Quality Colloquium Harvard University August 19 - 22, 2006 PlenaryCourneya--8.22@10am QC

HealthPartners at a glance Founded in 1957 as a cooperative Integrated, providing Health plans Care delivery Medical education Research Health improvement Largest non-profit, consumer governed organization in the nation (Group Health Seattle is second) 1 million members 25 medical clinics 16 dental clinics 2 hospitals Regional network of 30,000 providers National network with CIGNA alliance HealthPartners Research Foundation- 150 research projects Institute for Medical Education- 400 medical residents in 19 specialties HealthPartners Health Behavior Group 10K steps- first large scale walking program in U.S. 9 award winning phone courses PlenaryCourneya--8.22@10am QC

Seven step model Patient/ Member/ Consumer PlenaryCourneya--8.22@10am QC 3

Focus on goals Health goals 2010 Engage experts, staff, community Create system improvement by embedding goals in work plans Health goals 2010 8 stretch goals on service, quality, affordability Example: 75% performance on all optimal care outcome measures Report by age, gender, race and reduce identified disparities Sought feedback from the Institute for Health Care Improvement (IHI) in setting goals Expert panels:Informs about member, patient, community needs, best science and market demands. This engagement is important to the success of improvement initiatives . HealthPartners embeds goal setting in its annual and strategic plans to achieve system-level performance. HealthPartners links management incentive program directly to improvement goals. PlenaryCourneya--8.22@10am QC

Agree on best care Collaborate with providers Set targets Reward quality care Co-founder in 1993 of ICSI- with Mayo Clinic and Park Nicollet Health Services A collaborative of 62 medical groups and hospital systems dedicated to improving health care quality Funded by all six Minnesota health plans- 7,600 physicians- more than 75 percent of physicians practicing in Minnesota Promotes the use of evidence-based guidelines Established and updates more than 50 guidelines PlenaryCourneya--8.22@10am QC

Define success Clinical Indicators Report Significant improvements in: Optimal Diabetes Care BMI Assessment Pediatric Immunizations Generic Drug Use Cervical Cancer Screening Child & Teen Check Ups Lead Screening Annual report with comparative provider performance for primary provider groups, specialty provider groups and hospital. 36 clinical measures (127 individual measures) for preventive, chronic, specialty and hospital care, behavioral health, pharmacy,. Primary purpose: provide valid information for providers to improve patient care and outcomes. Statistically significant improvements in care. Examples: Optimal Diabetes Care: from 4.2% in 2002 to 12.8% in 2005 Tobacco use: In 1997 no group met HealthPartners tobacco target of 80 percent asked patients about tobacco use at every visit. Today: More than 94% assessed 80,000 fewer HealthPartners members use tobacco. Second-hand tobacco exposure at all-time low of 6.1%. PlenaryCourneya--8.22@10am QC

Aim high Composite measures supporting optimal care for: Diabetes Heart disease Preventive care Diabetes and heart disease are properly managed by controlling all risk factors not just one or two. HealthPartners collects and publicly reports composite scores for diabetes, coronary artery disease, and preventive care. PlenaryCourneya--8.22@10am QC

Institute of Medicine: Composite measurement “The committee believes this concept represents a turning point, and a relatively new challenge, for performance measurement.” Source: Performance Measurement: Accelerating Improvement (2006) IOM report case study (page 93) Quote from report: In the 2004 reporting period, although each separate clinical variable showed performance in the range of 45.5 percent (BP ≤130/85) to 82.8 percent (not smoking), the composite score revealed that only 18.4 percent of eligible patients were receiving the complete set of needed interventions (Personal communication, G. Amundson, HealthPartners, December 2004; Amundson et al., 2005). The use of composite measures suggests performance goals considerably more stringent than those captured by the usual single-variable measures. Using composites in this manner allows for a patient-centered approach that takes into account the full constellation of health care needs (McGlynn et al., 2003a PlenaryCourneya--8.22@10am QC

Aim high Optimal diabetes care 1. HbAlc < 7 2. LDL <100 3. Blood pressure <130/85 4. Documented tobacco free 5. Daily aspirin >age 40 Optimal diabetes care Impact: Average A1c surpasses treatment recommendations. Since 1997 falling from 8.7% to 6.8%. Average LDL cholesterol for heart disease decreased from 109 mg/dl in 1999 to 86 mg/dl in 2004 also surpassing current treatment recommendations. Average systolic blood pressure for diabetes dropped from 134 mmHg to 122 mmHg over the past five years P4P measures stretch goals: pay-outs for excellent (25% of bonus pool) and superior (100%) results. PlenaryCourneya--8.22@10am QC

Minnesota Community Measurement Performance data for 100 medical groups Comparative data for 13 conditions Search by city or county Ratings by * below average ** average *** above average At no charge, HealthPartners provided the proprietary methodology used to measure optimal care by provider groups in Minnesota HealthPartners is a founding member of MN community Measurement first in nation to offer comparative performance data for medical group performance statewide Performance data for 13 conditions from asthma, diabetes, cancer screening, well child visits Annual reports- First report in 2005- PlenaryCourneya--8.22@10am QC

Align incentives Pay for quality improvement Pay-for-performance – Partners in Excellence Stretch goals for Clinical quality (80%) Patient experience (20%) Payouts for superior, excellent performance HealthPartners was one of the first health plans in the nation to implement a pay-for-performance (P4P) program in 1997 to recognize and reward quality. Recognition very important Partners in Quality, rewards providers in 76 primary care and 40 specialty groups (cardiology, orthopedics, OB/GYN, behavioral health, emergency medicine, and ENT), 16 hospitals, retail pharmacies, and physical therapy practices. More than 90% of HealthPartners 640,000 members receive care from provider groups eligible to participate in Partners if Quality. Has two components: Partners in Excellence rewards excellent and superior performance in meeting stretch goals. In 2005: 31 provider groups met one or more ORP targets. PlenaryCourneya--8.22@10am QC

Align incentives Pay for quality improvement Pay-for-performance- Partners in Progress Reimbursement in provider contracts for: primary care specialists hospitals, pharmacies, physical therapy Second component, Partners in Progress: HealthPartners works with groups to establish their specific goals- providers rewarded for making improvement- even if they don’t meet stretch goals. Part of contract reimbursement. Not publicly reported. PlenaryCourneya--8.22@10am QC

Align incentives Never events 2003: New MN law to report adverse health events 2005: HealthPartners policy to not pay for never events 2006: Centers for Medicare and Medicaid investigates ways to not pay for never events Leapfrog never events policy On Jan. 1, 2005, HealthPartners implemented a policy that withholds payment to hospitals for extremely rare medical errors identified by the National Quality Forum as things that should never happen to a patient. 2004 first Minnesota report 30 hospitals reported 99 events that resulted in 20 deaths and four serious disabilities.  In the second year, 47 hospitals reported 106 events that resulted in 12 deaths and nine serious injuries.    New laws in New Jersey, Illinois.  Several other states y considering laws PlenaryCourneya--8.22@10am QC

Align incentives Engage providers in design and implementation Metrics based on consensus of evidence based guidelines Provider round tables Public recognition HealthPartners practitioners participate in the planning, design, implementation, and review of the Partners in Quality program. Partners in Quality outcome metrics are aligned with evidence-based clinical guidelines established by the Institute for Clinical Systems Improvement. Regular (quarterly to every 6 months) round tables provide counsel and direction in regard to the quality measures used in Partners in Quality. Providers who meet target measures are publicly recognized during an annual ceremony and in a news release regarding our Partners in Quality Program. In addition, they are highlighted on HealthPartners.com and financially recognized for clinical excellence. PlenaryCourneya--8.22@10am QC

Align incentives BMI Fairview Clinics Burnsville Family Physicians, PA HealthPartners Clinic Peds Prev Care UTD Children’s Physician Network Metropolitan Pediatric Specialists Example of slide from Recognition event in October 2006 PlenaryCourneya--8.22@10am QC

National Business Group on Health Recipient of 2006 Excellence and Innovation in Value Purchasing Award Recognizes efficiency, improved quality, affordability PlenaryCourneya--8.22@10am QC

Support improvement At risk registries Behavioral health case management Results: Outpatient behavioral health visits +26 % Emergency room visits -9% Hospital inpatient admissions - 9% ROI 5:1 At risk registries HealthPartners supports providers’ quality improvement efforts by identifying patients who are in need of required services to achieve optimal care for Asthma, Coronary Artery Disease (CAD), Cardiovascular Disease, Diabetes, Congestive Heart Failure, COPD, and Hypertension. Educational provider newsletters that address best practice topics and available resources are also available to providers Behavioral health predictive algorithm HealthPartners developed a predictive algorithm to identify and proactively reach out to members who are at risk for behavioral health crises and hospitalization within 12 months. Since 2003, early intervention for more than 2,000 high-risk members PlenaryCourneya--8.22@10am QC

Evaluate Transparency in reporting Ongoing evaluation for: trend impact improved performance improved patient outcomes provider satisfaction. HealthPartners publicly reports performance for all provider groups. A few select withhold measures are not shared publicly as they are confidential under the terms of the provider contract. Ways in which overall quality scores are reported: Clinical Indicators report available on HealthPartners.com. Measurement data translated into a consumer-friendly “star” chart format - which helps members make informed cost and quality decisions about their health care - is available on HealthPartners.com Measurement results used for HealthPartners tiered products PlenaryCourneya--8.22@10am QC

Saves 100 Hearts & 140 Legs & 740 Pairs of Eyes Each Year Since 1997: HealthPartners members with diabetes, suffer 100 fewer heart attacks, 140 fewer amputations and 740 fewer eye complications each year. Generic drug use has increased to 61%. Every one percent increase in generic use among HealthPartners members reduces drug costs by $6 million per year. Tobacco use among HealthPartners members is at an all time low of 13% falling by 50% since 1998. Children’s exposure to second hand smoke has fallen by 75% to 6%- PlenaryCourneya--8.22@10am QC

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Summary Leading for Quality: Establish goals Collaborate Measure Reward Report PlenaryCourneya--8.22@10am QC

“Progress through collaboration” HealthPartners approach: share measures, collaborate with providers, engage consumers “Michael, if you can't pass, you can't play.” - Coach Dean Smith to Michael Jordan in his freshman year at UNC PlenaryCourneya--8.22@10am QC