Transcript Slide 1

Making the Business Case for
Quality in Healthcare?
December 11, 2008
Roger Chaufournier
Kathy Reims, M.D.
NQC Consultant
Funded by HRSA
HIV/AIDS Bureau
Presentation Overview
•
•
•
•
•
The Environment
Lessons from Health Care Transformation
High Leverage Change Concepts
Impact on Finances
Dialogue
National Quality Center (NQC)
DANGEROUS
(>1/1000)
The Environment
REGULATED
ULTRA-SAFE
(<1/100K)
100,000
Total lives lost per year
HealthCare
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
1,000,000 10,000,000
Number of encounters for each fatality
Consumer Directed Healthcare
Malpractice/Risk Management
State Medicaid Crises
Medicare Modernization
40+ Million Underserved
Patient Safety
HRSA Core Measures
Changing Patient
Demographics
Pay for Performance
Work Force Dynamics
Competition for Patients
Public Accountability
& Transparency
Vendor Driven Healthcare(WalMart)
Employer Driven Healthcare
Medical Homes
Electronic Health
Information
Washington Post October 9, 2006
A Prescription for Worker’s Health: Employers Open InHouse Clinics to trim Costs and Boost Preventive Care
National Quality Center (NQC)
Results from Quality Improvement…
• Opened 2 additional clinical
sites without federal funding
• Added 2 Pharmacies
• Added services
 2 DSME Programs
 Literacy Program
 RSVP
• Developed 2 Wellness Centers
• Developed Community
Initiatives
• Each Owner received a $1000
Holiday Bonus
• Increased Cash Reserves - < 15
days to >200 days
 $100,000 to over $3M
• Implemented enterprise-wide
EHR
• billable services increasing by
36% even though the number of
encounters increased by only
8%.
• Self-pay collections increased
from 42% to 77% in two
months
• Billing rejections decreased
from 95% to 5%
• Insurance aging >120 days was
44%, now is 13%
National Quality Center (NQC)
Source: Greg Wolverton; WRRHC
The Potential-The Pioneers
CareSouth Carolina
•
•
•
•
•
•
•
•
Time with doctor has gone from 8.2 minutes to 12.5 minutes
Total visit time has gone from 90 minutes to 47 minute average
HbA1c for their population of focus came down from 11 to 8
Encounters and revenue for behavioral health services
skyrocketed (in Medicaid cost based reimbursed and Medicare is
60% of the cap for behavioral counseling services)
There are several key clinical indicators where they have
reversed the health disparities and outcomes for minority
populations are better
Third available appointment has gone from 140 to 0 days
Went from breakeven/deficit spending to 7% positive margin
Total average aggregate costs of care for people with Diabetes
30-70% less than all other providers
Source: Ann Lewis, CEO CareSouth Carolina
National Quality Center (NQC)
Why are payers interested?
Medical
Home
(CareSouth)
Average Total Annual Payment
Per patient
Annual drug payments per
patient
$1,340
25% less
Total costs
To the State
$502
All Family
Practice
Physicians
Median
$1,778
$576
Cost based
Reimbursed as
FQHC. Still did
better
Average office visit payment
$441
Average Inpatient Hospitalization
$172
$634
$15
$22
Average ER Payment
Source: South Carolina Office of Budget and Control 2004
$168
National Quality Center (NQC)
THE PREVALENT SYSTEM OF CARE DELIVERY
Practice
working in a vacuum
Health System
Organization of Health Care
Community
Resources and Policies
45% Internet
traffic is patients
seeking self
management
info
Informed,
Activated
Patient
Self-Mgt
Support
Delivery
System
Design
Productive
Interactions:
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Evidence-based clinical management
Collaborative treatment plan
Effective therapies
Self-management support
Sustained follow-up
40% waste
& inefficiency Functional and Clinical Outcomes
Delays & Waits for access 1-12 weeks
Decision
support
20%-55%
Compliance
with
guidelines
Less than
18%-24%
use IT for
patient
care
3:1 Staffing Ratio
National Quality Center (NQC)
OPTIMIZING MARGIN
IS A COMPLEX PUZZLE
National Quality Center (NQC)
Optimizing Your Margin is A
Complex Puzzle
Expense Drivers
Revenue Drivers
Demand
Charges
Productivity
Prod
uctivi
ty
Throughput
No
Show
Rate
Lean
Planned
Care
Materials
Design
Facility
Work
Environment
National Quality Center (NQC)
Driving the Business Case
Lessons from the Field
IHI Idealized Practice
Redesign lessons
High Leverage Drivers:
•Advanced Access
•Optimize Care Team
HRSA
Collaboratives
pilots
•Lean-Continuous flow/
•Cycle time reduction
IMPROVED
OUTCOMES
+
•Planned Care
Lean Applications
In Health Care
•Registries for Master
•Scheduling
•Revenue Optimization
National Quality Center (NQC)
Planned Care
• Use of a proactive care model such
as the Wagner Care Model
• Registries used for master
scheduling
• Population and patient level care
National Quality Center (NQC)
Health System
Organization of Health Care
Community
Self-Mgt
Support
Resources and Policies
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions:
Clinical
Information
Systems
Decision
support
Prepared,
Proactive
Practice Team
Evidence-based clinical management
Collaborative treatment plan
Effective therapies
Self-management support
Sustained follow-up
Functional and Clinical Outcomes
National Quality Center (NQC)
PLANNED CARE IN THE NEW ENVIRONMENT
Community resources
part of care team
DOH, Disease Vendors
Reimbursement
aligned to support
planned care
Medical Home
P4P, P4Play, P4Q
Health System
Organization of Health Care
Community
DIGMA’s
&Group visits
used 25%
Self-Mgt
Support
Resources and
Policies
17% visits by
Email
Informed,
Activated
Patient
Continuous flow
minimizes on-site time
Open access:
No shows decrease
to 2-5%
Delivery
System
Design
Productive
Interactions:
Clinical
Information
Systems
Decision
support
Prepared,
Proactive
Practice Team
Evidence-based clinical management
Collaborative treatment plan
Effective therapies
Self-management support
Sustained follow-up
Functional and Clinical Outcomes
Guidelines
In exam room with
PDAs/registry reminders
EMR: eliminate
all paper
Registry used for
master scheduling
and outreach
Expanded Care Team
N.P.
N.P.
R.N.
R.N.
M.D.
M.A.
DIETICIAN
National TEAM
Quality Center (NQC)
EXTERNAL
Advanced Access
• Majority of appointments held for
today’s and yesterday’s patients
• Planned visits scheduled
• Today’s work done today
• Max packing of visits
• Managing demand through alternative
models (e.g. Group visits/Electronic
visits)
National Quality Center (NQC)
What happens in Open Access?
Example of Nurse Triage
1. Call answered by a receptionist, message taken, or appointment booked
without further discussion (1-3 minutes)
2. The chart is pulled and a message attached (2 minutes)
3. If no appointment made, patient chart and message reviewed and
prioritized prior to call back (4 minutes)
4. A call back is placed. More information obtained and then appointment
made, referral made or a physician consult is required before
resolution (5 minutes: Note not all callbacks are reached on a first
attempt)
5. An additional call back to patient after a physician or nurse consult (2
minutes)
6. Receptionist asked to schedule an appointment, complete a managed
care referral form or call a script to a pharmacy (3-5 minutes)
7. An entry into patient’s chart is made (3 minutes)
8. The chart is refilled (2 minutes)
Total Staff Time: 24 minutes @ an average cost of $14/hr
Total annual dollar impact: 10 calls a day; 200 days; $11,200 in
staff time annually
Source: Case study from NCQA Web site
National Quality Center (NQC)
How did the role of the RN Triage Nurse at
UCDMG Roseville Change with Open Access?
100%
88%
80%
35%
5%
Triaging
Phone Calls
0%
1%
1%
20%
0%
20%
0%
Ass't Back
Office/Pts
20%
5%
15%
QA Duties
10%
Efficiency
Projects
Sep-02
Back Office
Procedures
40%
Apr-02
Triaging
walk ins
60%
Source: Marjorie Godfrey; Dartmouth Hitchcock
National Quality Center (NQC)
Optimizing the Care Team
• Expanded roles
 Deploying highest level of skill to
lowest level of licensure allowed by
the state
• Team based model
• Care coordination across the
continuum; Medical Home Model
National Quality Center (NQC)
Profitability by Full-time Support Staff
Profitability for Family Medicine Groups by Number of FTE Staff per FTE
physician
Median Revenue after
Operating Cost per FTE
Physician
300,000
$241,289
$227,890
250,000
$187,842
200,000
$176,894
150,000
$90,908
100,000
50,000
0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
FTE Support Staff per FTE Physician
Source: MGMA data
National Quality Center (NQC)
Applying Lean
• Process Mapping to identify bottlenecks and
waste
• Applying 7 forms of Waste to the clinic
• Optimizing flow and cycle time
• Purposeful design
• Implementing highly reliable systems
National Quality Center (NQC)
Revenue Optimization
•
•
•
•
Coding
Charge Capture
Compliance with the evidence base
Negotiating new lines of revenue
National Quality Center (NQC)
White River RedeFin Measures
National Quality Center (NQC)
The Pioneers-Mercy Campus, Iowa
•
•
•
•
•
IHI Impact
Wellmark Collaboration on Quality Initiative
Used SECAT Registry
Tested Health Coach Model
Tested Transparency of provider group
internal to the system
• Implemented Advanced Access
National Quality Center (NQC)
Diabetes Outcome Measures
October 2005 – September 2006
MCI
100%
80%
HEDIS 2005 (90%ile)
92% 88%
64%
HEDIS 2005 (mean)
79%
73%
60%
49%
40%
69% 65%
40%
20%
% HgA1c < 9.0
% LDL < 130
All MCI diabetes patients n = 8631
% LDL < 100
National Quality Center (NQC)
3000
MCI Microalbumin Tests (per Qtr.)
2500
CMS Profit = $8.00 / test
2000
Yields $100,000 / yr.
1500
1000
500
0
d
3r
02
20
1s
3
00
2
t
d
2n
03
0
2
d
3r
03
20
h
4t
03
0
2
1s
4
00
2
t
d
2n
04
0
2
d
3r
04
20
h
4t
04
0
2
1s
5
00
2
t
d
2n
05
0
2
d
3r
05
20
National Quality Center (NQC)
Dialogue?
Questions?
Reflections
National Quality Center (NQC)
Contact Information
Roger Chaufournier
Chief Executive Officer
CSI Solutions, LLC
[email protected]
301-529-7858
Kathy Reims, M.D.
Chief Medical Officer
CSI Solutions, LLC
[email protected]
720-890-8614
National Quality Center (NQC)