellmark and Iowa ProvidersMore than 1.5 million members1 in 2 Iowans1 in 4 South DakotansIndependent licensee of Blue Cross and Blue Shield AssociationComprehensive provider network


**

Health Care CrossroadsPremium cost has increased substantially

Increased number of uninsured

No clear data that increasing costs always translate to improved care

Health care affordability is at significant risk


**

Where did Wellmark start?Focus on Patient Centered Care

Work closely with clinical community

Voluntary Program for Primary Care Physicians

Reduce Practice Variation

Encourage Improved Quality and Efficiency

Collaborate to Improve Provider Office Infrastructure


**

How did Wellmark help?Provide usable data

Supply resources to support change

Encourage process improvement

Bring all stakeholders to the table

Recognize and reward those that succeed


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How did Wellmark start?Identified Physician Leaders in a participating clinicLeaders recruit participants Drive local activity

Participants identified relevant disease conditions for community

Aligned work with clinic initiatives and objectives

Jointly established guidelines and performance targets

Included physician care team in design


**

Encourage change agentsRecognize participating clinicians in directories Designate support resources from Wellmark

Simplify certain administrative processes

Deliver performance reports on pharmacy

Recognize publicly as performance objectives are met


Recognizing and Rewarding Best Practices

Mercy Clinics Perspective

David Swieskowski, MD, MBAV.P.for QualityMercy Clinics, Inc.Des Moines, Iowa


Mercy Clinics, Inc.Established in 1984Owned by Mercy Hospital Medical Center Non Profit23 Clinics 126 physicians668,613 patient visits in 2004Virtual Private PracticeAmbulatory Care Quality is a Board Strategic priority



Chart1

8

7.7

7.7

7.77

8.12

8.53

8.45

8.31

8.28

8.26

7.94

7.73

7.68

7.8

7.87

7.67

7.75

7.81

8.15

8.12

8.01

7.61

7.78

7.64

7.32

7.66

7.61

7.5

7.47

7.41

7.88

7.88

7.45

7.45

7.47

7.18

7.29

7.26

7.22

7.36

7.21

7.35

7.44

7.14

6.97

MCI Average HgA1C Values July 98 - Mar. 02Compared to a national average of 9%. (Clinical Diabetes: V.20, No.2, 2002)

Sheet1

ClinicControl

MeanMean

May7.82

Jun7.85

Jul7.92

Aug7.64

Sep7.72

Oct7.66

Nov7.50

Dec7.69

Feb7.68

Mar7.86

Apr7.79

May7.68

Jun7.615.6

Jul-988.00

Aug7.705.6

Sep7.705.5

Oct7.775.5

Nov8.125.6

Dec-988.535.8

Jan-998.455.7

Feb8.315.6

Mar8.28

Apr8.265.6

May7.945.9

Jun7.735.9

Jul7.68

Aug7.806.00

Sep7.876.07

Oct7.675.90

Nov7.756.00

Dec-997.816.20

Jan-008.156.20

Feb8.126.02

Mar8.016.13

Apr7.615.91

May7.786.04

Jun7.645.94

Jul7.325.37

Aug7.665.50

Sep7.615.65

Oct7.505.62

Nov7.476.01

Dec-007.415.95

Jan-017.886.03

Feb7.886.05

Mar7.455.72

Apr7.455.86

May7.475.73

June7.185.75

July7.295.85

Aug7.265.76

Sep7.225.89

Oct7.365.93

Nov7.21

Dec-017.35

Jan-027.44

Feb-027.14

Mar-026.97

Sheet1

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0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

MCI Average HgA1C Values July 98 - Mar. 02Compared to a national average of 9%. (Clinical Diabetes: V.20, No.2, 2002)

Sheet2

Sheet3

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

Delivery SystemDesign

DecisionSupport

Clinical Information Systems

Self- Management Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

MCI GoalsPatient Centered Care Performance measurementDisease RegistryImproved outcomesReduced costChronic Care ModelWellmark GoalsPatient Centered CarePerformance measurementClinical InformationImproved outcomesReduced costDisease managementAlignment of Goals


Engaging MCI Physicians

Data will be used against themBonus for high performance will evolve into a penalty for low performance Will use clinical data to take over disease management themselves

Out to game the systemWont cooperateNot capable of system improvementChoose data based on ease of collection not usefulness

BarriersResponseLack of trustPhysicians as partners in design of the programInaccurate patient listPhysician generated listFinancial disincentivesP4P & pay for Self-Management SupportDifficult to define ROISettled on pharmacy costHard to measure resultsLimited data setDesign process too longFinally just started


Recognize & Reward Best PracticesQuality ParametersPay for PerformanceData self-reported by providers


Process

Goal*

Outcome

Goal*

Diabetes overall** 80% 70%

Proportion with HgA1C < 8.0 or 1% improvement over the last year (i.e. 8.6 to 7.6)

85%

70%

Proportion with LDL < or = 130

85%

70%

Proportion with BP < or = 140/90

85%

70%

Nephropathy screening or evidence of disease

70%

Documentation of Diabetes education or Patient refusal

Establish Baseline

Hypertension Quality overall** 80% 70%

Proportion with BP < or = 140/90

85%

70%

Lipids checked in last 30 months

85%

Glucose checked in last 30 months

85%

Proportion with microalbumin documented in the last year

70%

Patient education documented

Establish Baseline

Quality Incentive Payment

$

$

Pharmacy Targets*** Incentive Payment

Per member per month cost: % < Wellmark Avg.

4.0%

$

Per member per month cost: % < Wellmark Avg.

6.0%

$

Mercy Clinics, Inc./Wellmark Quality Parameters

*If a parameter is not within goal, evidence of action to achieve the goal will meet criteria.

** Overall goal is the average of all the goals in the disease suite.

*** This is a group goal paid to all or none

Process Goals are whether or not a test was done within the last year (unless otherwise stated) and can often be determined by billing data.

Outcome Goals reflect clinical measurements described in the left hand column.

April 26, 2005

Improving Physician Quality ScoresCurrentlyDepend on physician memory and Individual effortIn the FutureWill depend more on the system physicians work in than on individual effort

Working harder is the worst plan -W. Edwards Deming


Delivery System RedesignDisease Registry for diabetes and HTNDiabetes Flow Sheet up to date on each chartDiabetes and Hypertension GuidelinesStanding orders for diabetes & HTN careDiabetes OV formChecklist so all critical elements are addressedCodes to a level 4 office visitLevel 4 EM visits went from 49% to 72% of total visitsPopulation Health Coaches


Population Health CoachFull time position in 4 clinics, part time in othersWellmark Foundation grant provided seed moneyProactively manages the populationOversees registriesCalls patients Overdue visitsNot meeting goalsPre-visit chart review for chronic care patientsPre-work saves Doctor timeProvide or arrange for education & SMSAssist with group visits


Physician Level Performance Reports


9-05

SECAT Performance Reports

Campus Clinic

Sep-05

WELLMARK Diabetes Data: 9/1/04-9/1/05

ProviderHeimsKennedyMooreSteinmetzSwieskowskiGoal

Total Patients1613373011

Process goals:

HgAlc last 12 mo.100%92%95%83%100%85%

LDL last 12 mo.81%85%70%80%91%85%

SBP last 12 mo.100%100%95%87%100%85%

Microalb last 12 mo.75%62%68%80%82%70%

Overall process goal %89.00%85.00%82%83%93.00%80%

Overall process goal met?YesYesYesYesYes

Drs. Kennedy and Moore-Adjusted denominator to reflect notification intervention by the

clinics' Population Health Coach regarding care opportunities

Outcome goals:

% HgAlc < 8.088%58%66%76%90%70%

% LDL < 13077%82%81%83%90%70%

% SBP < 14081%93%80%93%82%70%

Overall outcome goal %82%78%76%84%87%70%

Overall outcome goal met?YesYesYesYesYes


Campus Clinic

Sep-05

Wellmark HTN Data: 9/1/04-9/1/05



Process goals:

SBP last 12 mo.98%92%94%97%100%85%

Lipids last 30 mo.94%89%86%92%95%85%

Glucose last 30 mo.90%80%77%92%98%85%

Microalb last 12 mo.88%69%73%78%88% ]70%

Overall process goal %94.00%83%83.00%90.00%95.00%80%

Overall process goal met?YesYesYesYesYes

Dr. Moore-Denominator adjusted to reflect notification interventions regarding care opportunites conducted by the clinic's Population Health Coach

Outcome goal:

% SBP < 14076%75%73%79%83%70%

Overall Outcome goal met?YesYesYesYesYes


Campus Clinic

Sep-05

ALL PATIENTS Diabetes Data: 9/1/04-9/1/05



Process goals:

HgAlc last 12 mo.89%75%82%87%94%85%

LDL last 12 mo.73%57%60%73%89%85%

SBP last 12 mo.84%75%80%88%96%85%

Microalb last 12 mo.70%33%50%74%86%70%

Overall process goal %79%60%68%81%91%80%

Overall process goal met?NoNoNoYesYes

Outcome goals:

% HgAlc < 8.084%62%73%73%92%70%

% LDL < 13076%72%74%84%93%70%

% SBP < 14084%75%88%92%77%70%



8-19-05


Campus Clinic

Aug-05




Process goals:

HgAlc last 12 mo.87%77%85%83%86%85%

LDL last 12 mo.67%77%63%77%86%85%

SBP last 12 mo.87%85%85%87%86%85%

Microalb last 12 mo.67%62%63%73%79%70%


Process goal met?NoNoNoYesYes

Outcome goals:

% HgAlc < 8.092%70%61%76%92%70%

% LDL < 13070%90%71%82%92%70%

% SBP < 14092%90%78%93%83%70%




Campus Clinic

Aug-05




Process goals:

SBP last 12 mo.98%93%90%95%100%85%

Lipids last 30 mo.94%84%83%88%95%85%

Glucose last 30 mo.88%71%75%90%98%85%

Microalb last 12 mo.85%49%65%74%88%70%


Process goal met?YesNoNoYesYes

Outcome goal:

% SBP < 14074%78%72%78%83%70%


8-05


Campus Clinic

Aug-05



Total Patients15 (14)13 (10)29 (24)30 (23)13 (11)

Process goals:

HgAlc last 12 mo.93% (80%)77% (80%)90% (88%)80% (83%)92% (82%)85%

LDL last 12 mo.67% (64%)77% (70%)59% (63%)70% (74%)92% (82%)85%

SBP last 12 mo.87% (79%)85% (80%)90% (88%)83% (78%)92% (82%)85%

Microalb last 12 mo.60% (64%)54% (60%)45% (54%)67% (70%)85% (73%)70%


Process goal met?NoNoNoNoYes

Outcome goals:

% HgAlc < 8.093% (83%)70% (76%)66% (67%)75% (68%)92% (88%)70%

% LDL < 13080% (77%)90% (85%)71% (67%)86% (83%)92% (100%)70%

% SBP < 140100% (100%)90% (88%)85% (81%)92% (94%)83% (89%)70%




Campus Clinic

Aug-05



Total Patients53 (51)70 (70)75 (81)81 (82)43 (41)

Process goals:

SBP last 12 mo.98% (96%)94% (87%)92% (91%)96% (95%)100% (100%)85%

Lipids last 30 mo.89% (84%)83% (75%)81% (75%)88% (85%)88% (96%)85%

Glucose last 30 mo.83% (80%)69% (61%)69% (62%)89% (78%)98% (95%)85%

Microalb last 12 mo.81% (67%)46% (24%)61% (30%)73% (67%)93% (91%)70%


Process goal met?YesNoNoYesYes

Outcome goal:

% SBP < 14074% (78%)73% (74%)73% (70%)75% (77%)83% (83%)70%



Campus Clinic

Aug-05

ALL PATIENTS Diabetes Data: 8/1/04-8/1/05


Total Patients121 (116)71 (65)155 (143)98 (88)148 (148)

HgAlc last 12 mo.82% (80%)72% (69%)78% (78%)77% (76%)86% (84%)85%

% HgAlc < 8.083% (87%)65% (63%)73% (73%)74% (73%)93% (91%)70%

LDL last 12 mo.58% (57%)55% (48%)46% (46%)56% (58%)76% (72%)85%

% LDL < 13081% (83%)71% (68%)72% (71%)87% (87%)94% (95%)70%

SBP last 12 mo.72% (70%)69% (65%)77% (76%)77% (74%)85% (83%)85%

% SBP < 14085% (80%)78% (71%)84% (84%)88% (87%)74% (77%)70%

Microalb last 12 mo.55% (54%)25% (23%)34% (31%)52% (51%)68% (66%)70%

7-05


Campus Clinic

Jul-05

WELLMARK Diabetes Data: July '04-July '05



HgAlc last 12 mo.86%80%88%83%82%85%

% HgAlc < 8.083%76%67%68%88%70%

LDL last 12 mo.64%70%63%74%82%85%

% LDL < 13077%85%67%83%100%70%

SBP last 12 mo.79%80%88%78%82%85%

% SBP < 140100%88%81%94%89%70%

Microalb last 12 mo.64%60%54%70%73%70%

ALL PATIENTS Diabetes Data: July '04-July '05


Total Patients116 (118)65 (67)143 (144)88 (93)148 (148)

HgAlc last 12 mo.80% (79%)69% (69%)78% (81%)76% (76%)84% (85%)85%

% HgAlc < 8.087% (85%)63% (62%)73% (70%)73% (70%)91% (91%)70%

LDL last 12 mo.57% (53%)48% (43%)46% (43%)58% (63%)72% (71%)85%

% LDL < 13083% (96%)68% (93%)71% (84%)87% (88%)95% (100%)70%

SBP last 12 mo.70% (68%)65% (64%)76% (78%)74% (76%)83% (84%85%

% SBP < 14080% (77%)71% (70%)84% (84%)87% (86%)77% (78%)70%

Microalb last 12 mo.54% (55%)23% (22%)31% (27%)51% (49%)66% (64%)70%

HTN Data: July '04-July '05


Total Patients51 (42)70 (44)81 (60)82 (51)41 (24)

SBP last 12 mo.96% (95%)87% (75%)91% (87%)95% (90%)100% (100%85%

% SBP < 14078% (76%)74% (54%)70% (65%)77% (81%)83% (80%)70%

Lipids last 30 mo.84% (81%)75% (64%)75% (65%)85% (80%)88% (96%)85%

Glucose last 30 mo.80% (79%)61% (48%)62% (48%)78% (72%)95 % (100%)85%

Microalb last 12 mo.67% (69%024% (20%)30% (28%)67% (61%)83% (92%)70%

4-05

3-05


Campus Clinic

Diabetes Data: April '04-March '05

ProviderHeimsKennedyMooreSteinmetzSwieskowskiUdelhofenGoal


A1c Rate97%94%97%93%96%100%85%

A1c %

RRBP Diabetes Pilot DataN=497 Wellmark patients


Chart1

0.78A1c %

Cost of Poor Glycemic Control


1% reduction in HgA1c saves $685 - $950 per year

JAMA. January 10, 2001

Chronic Care Model Spread2002: Joined IHI IMPACT2 Clinics2004: Grant for disease registry3 Clinics2004: RRBP Pilot4 Clinics2005: RRBP second year13 Clinics


**

Program ExpansionIncrease number of physicians in program

StructureMust align with national standardsMonitor CMS, NQF other standards setting organizationsFocus on Diabetes, Asthma, prevention

Baseline performance of physicians

Support provider change processes

Reduce variation in program administration


**

Critical to SuccessWillingness to adopt change

Active involvement of the entire physician care team

Effective patient follow-up

Application of technology to processes

Ongoing evaluation of progress

Clear measures and measurements


**

How will Wellmark support change?Work with clinical community to identify barriers

Implement technology to encourage reduction of practice variation

Support relationship between patient and physician

Promote patient advocacy and education

Engage all stakeholders in the process

Encourage and support Quality

Recognize and reward as appropriate


**

How does technology help?Change Processes First

Technology supports changeMonitoring of patient care coordinationMore timely feedback on performanceAppropriate information sharing

Wellmark believes that technology is a key enabler


**

What kind of technology?Align cost with expected benefit

Incremental improvements vs. Big BangPlan for change Migrate over timeDo Not interrupt serviceAllow for successes to fuel innovation

Minimize re-work / duplicate entry

Integrate tools into office processes


**

Support adoption of changeIdentify your change champions

Listen to concerns

Set achievable goals

Work together to monitor progress

Celebrate small wins

Educate others on what is in it for them


**

Financial Incentives Future reward structure componentsQuality clinical suite measuresCost generic vs. brand prescription rates, ER visits, Inpatient days, etc.

Rewards will be based on Improvement in agreed upon Quality Measures


**

Wellmarks Next StepsEvaluate other opportunities for measurement

Work with clinicians to increase program scope

Begin working with specialists

Improve performance metrics and monitoring

Celebrate improved quality


McGlynn Study, Midwest Business Group on Health StudyDouble-digit increases on already significant premiumsCompetitive disadvantage to businessesA family of four insurance topping 10k? Not sustainableImprove Adherence National Guidelines which is at 54% Electronic data collectionsProcess improvementConcept of coordination of care / Wagner Chronic care modelTalk about Medical Home conceptWellmark provided access to case managers, education meeting reimbursementCommunity focused approach Influential leaders, Quality / Cost buy in and tie-inConcept is to collaborate to drive change in our Health care systemExemption from prior authorization requirements for all drugs requiring a prior authorization under the pharmacy benefit

Key Success criteria:Strong physician leader advocating for changeTechnology to support case coordination for chronic patientsInvolvement of entire care team in improving qualityFeedback on performance as close to real-time as possibleRedesign health care delivery - Example (S-Codes), Medical HomePromote Physician relationship with Wellmark Include employer groups as active stakeholders

wellmark blue cross blue shield 2006 1 collaboration on quality: a foundation built on trust michael...

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