High-Needs Patients Under a Pay-for-Value Program Dori A. Cross, - - PowerPoint PPT Presentation

Practice Strategies to Improve Primary Care for High-Needs Patients Under a Pay-for-Value Program

Dori A. Cross, PhD Candidate University of Michigan School of Public Health AcademyHealth Annual Research Meeting June 25, 2017

Acknowledgements

• Generous support from the Commonwealth Fund
• “Understanding What Works: Improving Primary Care Physicians’

Performance Caring for High-Cost, High-Need Patients”

• Co-authors
• Julia Adler-Milstein (Co-PI)
• Christy Harris Lemak (Co-PI)
• Genna R. Cohen
• Ariel Linden
• Paige Nong

Motivation

• Numerous ongoing policy initiatives to promote higher

value primary care

• Patient-centered medical homes
• Pay-for-performance
• Inter-organizational affiliations/collaboration
• Evaluation of these efforts yields mixed results, often

marginal net significance

• Masks underlying variation in which organizations achieve

significant improvements, and for which patients

Motivation • Approach • Results • Discussion

Motivation

• Numerous ongoing policy initiatives to promote higher

value primary care

• Patient-Centered Medical Homes
• Inter-organizational affiliations/collaboration
• Pay-for-performance
• Evaluation of these efforts yields mixed results, often

marginal net significance

• Masks underlying variation in which organizations achieve

significant improvements, and for which patients

Motivation • Approach • Results • Discussion

Motivation

• Great opportunity, and significant challenge, in efforts to

improve care for complex, high-needs patients

• High needs patients experience:
• Higher utilization
• Lower quality
• Distinct healthcare needs
• Practices need targeted strategies to manage this

population, strengthen performance

Motivation • Approach • Results • Discussion

Motivation

• What practice strategies are effective in advancing practice

performance for high-needs patients?

• Prior research suggests three strategic domains may prove

critical:

• Organizational learning
• Practice motivational techniques
• Acquisition and use of resources

Motivation • Approach • Results • Discussion

Research Aims

• 1. Identify specific primary care practice strategies within

three focal domains – learning, motivation, and resources

• used to improve care for high-needs patients
• 2. Determine which of these strategies differentiated

practices that demonstrated meaningful improvement in high-need patient care under pay-for-value incentive structures

Motivation • Approach • Results • Discussion

Approach

• Needed to stratify, recruit and interview practices that did
• vs. did not improve high-need patient care over time

Calculation of 10 claims- derived outcome measures

• ver time (2010-13) for target

practices, relative to matched control MI practices participating in Physician Group Incentive Program MI practices NOT participating in Physician Group Incentive Program

Propensity-score matched (demographics & baseline year

• utcomes)

Motivation • Approach • Results • Discussion

Approach

• Outcome measures used for assessment

Medical-Surgical Costs 30-day Readmissions ED Visits 90-day Readmissions Ambulatory care-sensitive ED visits Quality Composite Score Inpatient Admissions Preventive Care Composite Score Ambulatory care-sensitive Inpatient Admissions Medication Management Composite Score

Motivation • Approach • Results • Discussion

Approach

• PGIP practices that performed better than their matched

control on:

• 7 or more out of 10 measures  Improving Practices
• 4 or fewer out of 10 measures  Non-improving Practices

Motivation • Approach • Results • Discussion

Approach

• 14 practice interviews conducted
• 7 improving, 7 non-improving
• 60-90 minute semi-structured interviews [double-blind]
• Analytic Approach
• Notes transcribed, coded, reviewed for accuracy
• Iterative approach to strategy identification, refinement
• Use of data tables to weigh evidence, ascribe strategic

approach(es) to practices

Motivation • Approach • Results • Discussion

Results

• 31 respondents interviewed across 14 practices
• Practice respondents generally in consensus RE: what categorized

patients as “high-need”

• 11 strategies identified across 3 domains of interest

Motivation • Approach • Results • Discussion

Practice Managers 13 Physicians, NPs, PAs 6 Nurses 2 Medical Assistants/Techs 6 Care Managers 4

Non-Differentiating Strategies

Learning Standard processes for internal communication and knowledge sharing Motivation Changed staff responsibilities to align with PGIP program guidelines Use of non-financial provider/staff incentives Resources Use of EHR and registry Leveraging available community-based social services

Motivation • Approach • Results • Discussion

Key Results - Learning

Improving Practices (n=7) Non-Improving Practices (n=7)

Participation in external learning collaboratives

5 3

Motivation • Approach • Results • Discussion

“The health system has a practice manager meeting every month that I go to. A couple hours, anything new, or that needs to be done or that’s going on, they tell us about. The doctors always go to meetings too, with the hospital network.”

Key Results - Learning

Improving Practices (n=7) Non-Improving Practices (n=7)

Participation in external learning collaboratives

5 3

Accessing online payer tools that provide claims-based measures of patient utilization and care quality

6 4

Motivation • Approach • Results • Discussion

"Any day of the week I can pull up our quality summary report and see - for every measure – exactly where we’re at.”

Key Results - Motivation

Improving Practices (n=7) Non-Improving Practices (n=7)

Framing P4P participation as a transformation opportunity

6 4

Motivation • Approach • Results • Discussion

“We now consider ourselves a servant practice…The board leads, supporting the providers and managers. The patient is obviously at the top –it’s about whatever the patients

• need. That’s our mission and our vision."

Key Results - Motivation

Improving Practices (n=7) Non-Improving Practices (n=7)

Framing P4P participation as a transformation opportunity

6 4

Investment of earned incentive money in an equitable, practice-centric way

4 2

Motivation • Approach • Results • Discussion

“Yes, everyone gets a piece of the pie. Because, we feel everyone - from the person who makes that first outreach phone call to the person who signs out the patient when they leave - has worked on that patient.”

Key Results - Resources

Improving Practices (n=7) Non-Improving Practices (n=7)

Employment of a care manager

6 3

Motivation • Approach • Results • Discussion

“I don’t know how the office would run without our care manager. There is so much to do…the MAs don’t have time to do everything. With a care manager, you have somebody who can do that face-to- face, say “Okay, tell me what you need”. That’s a huge benefit.”

Key Results - Resources

Improving Practices (n=7) Non-Improving Practices (n=7)

Employment of a care manager

6 3

Use of external technical and administrative support for performance improvement

6 3

Motivation • Approach • Results • Discussion

“My PO contact…she knows what [the payer] is looking for during site visits. She’ll read through my documentation and make recommendations like ‘be more specific here, you need to do this here.’ That’s a huge help.”

Key Results – Summary

Learning

(1) Participation in external learning collaboratives (2) Accessing online payer tools that provide claims-based measures of patient utilization and care quality

Motivation

(3) Framing P4P participation as a transformation opportunity (4) Investment of earned incentive money in an equitable, practice-centric way

Resources

(5) Employment of a care manager (6) Use of external technical and administrative support for performance improvement

Motivation • Approach • Results • Discussion

Limitations

• Self-report of practice strategies
• Small sample from which to distinguish differentiating

strategies

• Needed to use loose definition of “high-needs” to include

enough patients for evaluating practice performance

• Used data from commercially insured, <65 population
• Different, more tailored strategies and resources may be needed to

successfully treat patients of higher complexity

Motivation • Approach • Results • Discussion

Discussion

• Practices able to demonstrate meaningful improvement in high-

need patient care chose strategies that:

1.

Brought new knowledge in to the practice

• Culture of “openness”, organizational flexibility

2. Foster intrinsic motivation

• Leveraging extrinsic financial motivators to promote

fundamental changes in how care teams work together

3. Prioritize resources that serve as capacity-expanding strategies

Motivation • Approach • Results • Discussion