Community Partnerships in Quality-Based Purchasing Roy Plaeger-Brockway, MPA Senior Program Manager Health Services Analysis Washington State Labor & Industries Olympia, Washington

Objectives Describe two Washington State pilots Explain how pilots encourage community based quality improvement Share results of pilots based on a University of Washington evaluation Discuss lessons learned

Background L&I is a state workers’ compensation insurer Purchase $500 million of health care a year Quality of care is a top priority To improve care we engaged our customers in designing two community-based quality improvement pilots Centers of Occupational Health & Education 700 participating doctors 20,000 patients a year

What was the problem? Difficult for purchaser to influence quality Doctors with imperfect knowledge about work related conditions No incentives for physicians to adopt occupational health best practices No infrastructure for community-wide disability prevention Delivery system not organized to prevent disability Lack of care coordination No education or feedback for doctors No information systems to track clinical data Not using data for health care quality improvement

What was the solution? Develop a community-based infrastructure Local centers and experts to provide education and support to community physicians Health services coordinators Align payment incentives to support quality Enhanced payment linked to quality indicators to encourage use of occupational health best practices Improved work force training Free CME and individualized physician training and support More effective use of information technology Patient tracking tool with reminders and alerts

Two providers chosen with RFP Inland Northwest Health Services St. Luke’s Rehab Institute Valley Medical Center

Community-based model supports use of best practices State Insurer Customer Advisors Education & reminders Patient tracking tools Health services coordinators Health System Pilot Community Payment linked to quality indicators Community Physicians

Design of quality measures Review evidence Develop seed measures (best practices) Share with practicing physicians Rank with physician leaders Establish payment levels and billing codes Develop quarterly reporting to track progress on measures based on billing codes

Best practices with incentives Submit accident report within 2 days Document worker’s physical status and limitations at each visit Contact the worker’s employer about return to work options Assess barriers to return to work at 4 weeks of lost time

Example of a best practice “Activity Prescription” Use at patient visit Script best practices Document employment issues Work status Employer contact Light duty accommodation Set patient expectations

Increased adoption of best practice Percent of Claims Where Doctors Used Best Practice (Physical Status Form)

Evaluation of Western WA COHE Disability outcomes Incidence was 17.8% vs. 23.7% for control Workers on time loss at 6 months was 15.1% vs. 18.9% Workers on time loss at 12 months was 7.4% vs. 9.4% Costs Medical costs were $1,785 per claim vs. $2,167 Disability costs were $711 per claim vs. $1,209 Satisfaction Patient satisfaction was equal to control group Physicians reported greater willingness to work with injured workers Based on 10,000 claims

Evaluation of Eastern WA COHE Disability outcomes Incidence was 15.1% vs. 21.5% for control Workers on time loss at 6 months was 20.5% vs. 20.4% Workers on time loss at 12 months was 10.2% vs. 9.7% Costs Medical costs were $1,643 per claim vs. $2,138 Disability costs were $610 per claim vs. $930 Satisfaction Patient satisfaction was equal to control group Physicians reported greater willingness to work with injured workers Based on 10,000 claims

Overall results University of Washington evaluation shows: Reduced incidence of disability Improved patient outcomes Lower medical and disability costs High patient satisfaction Improved physician satisfaction Overall savings $441 per claim Western WA $359 per claim Eastern WA

Lessons Learned Community-based partnerships between purchaser and health care leaders help: Create infrastructure needed to improve quality and outcomes Foster physician support for solutions by involving local leaders in program design and development Place responsibility for quality improvement within the local marketplace, which increases adoption

Lessons Learned Physicians are willing and able to adopt best practices and improve quality when they have: Local institutional support from clinical leaders Incentives for use of best practices Health services coordinators Better information tools and education Reduced administrative burden Reminders and academic detailing

2001 IOM Report: Crossing the Quality Chasm - Similarities Institute of Medicine Washington State Pilot Design more effective organizational support Local centers and experts to provide education and support Create infrastructure to support evidence-based practice Free CME for doctors and assistance from health services coordinators More effective use of information technology Patient tracking tool with reminders and alerts Alignment of payment incentives to support quality Enhanced payment linked to quality indicators Improved work force training Individualized physician training