Estelle Richman
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Estelle Richman
- 1. Estelle B. Richman, Secretary PA Health Care Reform Lessons from Pennsylvania Health Care Reform Estelle B. Richman Secretary, Department of Public Welfare
- 2. Estelle B. Richman, Secretary PA Health Care Reform Presentation Overview 1. Pennsylvania Framework – Governor Rendell’s Prescription for Pennsylvania – Role of Medical Assistance program 1. Outcomes from selected initiatives 2. Lessons for national health care reform
- 3. Estelle B. Richman, Secretary PA Health Care Reform Governor Rendell announces major health care reform initiative in 2007
- 4. Estelle B. Richman, Secretary PA Health Care Reform Prescription for PA Components Rx for Affordability Rx for Access Rx for Quality Cover All Pennsylvanians Health Care Workforce Hospital-Acquired Infections Coverage for College Students and Young Adults Removing Practice Barriers Serious Preventable Adverse Events Community Benefit Requirements Cost-Effective Sites Pay for Performance Uniform Admission Criteria Co-Occurring PH/BH Disorders Chronic Care Fair Billing and Collection Practices Health Disparities Capital Expenditures Child & Adult Wellness Small Group Insurance Reform Long Term Living Transparency of Cost and Quality Data End of Life and Palliative Care
- 5. Estelle B. Richman, Secretary PA Health Care Reform Medical Assistance program is key venue for PA health care reform 1,000,000 1,250,000 1,500,000 1,750,000 2,000,000 1991-92 1993-94 1995-96 1997-98 1999-00 2001-02 2003-04 2005-06 2007-08 2009-10* 2.022 million (projected*) MEDICAL ASSISTANCE ENROLLMENT
- 6. Estelle B. Richman, Secretary PA Health Care Reform Medical Assistance is a cost driver for Pennsylvania state budget Higher Education 8% Debt Service 4% All Other DPW Human Service Programs 18% Medical Assistance 16% Pre K-12 Education 37% All Other 12% Corrections 5% Education is biggest slice. Medical Assistance is biggest program. Education is biggest slice. Medical Assistance is biggest program. Distribution of State General Fund Spending
- 7. Estelle B. Richman, Secretary PA Health Care Reform PA Strategies & Innovations 1) Improve chronic care management 2) Reduce Healthcare Acquired Infections 3) Reduce “Preventable Serious Adverse Effects” 4) Rebalance Long Term Care System 5) Establish combined Physical Health / Behavioral Health homes 6) Pay for Performance
- 8. Estelle B. Richman, Secretary PA Health Care Reform Cost and Quality Drivers PA business, consumers and taxpayers pay over $7.6 billion a year for unnecessary and avoidable costs.
- 9. Estelle B. Richman, Secretary PA Health Care Reform 1) Improving outcomes for persons with chronic conditions • Strategy: Regional collaboratives with 20-32 practices each using a medical home model • diabetes • pediatric asthma • May 2008 – launch Southeast PA collaborative • Today - 400 health care providers in 170 medical practices serving 1 million statewide
- 10. Estelle B. Richman, Secretary PA Health Care Reform Diabetes: Year One results • 195% increase in number of patients with self- management goals • 142% increase in number of patients getting annual foot exams • 71% increase in the number of patients getting eye exams • 43% increase in the number of patients who have lowered their cholesterol below 130 • 25% increase in the number of patients who lowered their blood pressure below 140/90
- 11. Estelle B. Richman, Secretary PA Health Care Reform Chronic care: more results • Pediatric asthma: – Doubled the number of patients with a documented asthma action plan on how to take controller medications, avoid asthma triggers, and what to do in the event of an attack • Cost savings data (preliminary) – Inpatient and outpatient hospitalization costs went down by 26% – ER costs were reduced by 18.4% – Overall costs were reduced by 15.9% ($46.37) per member per month
- 12. Estelle B. Richman, Secretary PA Health Care Reform 2) Reducing number of health care acquired infections • PA Health Care Cost Containment Commission study identified 27,949 hospital acquired infections in 2007 • Patients with HAIs are 6 times more likely to die than other patients • Average bill if HAI is nearly 5½ times higher than for patients with no HAI • Adds up to over $3 billion hospital charges
- 13. Estelle B. Richman, Secretary PA Health Care Reform PA passes groundbreaking HAI Prevention Legislation (2007) • Legislation requires hospitals, nursing homes and ambulatory surgical facilities to: • Submit an infection control plan • Report HAIs throughout their facility and • Implement electronic infection control surveillance. • Year one outcomes: the infection rate in PA hospitals dropped 7.8 percent resulting in an estimated savings of $372 million.
- 14. Estelle B. Richman, Secretary PA Health Care Reform 3) Reducing “Preventable Serious Adverse Events” (Never Events) • National Quality Forum list includes: o Surgery performed on the wrong body part or wrong patient o Foreign object left in a patient after a procedure o Infant discharged to the wrong person o Death or serious disability from a medication error o Death or serious disability from a fall while being cared for in a health care facility • Core concept: physicians and hospitals will not be paid for PSAEs or for correcting them • Primary goal is to improve quality and outcomes – not cost containment
- 15. Estelle B. Richman, Secretary PA Health Care Reform Reform began with MA Bulletin, now statewide in statute • January 2008 – DPW issued Bulletin covering Medical Assistance providers. • June 2009 – “Preventable Serious Adverse Events Act of 2009” signed into law covering health care facilities statewide • June 2010 – Deadline for DPW to develop a new bulletin addressing PSAEs in nursing facilities
- 16. Estelle B. Richman, Secretary PA Health Care Reform 10% 15% 20% 25% 2000 2010 2020 2030 4) Rebalancing to address needs of seniors and persons with disabilities • 162,000 Pennsylvanians with disabilities also need long term care services 65 & Older • PA will have more seniors (ages 65+) than school age kids by the year 2030 Under 18
- 17. Estelle B. Richman, Secretary PA Health Care Reform Seniors and people with disabilities use largest share of MA resources Seniors and Persons with Disabilities are 36% of enrollment, but account for 69% of program expenditures Elderly Disabled Families Adults w/o Children 14% 22% 59% 5% 32% 37% 25% 6% Number of Eligible People Expenditures
- 18. Estelle B. Richman, Secretary PA Health Care Reform Goal: Rebalance the Long-Term Care System • Rebalancing Goal: 50/50 split between home & community based and institutional care • This more cost effective approach is in line with what consumers want 010,00020,00030,00040,000 $51,852 for one year of nursing facility care $20,892 for one year of home and community based services
- 19. Estelle B. Richman, Secretary PA Health Care Reform Rebalancing progress since 2006 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 2006 2007 2008 2009 2010 Projected Fiscal Year % Consumers in Nursing Facilities % Consumers receiving Home & Community Based Services
- 20. Estelle B. Richman, Secretary PA Health Care Reform High BP Diabetes Cardiovascular Disease Obesity Poor Nutrition Smoking Low Physical Activity Substance Abuse Side Effects of Psychotropic Medications Poor Access to Primary Care Services Stigma Lack of Cross-Discipline Training SMI reduces life expectancy by 25 years --- Many risk factors are preventable 5) Establishing Accountable Physical / Behavioral Health Care Homes Pilot
- 21. Estelle B. Richman, Secretary PA Health Care Reform Structure of the pilot • Target population: Adults (18+) in southeast and southwest PA in participating health plans • Diagnosis: schizophrenia, major mood disorder, psychotic disorder NOS, borderline personality disorder • Defined performance measures • Shared incentive pool for managed care and behavioral health plans
- 22. Estelle B. Richman, Secretary PA Health Care Reform Southwest Connected Care UPMC for You, Allegheny County, Community Care Behavioral Health ≈ 4,200 members Southeast HEALTHCHOICES HealthConnections Keystone Mercy Health Plan, Bucks, Montgomery, Delaware Co & Magellan Health Services ≈ 3,600 members •Provider engagement and medical home •Consumer engagement •Data management and information exchange •Coordination of hospital discharge and follow-up •Pharmacy management •Appropriate ED use for behavioral health treatment •Alcohol and substance abuse treatment/care coordination •Co-location of resources Key elements of coordination
- 23. Estelle B. Richman, Secretary PA Health Care Reform Established Joint Incentives Pool PH and BH plans Year One – Process Measures 1) Member stratification 2) Development of integrated care plan 3) Real time notification of hospital & ER admission 4) Identification of medication gaps Year Two – Add Outcome Measures 1) Reduced hospital admissions 2) Reduced ER utilization Performance Measures & Incentive Pool
- 24. Estelle B. Richman, Secretary PA Health Care Reform • Through P4P, DPW is shifting from “paying for care” to “paying for quality care” • HealthChoices program performance has improved since P4P implementation • The HealthChoices weighted average improved for 10 of 13 P4P measures 6) Pay for performance realigns HealthChoices incentives
- 25. Estelle B. Richman, Secretary PA Health Care Reform Slide 25 P4P Measure Avoidable Deaths Avoidable Hospital Costs Breast Cancer Screening 500 - 1,900 $212 million - $232 million Cervical Cancer Screening 600 - 800 N/A Cholesterol Management 7,000 - 17,000 $34 million - $115 million Controlling High Blood Pressure 14,000 - 34,000 $425 million - $1.1 billion Diabetes Care - HbA1c Control 3,000 - 12,000 $550 million - $1.3 billion Prenatal Care 1,000 - 1,600 N/A Source: 2008 NCQA The State of Health Care Quality, pp. 15-16. Available at: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_08.pdf. National Estimates of Avoidable Deaths and Hospital Costs Goal: improve quality of care and reduce avoidable costs
- 26. Estelle B. Richman, Secretary PA Health Care Reform Performance Measures (2007-08) HEDIS® Measures 1. Breast Cancer Screening 2. Cervical Cancer Screening 3. Cholesterol Management for People with Cardiovascular Conditions: LDL Control <100 4. Comprehensive Diabetes Care: LDL Control <100 5. Comprehensive Diabetes Care: HbA1c Poorly Controlled 6. Controlling High Blood Pressure 7. Frequency of Ongoing Prenatal Care: ≥81% of the Expected Number of Prenatal Care Visits 8. ER Utilization 9. Adolescent Well-Care Visits 10. Prenatal Care in the First Trimester 11. Use of Appropriate Medications for People with Asthma PAPM Measures1 12. Early Blood Lead Screening: 19 Months 13. Early Blood Lead Screening: 3 Years 1 The PAPM measures will be replaced by the HEDIS measure Lead Screening in Children in the 2008/2009 P4P Program.
- 27. Estelle B. Richman, Secretary PA Health Care Reform Slide 27 Comprehensive Diabetes Care: LDL Control <100 Measure Description: The percentage of adults with Diabetes whose cholesterol level was adequately controlled (LDL-C <100mg/dL) during the measurement year. Rate (CY) 2004 2005 2006 2007 HC Wtd Avg 35.2% 37.9% 37.7% 38.6% 90th Percentile BM 41.6% 46.5% 44.1% 42.3% 75th Percentile BM 36.5% 41.0% 37.2% 37.7% 50th Percentile BM 32.0% 34.1% 31.3% 33.1% 1. Arrows indicate a statistically significant change from the previous year. HealthChoices Weighted Average and Plan-Specific Rates by Calendar Year 0% 20% 40% 60% 80% 100% HC Wtd Avg ACPA AMHP GHP HP KMHP UHP UPMC CY 2004 (Baseline) CY 2005 (P4P Year 1) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3) CY 2007 50th Percentile BM CY 2007 75th Percentile BM CY 2007 90th Percentile BM
- 28. Estelle B. Richman, Secretary PA Health Care Reform Slide 28 Comprehensive Diabetes Care: LDL Control <100 (Continued) • The HealthChoices weighted average has remained above the 50th percentile benchmark since CY 2004, and above the 75th percentile benchmark in CY 2006 and CY 2007 • From CY 2006 to CY 2007, the rates for 4 plans increased, with a statistically significant increase for 2 of these plans • In CY 2007, rates for 5 plans exceeded national benchmarks: – 2 plans exceeded the 50th percentile benchmark – 2 plans exceeded the 75th percentile benchmark – 1 plan exceeded the 90th percentile benchmark OVERALL, RATES ARE IMPROVING FOR THIS MEASURE
- 29. Estelle B. Richman, Secretary PA Health Care Reform Slide 29 Early Blood Lead Screening: 19 Months Measure Description: The percentage of members under 19 months who live in a high lead area and received at least one blood lead screening exam. Rate (CY) 2004 2005 2006 2007 HC Wtd Avg 61.5% 55.3% 58.4% 59.6% Note: This is a PAPM measure, therefore, NCQA benchmarks are not applicable. HealthChoices Weighted Average and Plan-Specific Rates by Calendar Year 0% 20% 40% 60% 80% 100% HC Wtd Avg ACPA AMHP GHP HP KMHP UHP UPMC CY 2005 (Baseline) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3) 1. Arrows indicate a statistically significant change from the previous year. 2. This measure became a P4P measure in CY 2006 during the second year of the P4P program, therefore, CY 2005 serves as the baseline for this measure.
- 30. Estelle B. Richman, Secretary PA Health Care Reform Slide 30 Early Blood Lead Screening: 19 Months (Continued) • Since inclusion of this measure in the P4P program, the HealthChoices weighted average has: – Continually increased, increasing by 4.3% from CY 2005 to CY 2007 – Shown a statistically significant increase in CY 2006 and CY 2007 • From CY 2006 to CY 2007, the rates for 4 plans improved, with a statistically significant increase for 1 of these plans OVERALL, RATES ARE IMPROVING FOR THIS MEASURE
- 31. Estelle B. Richman, Secretary PA Health Care Reform Slide 31 Prenatal Care in the First Trimester Measure Description: The percentage of women who received prenatal care during their first trimester of pregnancy. Rate (CY) 2004 2005 2006 2007 HC Wtd Avg 82.3% 84.2% 82.7% 82.2% 90th Percentile BM 89.5% 91.5% 91.5% 91.7% 75th Percentile BM 86.4% 88.1% 88.7% 88.6% 50th Percentile BM 81.3% 83.3% 84.2% 84.0% HealthChoices Weighted Average and Plan-Specific Rates by Calendar Year 0% 20% 40% 60% 80% 100% HC Wtd Avg ACPA AMHP GHP HP KMHP UHP UPMC CY 2004 (Baseline) CY 2005 (P4P Year 1) CY 2006 (P4P Year 2) CY 2007 (P4P Year 3) CY 2007 50th Percentile BM CY 2007 75th Percentile BM CY 2007 90th Percentile BM 1. Arrows indicate a statistically significant change from the previous year.
- 32. Estelle B. Richman, Secretary PA Health Care Reform Slide 32 Prenatal Care in the First Trimester (Continued) • The HealthChoices weighted average has: – Declined slightly since P4P implementation in CY 2005 – Been below the 50th percentile benchmark in CY 2006 and CY 2007 • The rates for 4 plans decreased from CY 2006 to CY 2007, with a statistically significant decrease for 1 of these plans • In CY 2007, rates for 4 plans exceeded national benchmarks: – 2 plans exceeded the 50th percentile benchmark – 1 plan exceeded the 75th percentile benchmark – 1 plan exceeded the 90th percentile benchmark WHILE LARGE RATE INCREASES ARE NOT EXPECTED FOR SUSTAINING MEASURES, RATES ARE NOT IMPROVING FOR THIS MEASURE
- 33. Estelle B. Richman, Secretary PA Health Care Reform Lessons from PA: “must haves” for national health care reform • Payment reform – create change with meaningful financial incentives • Need to pay for quality, not billable units • Breakdown silos and create new partnerships • Need capacity to measure quality • Health Information Technology will be key to national health care reform
- 34. Estelle B. Richman, Secretary PA Health Care Reform Lessons from Pennsylvania Health Care Reform Estelle B. Richman Secretary, Department of Public Welfare
Notas do Editor
- Introduction … Thank you for inviting me …
- What I would like to do today is talk about Pennsylvania’s experience with health care reform on state level. Will do this in 3 parts. First, describe the 2 key parts of the framework: Prescription for Pennsylvania in January 2007 was the roadmap Medical Assistance program was testing ground for many Rx for PA and related initiatives Then, I want to walk through the outcomes from selected initiatives. Finally, I want to sum up some key lessons for national health care reform we can take from the PA experience.
- Governor Rendell announced Prescription of Pennsylvania in January 2007, right before the budget address. Multiple state agencies worked hard to develop and advance these initiatives – Gov Office of Health Care Reform, Department of Health, Insurance Department, and Department of Public Welfare. This was the umbrella for a vast number of interrelated reforms to improve: Affordability Access Quality We have had some successes and other initiatives – including our effort to expand coverage to “Cover All Pennsylvanians” – will have to wait for federal health care reform.
- Here is a list of initiatives that were proposed in Prescription for Pennsylvania. Each is shown as a Affordability, Access or Quality initiative but in reality many of them cross categories. I am going to primarily talk today about the initiatives shown in red. As you can see they tend to be characterized as quality initiatives
- MA covers a lot of lives. It also accounts for a major share of the state budget. Pre-K through 12 is primary and secondary education spending (shown is red) is 37% of the state general fund budget. Medical Assistance (shown in orange) is 16% and is probably the single biggest program the state operates. Other DPW spending (shown in yellow) is 18%. MA + Other DPW = 34%. This is down from 37% last year – education is growing. MA spending is a major cost driver in state budget and we work hard to find ways to manage those costs without sacrificing quality or reducing eligibility or benets.
- I am going to talk about 6 different strategies and health care innovations that we have implemented here in Pennsylvania – either as part or Rx for PA or as part of the MA program – or both.
- As we started looking at our health care system and how it was performing. What we found were a lot of unnecessary costs and unsatisfactory outcomes. These include: Cost of caring for the uninsured Costs associated with health care acquired infections Costs from hospitalizations of persons with chronic diseases Costs from readmissions and errors. Overall, Pennsylvania business, consumers and taxpayers pay over $7.6 billion a year for unnecessary and avoidable health care costs. Rx for PA and the MA program launched a number of initiatives to try to reduce these costs – and improve the quality of care in the process.
- #1 of 6 – Improving Chronic Care THE PROBLEM: Over 63,000 Pennsylvanians with chronic disease were hospitalized because they did not receive the right care recommended for their disease. These avoidable hospitalizations cost $1.7 billion in hospital charges. GOV CREATED CHRONIC CARE COMMISSION (2007) Model: Regional collaboratives with 20-32 practices each using a medical home model focusing on pediatric asthma and diabetes. Collaboratives engaged in learning sessions on practice redesign, patient registry and practice coaching. Financial incentives: a framework for payors to help practices defray the costs of changing their practices. First rollout was in Southeast PA (May 2008) and today we have 400 practices serving 1 million lives.
- Practices must report data so we can measure outcomes. We now have one year of data from the Southeast. Diabetes 195% increase in # of patients with self-management goals 142% increase in # of patients getting annual foot exams 71% increase in the # of people getting eye exams 43% increase in the # of patients who have lowered their cholesterol below 130. 25% increase in the # of patients who lowered their blood pressure below 140/90
- Pediatric asthma: compared to last June, twice as many patients now have a documented asthma action plan that tells them how to take their controller medications, how to avoid asthma triggers that may prompt an asthma attack, and what to do in the event of an attack and depending on the severity of the attack. Preliminary cost savings data (for patients of one insurer): inpatient and outpatient hospitalization costs went down by 26%; ER costs were reduced by 18.4%; costs were reduced by 15.9% ($46.37) per member per month. NCQA Certification: All of the medical practices that participated in the Southeastern rollout were certified by the National Committee for Quality Assurance (NCQA) as patient-centered medical homes – which is the national standard for chronic illness care.
- #2 – REDUCING HEALTH CARE ACQUIRED INFECTIONS PHC4 – the Pennsylvania Health Care Cost Conttracks the prevalence of Health Care Acquired Infections PHC4’s latest study looked at infection rates at 165 general hospitals. They found that 27,949 patients contracted infections during their care in 2007. This was an improvement over 2006. Patients who contracted infections were six times more likely to die, according to the study. The average bill for Pennsylvanians who contracted infections during their hospital care was almost 5.5 times more than patients who did not contract infections – totally over $3 billion in unnecessary charges.
- HAIs - continued As part of the Prescription for Pennsylvania, Governor Rendell signed into law the toughest HAI prevention legislation in the county, Act 52 of 2007. The legislation requires hospitals, nursing homes and ambulatory surgical facilities to submit an infection control plan; to report HAIs throughout their facility; and to implement electronic infection control surveillance. After the first year of implementation of Act 52, the infection rate in PA hospitals dropped 7.8 percent resulting in an estimated savings of $372 million.
- #3 of 6 – REDUCING PREVENTABLE SERIOUS ADVERSE EVENTS aka NEVER EVENTS This is an example where change began with a DPW’s Medical Assistance quality initiative, and then was adopted statewide. Examples of Preventable Serious Adverse Events are listed on the slide. These are obviously things no one wants to have happen. The core concept is to change the payment policy so that doctors and hospitals are not paid for a PSAE – or for fixing the damage. Even though this is a change in payment policy, this is more of a quality initiative than a cost containment initiative.
- PSAE - continued This is a terrific example of how the Medical Assistance program served as a testing ground for a quality initiative that was later adopted statewide in statute. In January 2008 – we issued a Bulletin that only applied to Medical Assistance providers and enrollees. This was the first in the nation. In June 2009 – a year and a half later, the General Assembly passed and the Governor signed a new law that prevented facilities from billing for PSAEs or from procedures or treatment to reverse the damage. PSAEs can occur in other kinds of health care facilities than just hospitals. Part of the June law requires DPW to develop a bulletin covering PSAEs in nursing facilities.
- 4) REBALANCING LONG TERM LIVING DEMOGRAPHICS The chart on this slide shows that Pennsylvania will have more senior citizens than children under the age of 18 by the year 2030. That is quite a change from the year 2000 when seniors made up about 16% of the population and children under 18 were 24%. Pennsylvania is home to 162,000 persons with disabilities. And if you think back to the beginning of this presentation, we know that persons with disabilities – and seniors – are one of the fastest growing portions of the Medical Assistance caseload.
- 4) REBALANCING LONG TERM LIVING - ENROLLMENT VS. RESOURCES Seniors and persons with disabilities combined are 36% of enrollment but account for 69% of program expenditures. Breakdown: Seniors: 14% of enrollment and 32% of costs. PWD: 22% of enrollment and 37% of costs
- 4) REBALANCING – CONTINUED In 2006, Governor Rendell created the Long Term Living Council and charged it with coming up with a strategy for rebalancing the system. The Council adopted a very ambitious goal of rebalancing the long term living system to achieve a 50/50 split between home and community based services and institutional care by 2012. We are making progress but this goal is ambitious. We know this intuitively – people want to stay in their own homes as long as possible. Surveys bear this out as well -- 90% of Americans age 50 and older wish to stay in their current home and community as they age and over 18% of Pennsylvania nursing facility residents want to return home. Home and community based services are also are more cost effective. Pennsylvania can provide care to 2.5 persons at home for less than the cost of serving one person in a nursing facility.
- 4) REBALANCING LONG TERM LIVING PROGRESS SINCE 2006 There is progress. The number of bed days PA nursing homes have billed Medical Assistance has declined by over 600,000 since 2002. In 2006 we were at about a 70/30 split meaning 70 out of 100 consumers were treated in a nursing facility. By 2010 we are projected to be close to a 60/40 split. This reflects efforts like nursing home transition. More than 5,000 nursing home residents returned to their homes or communities through the Department of Long-Term Living’s Nursing Home Transition Program.
- 5 of 6) PHYSICAL HEALTH / BEHAVIORAL HEALTH HEALTH CARE HOMES Coordination between PH – BH systems has been a longstanding challenge. We know from reviewing claims data that serious mental illness is a predictor of poor health outcomes. We also know that this population can be costly to treat. Complex SMI care needs can only be addressed with effective coordination across both physical health and behavioral health systems.
- 5) PH/BH HOMES PILOT We launched a pilot with the Center for Health Care Strategies improve cross systems coordination Target population: Adults with SMI at least 18 years old located in the SE and SW PA – and enrolled in participating health plans. SMI is defined to include: schizophrenia, major mood disorder, psychotic disorder, and borderline personality disorder. The goal is stronger connections between BH/PH and consumer at all levels
- 5) BH/PH HOMES - CONTINUED We are testing out two different models within the pilot: SOUTHWEST: Parent Company – Same entity Approach HealthChoices Southwest Allegeny County – PH & BH (through the county’s managed care subcontractor) provided by the same entity; SOUTHEAST – Multiple unrelated Entity Approach 3 HealthChoices Counties (Bucks, Delaware and Montgomery) PH & BH Care provided via different entities Counties subcontract with Magellan Behavioral Health of PA , & KMHP Goal is to create a true medical home that includes both BH & PH
- 5) PH-BH HOMES - CONTINUED PA established joint PH-BH incentives pool. PH managed care plan and BH counties “rise and fall” together. The funds for the pool do not depend on state savings. Performance measures: Partners will be evaluated based on performance on a series of measures phased in over two years. Year one – process measures… Year two – will add two outcome measures…
- 6 of 6) PAY FOR PERFORMANCE DPW implemented the Pennsylvania Pay for Performance (P4P) program for HealthChoices in July 2005. Goals: Improve plan performance to ultimately benefit consumers’ quality of life, save lives and reduce inappropriate health care costs Encourage plans to implement initiatives that will improve access and quality for consumers We have seen improvements in 10 of 13 measures for the group as a whole. Most of health plans have shown improvement.
- 6) PAY FOR PERFORMANCE - CONTINUED Pay for performance payments create a financial incentive for our MA Managed Care plans to improve the quality of care and reduce avoidable costs. We have structured the program to target practices like breast and cervical cancer treatments, reducing cholesterol, controlling diabetes and high blood pressure and encouraging prenatal care. These practices save lives. These practices reduce avoidable hospital costs.
- 6) PAY FOR PERFORMANCE - CONTINUED Our P4P program uses 11 nationally recognized HEDIS measures. This gives us benchmarks and makes it possible to see how our plans are doing against peers in other states. In 2008-09, we also added 2 Pennsylvania Performance Measures: Early Blood Lead Screening at 19 months Early Blood Lead Screening at 3 years I am now going to walk through results for 3 measures: Comprehensive Diabetes Care: LDL Control &lt;100 Early Blood Lead Screening: 19 Months Prenatal Care in the First Trimester
- 6) PAY FOR PERFORMANCE – CONTINUED Here are the results for Comprehensive Diabetes Care: LDL Control &lt; 100. (Explain how to read this slide) This slide shows both a weighted average and plan-specific results for the last 4 years. The upper left quadrant describes the measure. The upper right gives the HC Weighted Average and comparable values for the 50th, 75th and 90th percentiles. Bars show each of the 7 plans and the weighted average Arrow indicates a statistically significant changes. Colored lines show the 50th, 75th and 90th percentiles.
- 6) PAY FOR PERFORMANCE This slide summarized the results for Comprehensive Diabetes Care. Overall, rates are improving for this measure. Weighted average is above the 75th percentile in last 2 years. Performance for individual plans are improving with a statistically significant increase for 2 plans.
- 6) PAY FOR PERFORMANCE A second example: Early Blood Lead Screening at 19 months. This is not a HEDIS measure, it is one we added in 2005. From the table in the upper right, the HC weighted average has improved from 55.3% to 59.6%.
- 6) PAY FOR PERFORMANCE Overall, rates are improving for this measure, increasing by 4.3% from 2005 to 2007. This translates into more kids getting screened. We estimate that for 2007, approximately 1,630 additional children received blood lead screenings as a result of the uptick in rates. This includes includes children ages 19 months and 3 years.
- 6) PAY FOR PERFORMANCE The third example, Prenatal care in the first trimester, shows a more mixed picture. Looking at the Health Choices Weighted Average, we had what looked like early improvement from 82.3% in 2004 to 84.2% in 2005. This improvement was reversed in 2006 and 2007. About 82.2% of women received prenatal care during their first trimester in 2007 – virtually unchanged from 2004.
- 6 of 6) PAY FOR PERFORMANCE We are not showing improvement – and we are not performing very well against the national benchmarks. The Health Choices weighted average was below the 50th percent benchmark in 2006 and 2007. Looking at individual plans, 2 plans exceed the 50th benchmark, 1 exceeded the 75th benchmark and 1 exceeded the 90th
- LESSONS FROM PA (THIS IS LAST SUBSTANTIVE SLIDE) NOTE – PLEASE REVIEW/REVISE. I AM NOT SURE I HAVE WHAT YOU WANT HERE.