Transcript NCQA HEDIS Adolescent Combo 1 Commercial Product Line

Total Quality Management in
Health Care Marketing
How the Market’s Demand for Quality is Changing!
JJ Parsons
Presbyterian Healthcare Services
Vice President, Business Development & Contracting
[email protected]
(505) 923-8512
Improving the health of individuals, families and communities
Americans are more likely to want a new direction in
health care even compared to the situation in Iraq!
Health care
Iraq
Immigration
Foreign policy in places other than Iraq
Family values issues
Global Warming
Trade
Source: Public Opinion Strategies (2007)
Improving the health of individuals, families and communities
39%
35%
29%
22%
20%
13%
10%
Healthcare Needs a Quality Focus
• “The current healthcare system is economically
unsustainable and negatively impacting our nation's
ability to compete globally.” Craig Barrett, Intel
Chairman, 2006.
• The Institute Of Medicine estimates that
44,000-98,000 deaths occur annually in American
Hospitals due to medical errors.
Improving the health of individuals, families and communities
Market Implications:
1. National and local healthcare reform and legislation
2. Market transparency of quality outcomes
3. Changes in Reimbursement
4. Increase focus by regulators
5. Increased competition by healthcare travel companies
6. Healthcare corporations focused on balanced scorecards
Improving the health of individuals, families and communities
Don’t Try this at Home
“Why are they always pushing
quality on us?”
Improving the health of individuals, families and communities
1. National & Local Healthcare Reform & Legislation
• Massachusetts
– 2006 - First state to require health insurance and provide
universal coverage
• California
– Governor introduced $12B universal coverage plan, but
failed in Legislature in 2008
• New Mexico
– Governor Richardson seeking healthcare coverage
expansion but outlook in Legislature is uncertain
Improving the health of individuals, families and communities
Insurance: National Scene
•
•
•
•
•
•
Rising healthcare costs
Evolving consumer role & interests
Importance of technology
Increasing government involvement
Increasing focus on quality & customers
Consolidation
Improving the health of individuals, families and communities
Improving the health of individuals, families and communities
Insurance: New Mexico Market - Overall
• Increasing role of government including
legislative bill and restrictions on profit levels
of health plans
• Higher percentage of individuals covered
under government programs; lower
reimbursement for these programs increase
rate for Commercial market
Improving the health of individuals, families and communities
Physicians/100,000 Population: New Mexico
4500
200.0
197.4
195.0
3500
190.0
3000
185.0
3858
2500
2000
180.0
3186
173.8
175.0
1500
1000
1832.28
1954.60
170.0
500
165.0
0
160.0
2001
Source: US Census Bureau &
Center for Health Workforce Studies
2006
Year
Improving the
health
of individuals,
families
and communities
Number
of Active
Patient Care
Physicians
NM Population (in 0's)
Physicians per 100,000 Population
NM Population (in 0's)
Number of Active Patient Care Physicians
4000
2. Market transparency of quality outcomes
Who are the audiences for health performance
information?
Consumers…use this information at various points of
interaction with the health system, from the time
they choose a health plan to the point of selecting a
health care provider for a specific service.
Employers/Purchasers…want information to use in
selecting from among various health plans,
including the cost and outcomes of providers and
quality standards.
Improving the health of individuals, families and communities
Transparency (continued)
Health Plans…want to evaluate the price and quality
of all physicians, hospitals, and other providers.
May also want to benchmark their performance on
service and quality measures to their competitors.
Providers…Hospitals, physicians, and other health
care providers would benefit from more transparent
price and quality information as a feedback loop for
improved performance efficient or effective referrals.
Policymakers…Federal/state officials for oversight
and monitoring of provider and health plan
performance.
Improving the health of individuals, families and communities
Improving the health of individuals, families and communities
Quality in Healthcare: Performance Scores (continued)
Improving the health of individuals, families and communities
Response: Demand for Increased Transparency
• Cost (IRS Form 990)
– Collection practices
– Community benefit
– Tax-exempt status
• Quality
– IHI: “5 Million Lives Campaign”
– Leapfrog: 27 Safe Practices
– Never Events
– Regulatory
Improving the health of individuals, families and communities
3. Changes in Reimbursement: CMS Halts
Payments for Never Events
• CMS – “The right care, for every patient, every time.”
• October, 2007: 1st step toward preventing Medicare from
paying hospitals for costs of treating a patient who
acquires specific conditions during hospitalization.
• “Never Event” Examples:
– Objects left in surgery
– Catheter-associate urinary tract infections
– Decubitus ulcers
Improving the health of individuals, families and communities
4. Increased focus by regulators: Transparency of
Patient Satisfaction Data
Hospital Consumer Assessment of Healthcare Providers and
Systems
As stated by CMS and AHRQ:
• “HCAHPS is a tool to be used for public reporting
of major areas of hospital performance to support consumer
choice”
• “HCAHPS is not a stand-alone quality improvement tool”
HCAHPS presents the symptoms—additional measurement is needed
to make a diagnosis and improve.
Improving the health of individuals, families and communities
Transparency of Patient Satisfaction Data
• Consumers will have access to the data
– Consumers will relate more easily to HCAHPS
than to clinical data
– Some will use HCAHPS data to choose hospitals
– Will have volume, revenue, and reputation implications
• HCAHPS will be in the public eye
– Media coverage
– Promotion by hospitals themselves
• Reported for consumers on Hospital Compare Web site
(www.hospitalcompare.hhs.gov)
• Typical public report data are shown as frequencies
– Hospital performance frequencies
– National and state average performance frequencies
Improving the health of individuals, families and communities
Transparency of Patient Satisfaction Data
Public reporting will include the following six domains
(March 2008):
• Communication with Doctors
• Communication with Nurses
• Responsiveness of Hospital Staff
• Pain Control
• Communication about Medicines
• Discharge Information
The following four questions will also be reported:
• Cleanliness of Hospital Environment
• Quietness of Hospital Environment
• Overall Rating of Hospital
• Recommend Hospital
Improving the health of individuals, families and communities
Don’t Speak in “Quality-ese”
“It’s a vice-president thing, Berger.
You wouldn’t understand.”
Improving the health of individuals, families and communities
5. Increased competition by healthcare travel companies
Medical Tourism Plans Blossoming Around the country
• Why?
– Reduced costs
• Ex: Open Heart Surgery in US: $100,000
Wockhardt, India: $7,500
- Way in which patient Treated
• Care outside medical services includes: gourmet meals;
laundry services; quality of room; hotel suite like room
• Access to physician call phones
- Opportunity to see new part of the world: “vacation”
- Access to procedures not yet approved by FDA
Source: ForbesLife
Improving the health of individuals, families and communities
6. Healthcare corporations focused on balanced scorecards
National Excellence
Three Things
Growth &
Mission
Staff
Focus
Customer
Loyalty
Clinical
Outcomes
Financial
Outcomes
• Commercial Sales
• Throughput
• Facilities/SM
• Advanced Access
• Hire Right
• Rounding
• TYN
• 30/90
• Customers First
• Customer Loyalty
Bundle
• Advocate
• Medical Safety
• Clinical Bundles
• Comprehensive
Diabetes Care
• MCR
Management
• Expense Control
• PFS
• Customer Count
• Time to 3rd next
available
• Turnover
• Employee
Satisfaction
• PHP Satisfaction
• PDS Satisfaction
• PMG Satisfaction
• Mortality
• Harm Rate
• Diabetes AIC
• Operating Margin
• Day’s Cash
Improving the health of individuals, families and communities
Baldrige Criteria Framework: A Systems Perspective
Improving the health of individuals, families and communities
MBNQA Applicants by Stage
MBNQA
2005
2006
Stage 2
Stage 3
2007
Stage 2
Stage 3
Applicants /
Stage 3
Award Category Applicants (Consensus) (Site Visits) Recipients Applicants (Consensus) (Site Visits) Recipients Consensus (Site Visits) Recipients
Manufacturing
1
1
1
1
3
2
0
0
2
0
0
Service
6
3
1
1
4
2
1
1
4
0
0
Small Business
8
3
1
1
8
3
3
1
7
2
1
Healthcare
33
21
7
1
45
22
6
1
42
7
2
Education
16
8
3
2
16
10
3
0
16
1
0
Nonprofit
NA
NA
NA
NA
10
10
2
0
13
4
2
Total:
64
36
13
6
86
49
15
3
84
14
5
Improving the health of individuals, families and communities
Strategy:
Goals:
National Excellence
3 Things
1. Malcolm Baldrige Award 2. Top 10% in Patient Safety 3. “AA” Rating
PresEssentials : Clinical Outcomes Financial Outcomes Customer Loyalty
Staff Focus
Growth and Mission
Results:
PHS Board Measures
2007 Vital Few Create process and information infrastructure changes to:
Objectives:
– Improve outcomes of the Patient Care Process
(access, throughput, satisfaction, safety)
– Reduce cost per member and cost per unit of service
2007 Theme:
Must Haves:
How We Work
Every Patient, Every Member, Every Time
Employee
Retention
Bundle
Hire Right
Bundle
– Behavioral
Interviewing
– Rounding
– Pre-Interview
– Thank You
Assessment
Notes
– Peer
– 30/90 Day
Interviewing
Improving the health of individuals, families and communities
Meetings
Customer Loyalty Bundle
– Key Words at
Key Times (AIDET)
– Rounding on Customers
– Pre, Post and
Welcome Calls
– Service Recovery
(Advocate)
Sense of Mission
se
o
p
r
Pu
To earn from each
community served:
Presbyterian
serves to improve
the health of individuals,
families and communities.
Vi s
i on
D ea r Pres byte ria n:
Yo u w ere bo rn an d ra is ed h ere be cau se w e n ee de d
a p la ce for h ea li ng a nd car in g. A s w e g re w an d ch an ge d,
yo u ha ve g ro wn w i th us. Y ou s erv e ea ch i nd ivi du al a nd fa mi ly
w ith co mp assi on an d se nsi tivi ty . By yo ur e xam pl e, you te ach us
to take be tte r care of ou rse lve s. We are w il li ng pa rtn er s wi th you
in ma kin g ou r co mmu ni ti es b etter p la ces to l ive . Yo u h ave met
the cha ll en ge o f m aki ng you r ser vice s ac cess ib le, affor da bl e, an d
a ccou nta bl e to the c omm un ity. It’s n o w on de r you are r eco gn ize d
n atio na ll y fo r he al th ca re e xcel le nc e. We are pro ud to
cal l yo u ou r ow n.
Co mm un itie s Thro ug ho ut the S ou th we st
C.A.R.E.S.
We value clinical and service excellence
through:
-- People helping people
-- Stewardship
-- Integrity
-- Honest, caring relationships
-- Totality of health: body,
mind and spirit.
Va lu
es
benefit patients and members,
To
benefitTopatients
and members, Presbyterian
Presbyterian is dedicated to national excellence by the
of 3 Things:
isachievement
dedicated
to national excellence by
1 . Ma lc olm Ba ldrige Quality A war d - c on ti nu ou sly i mp rov e
pro ce
sses to p ro du ce n atio na of
ll y exce
en t c lin ic al, se rvic e
the
achievement
3 llThings:
an d b usi ne ss res ul ts .
continuously
improve processes to produce
nationally excellent
gi es clinical, service
e
t
Str a results.
and business
1.Malcolm Baldrige Quality Award -
2 .Top 1 0% in Pa tient Sa fet y - cre ate the safe st p oss ib le
e nvi ro nme nt for tho se w ho pl ace th ei r tr ust in u s.
3 . “A A” R a ting - co ntrol exp en se s wh il e gro w in g
o ur bu si ne ss to sus ta in po sitiv e fin an cia l
pe rform an ce a nd to fu nd
e xce ll en ce.
Or iginal Board Ap proval 12 /9 5
3rd Revision A dopted 10/22/02
2.Top 10% in Patient Safety - create the safest possible environment for those who
Sense of Mission
place their trust in us.
3.“AA” Rating - control expenses while growing our business to sustain positive
financial performance and to fund excellence.
Improving the health of individuals, families and communities
PHS Baldrige Journey Timeline
Training
Define customers and
requirements
Key core process
identification
Achieve MBNQA Consensus
Stage
MBNQA Site Visit
NMQA Zia Award Recipient
Two MBNQA examiners:
One senior
Organizational Profile
40 QNM Examiners
Self Assessment
One MBNQA Examiner
26 QNM Examiners
Four areas of focus
2002
2003
2004
2005
2006
Plan from self-assessment
MBNQA Site Visit
Zia application completion
25 QNM Examiners
QNM Roadrunner Recipient
One MBNQA Examiner
49 QNM Examiners
Improving the health of individuals, families and communities
2007
Focused on Key
Learnings
49 QNM Examiners
1 MBNQA Examiner
Looking Ahead (The journey is challenging but we are better prepared)
1st Quarter
Presbyterian Annual Rhythm
2nd Quarter
People
Celebration/Kickoff
•Annual Theme
•Vital Few Objectives
January
February
March
April
MPR
MPR, QPR, ELF,
LDI, QEF
MPR
•Staff reviews
•Leadership evaluations
•People summit
May
MPR
MPR, QPR, ELF,
LDI, QEF
June
Start
MPR
Performance Reviews:
•Monthly Leadership (MPR)
•Quarterly Leadership (QPR, LDI, ELF)
•Quarterly All Employees (QEF)
MPR, QPR, ELF,
LDI, QEF
July
MPR
December
4th Quarter
Preparation
•Budget
•Work Plan
•Measures
•Incentives
•Theme
Improving the health
Revision: 1/11/2008
MPR
MPR
November
MPR, QPR,
ELF, QEF
MPR, LDI
October
September
August
LDI : Leadership Development Institute QPR: Quarterly Performance Review
MPR: Monthly Performance Review
QEF: Quarterly Employee Forums
ofELF
individuals,
families
communities
: Extended
Leader and
Forum
3rd Quarter
Strategy
•Project Prioritization
•Strategic Plan
•Tactical Plan
•Capital Plan
• IT Plan
•Budget assumptions
Process link
PHS Work System
Presbyterian Healthcare Services
EST and EOT
PHP
Annual Rhythm Process
PDS
Operating Units
Senior Leader
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Department
Patient Care Process/Council
COB UNIT PROCESSING Detailed Process Map – Baseline State Process
Department
Department
Department
Department
Department
Department
Department
Customer Acquisition and
Retention Process/Council
1
1
2
PFS
PFS COB Unit
Work Individual
Denied Claims
from Provided
Denial Report
Downloads
Weekly Automated
PHP Denial Report
2
PFS COB Unit
Verify
Information
on file is
enough to
file the
claim
Online System
Available?
Customer Service Process/Council
Selection & Engagement Process/Council
Customer Financial Experience/Council
Yes
No
4
PFS COB Unit
PFS COB Unit
Updates Patient
Accounting
System
Verifies Timely
Filing Period
A
2
PFS COB Unit
Patient
Eligibile?
Contact Insurance
Payor who is
Primary
2
Yes
Contacts Primary
Insurance Payor
7
No
8
PFS COB Unit
PFS COB Unit
Contacts PHP
COB for
Investigation
Determines Other
Coverage
9
PFS COB Unit
Other Primary
Coverage?
Yes
PHP Provides
Corrected
Information
1
10
No
11
Support
Each
Employee
connects to
PHS’
Purpose
through the
management
structure
Patient
Eligible?
6
PFS COB Unit
Department
Department
Validates Patient
Eligibility and
Insurance Address
Yes
No
5
12
PFS COB Unit
Department
3
PFS COB Unit
Verifies Primary
Insurance is
Eligible for
Dates of Service
Weekly Decision
Support
Generated from
PHP Denials –
Eligibility
information also
included on the
existing report
A
Within Timely
Filing Period?
Yes
Electronic
Submission?
No
22
Yes
Submits Electronic
Claim
Adds Account to
TRAC for Further
Follow-up
18
19
14
PFS COB Unit
Adds QUIC
Deficiency
Waits 30 Day
Check Account
Status in PAC
PFS COB Unit
Adds QUIC
Deficiency
26
Unpaid?
Yes
No
20
PFS COB Unit
Adds Account to
TRAC for Further
Follow-up
25
15
PFS COB Unit
Mails Claim
24
B
PFS COB Unit
PFS COB Unit
No
23
13
PFS COB Unit
27
Paid?
28
PFS COB Unit
PFS COB Unit
PFS COB Unit
PFS COB Unit
PFS COB Unit
PFS COB Unit
PFS COB Unit
Rebills/Void and
Repost Claim to
Correct Primary
Payor
Adds Account to
TRAC for Next
Day Follow-up
Adds QUIC
Deficiency
Waits 1 – 7 Days
for Claim
Generation
Attaches Denial
and Claim
Documents in
TRAC for Further
Follow-up
Mails Claim
Non-COB
Denied?
No
Employees
and other
Stakeholders
engaged at
each process
step
PFS
Go to Secondary
Coverage
Collection
16
17
PFS COB Unit
PFS COB Unit
Contacts Payor for
Claim Status
(Phone/Online)
Documents in
TRAC for Further
Follow-up
B
21
Yes
No
29
PFS COB Unit
Pulls PHP Denial
PFS COB Unit
PHP Updates and
Adjudicates Claim
as Primary
PFS COB Unit
PFS
Updates TRAC/
QUIC Deficiency/
PAC
Paid Claim
30
Yes
1
31
PFS COB Unit
PFS COB Unit
PFS
Updates TRAC/
QUIC Deficiency/
PAC
Send to Denial
Team for Appeal
Follow Appeal
Process
Improving the health of individuals, families and communities
HEDIS: Diabetes A1c Poor Control--Commercial
70%
Good
60%
Percent in Poor Control
50%
40%
30%
20%
10%
0%
2003
2004
90th Percentile
Presbyterian Health Plan
Improving the health of individuals, families and communities
2005
2006
National Average
Best Competitor
2007
Presbyterian’s Commitment to Quality
• Earned two consecutive site visits
from National Malcolm Baldrige
Quality program. Earned QNM’s Zia in 2004.
• Health Plan one of 14 in nation with three
“excellent” accreditations for managed care.
• Medical Group setting the benchmark for care
of patients with diabetes.
• Investing millions in patient safety, reduced
hospital medication errors by 80 percent.
Improving the health of individuals, families and communities
Perspective on the Future
• Healthcare will continue to be front page news
– It will be painful for those not prepared
• All stakeholder's of the healthcare arena will demand data to make
decisions
• The value equation = quality over cost
• Will under go many cycles of change
• Every service will be faster
• Those who don’t accelerate on the technology journey will not be
around
• Very soon there will be no payment for mistakes
• Consumer will own their own healthcare data
Improving the health of individuals, families and communities