This is a presentation I just did for MGMA Alabama on how providers should develop their own cost and quality data. Thanks to RealTime Medical Data for their support.

1. Dealing with Payers with Physician Driven Cost and Quality Data Hilton Sandestin Beach & Golf Resort, Destin August 2, 2011 William F. (Bill) Cockrell, FACMPE

2. What’s the Next “Big” Option “Accountable Care Organizations (ACOs), Why They Will Fail and What We Will Need to Learn From the Experience” The main ingredients (who can argue with these?) Cost Effective Quality Because In 2014 we have Healthcare Exchanges

3. Healthcare Exchanges The Affordable Care Act requires each state to establish by 2014 a health insurance exchange where individuals and small businesses can purchase affordable health insurance plans. The exchanges are the centerpiece of the reform law: they will be the main portals for people without employer-sponsored or public insurance to both find a health plan and learn about and apply for any federal subsidies for which they are eligible.

4. Essential Elements of a Healthcare Exchange * offering the essential benefit package (to be determined in regulations later this year); adhering to cost-sharing limits; being licensed and in good standing to offer health insurance; compliance with quality standards established in the law, including required quality data reporting, quality improvement strategies, and enrollee satisfaction surveys, all of which will be addressed in future regulations; offering at least one qualified health plan at the silver and gold benefit levels;

5. Status of State Legislation to Establish Exchanges, as of July 2011 AK NH WA ME VT MT ND MN OR NY ID WIWI MA SD RI WY MI CT PA IA NJ OH NE NV DE IN IL MD UT WV IA VA CO DC CA KS MO KY IL NC WV VA TN SC OK AZ AR NM GA AL MS LA HI TX FL State exchange in existence prior to passage of ACA Legislation pending in one or both houses Legislation signed into law post passage of ACA Pending legislation failed Legislation signed: intent to establish an exchange, creation of study panel, creates an appropriation Governors have pursued/considering non-legislative options Governor veto or decision not to establish exchange Legislation passed one or both houses Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis.

6. What are Our Options We can run We can hide We can retire We can complain But – There will be changes in the Healthcare Delivery System

7. Here’s an Option What patients and doctors need is a U.S. government Web site run by an enlightened, well-intentioned policy elite that studies various treatments for the same condition and compares their performance. That’s how we can find effective, less costly care.” July 4, 2011 Birmingham News Froma Harrop is a member of The Providence (R.I.)Journal’s editorial board and a syndicated columnist.

8. Can an Enlightened, Well Intentioned, Elite Group Design One Plan to Fit All?

9. Can the Government (Federal or State), Employers (the current primary insurance coverage purchasers), Payers (Medicare or Private), or any other one group design one plan to fit all?

10. “The barrier to change is not too little caring; it is too much complexity.” -Bill Gates

11. Medicare Cost Data

12. 2007 Medicare Beneficiary Cost and Readmission Rate Louisiana - $9,500 and 22 day readmission rate West Virginia - $7,600 and 23 day readmission rate Alabama - $7,600 and 17.5 readmission rate Vermont - $7,400 and 14.5 readmission rate Oregon - $6,100 and 13 day readmission rate Rhode Island - $8,600 and 18.5 day readmission rate

13. Cost and Readmission Rate Ranges Louisiana $9,500 West Virginia 23 day readmission rate Oregon $6,100 Oregon 13 day readmission rate

14. The Usual, but Real, Data

19. trimming payments by reducing the prices paid for covered services; or reducing utilization of services.

21. Option Three Depends on Real Data that Requires a Number of Sources and Results in Some Providers Changing, or Being Left Out

22. The Financial Issues Define cost effective Comparison to the current fee for service / transaction based model? This is the initial policy under the ACO model Long term model? How do you find out Payers BCBS and others have great information but difficulties in accessing it in a usable form Data sources Independent sources have data but it is blinded by individual patient name

23. The Quality Issues The Accountable Care Organization (ACO) Quality Performance Measures Initial 65 quality measures The measures are divided by five “domains” that are weighted equally: Patient/Caregiver Experience (7 measures) Care Coordination (16 measures, including transitions of care and HIT) Patient safety Preventative Health At Risk Population/Frail elderly Health (31 measures) on the following Diabetes, Heart Failure, Coronary Artery Disease, Hypertension, Chronic Obstructive Pulmonary Disease, Frail Elderly

24. Scoring of Quality Performance Providers are scored on their overall achievement relative to a national or other benchmark Quality performance standards will be issued in future rulemaking Performance Scoring CMS sets benchmarks at beginning of each reporting year using FFS, Medicare Advantage or data it has modeled Points are assigned to each measure (and summed by domain) based on performance related to the national benchmark. There is a maximum of 2 points per measure, with a maximum of 130 points for 65 measures Domain scores are determined by dividing the actual points by the maximum potential points to determine a % of performance The 5 domain scores are averaged to determine the overall score

25. So, If We See Traction on Alternative Delivery Systems, and We Will, We Are Going to Be Faced with Getting from Here:

26. Medical Treatment Cath Sample Referral Decision Tree Diagnostics Hospital A Hospital B CT Surgeon Cath Cardiologist CT Surgeon Hospital C PCP Interpreter A Mobile Diagnostics Interpreter B

27. To Here:

28. Medical Treatment Hospital A Cath Sample Referral Decision Tree - Modified Hospital B Diagnostics Hospital C CT Surgeon Cath Cardiologist CT Surgeon PCP Interpreter A Mobile Diagnostics Interpreter B

29. And the New Decision Tree Must be Based On: Cost Quality

30. What do Providers Need Information Keeping track of the rules Understanding models Organization Systems EMR’s Real medical record data sharing Reality There will be those who don’t get to participate

31. What’s Out there now for Patients, Payers and Providers

32. Robert Woods Johnson Foundation Comparative Healthcare Quality: A National Directory June 28, the RWJF “launched the nation's most comprehensive online directory for patients to find reliable information on the quality of health care provided by physicians and hospitals in their community.” “Data on the performance of healthcare providers helps patients take a more active role in managing their healthcare because it lets them see what proper care looks like and whether local hospitals and physicians are delivering it.

33. Data Research Results http://www.rwjf.org/pr/product.jsp?id=71857

34. Other Information Sources http://healthcarequalitymatters.org/?p=fqc http://www.checkbook.org/patientcentral/?cb=hmct&ref= www.healthgrades.com

35. Sample Using Real Data A hospital in Alabama 25 primary care physicians Referral to cardiologists based on top diagnoses Medicare data used available through Freedom of Information Act HPI information scrubbed

36. BCBS Patient Satisfaction and Quality Measures for Selected Cardiologists

37. Healthgrades Patient Satisfaction Measures for Selected Cardiologists

38. What about the Financial Side of Things

40. ICD9 Diagnosis Codes Effective Year: 2010(5) Category: (CUSTOM) TOP FIVE CARDIOLOGY DIAGNOSES(5) 4011 - Essential hypertension, benign 41400 - Coronary atherosclerosis of unspecified type of vessel, native or graft 41401 - Coronary atherosclerosis of native coronary artery 42731 - Atrial fibrillation 78650 - Chest pain, unspecified 7/26/2011 ©RealTime Medical Data (205) 941-1211 [info@rtmd.org] 00:00:09.1553124 Page 1 of 1 The Source for Timely and AccuratePaid Medicare Claims Data™

41. CY MGMA 2010 Cost per Physician for Top Five PDX Total InPatient Discharges(DRGs) by PrincipalDx then Physician and Major Diagnostic Categories(MDCs)(1).xls

42. Coronary Atherosclerosis of Native Coronary Artery

43. Ranking system 5 to 1 point(s) for high to low volume 5 to 1 point(s) for low to high LOS 5 to 1 point(s) for high to low CMI 5 to 1 point(s) for low to high cost 5 to 1 point(s) for high to low BCBS Patient Satisfaction Points totaled and physicians ranked high to low

44. Coronary Atherosclerosis of Native Coronary Artery Ranking

45. Atrial Fibrillation

46. Atrial Fibrillation Ranking

47. Now What If I’m a specialist and highly ranked, I find the way to get the word out to referring doctors and payers If I’m a specialist and ranked low, I find out why and work to change or get better information If I'm primary care, I let the specialists know I need this information in the future

48. What can we (Providers) Do Today? Start gathering data internally As Primary Care Physicians ask for quality and cost data from our specialists As Specialists, be proactive in gathering the necessary data and providing it to our PCP’s As organizations, find out data sources, communicate this information to our members and help our members understand the information (MASA, MGMA research?) Work with payers when the opportunity presents itself for meaningful analysis of information

49. The Role of Electronic Records In May, the federal government awarded its first payments to physicians who successfully demonstrated that they are making meaningful use of electronic health record systems (EHR). To qualify for the payments, physicians had to prove that—among other things—their EHR systems were capable of capturing and exchanging health information on patients, including lists of medications, allergies, and test results. Physicians were also required to demonstrate that the EHR had the functionality for computerized physician order entry, electronic prescribing, and reporting of clinical quality measures to state and federal bodies.

50. The Role of Electronic Records Reality, we cannot get the information we need through paper charts We have to have discrete, searchable data elements We have to have dashboards We have to efficiently communicated reports and data We have to share information, appropriately

51. Questions? Cockrell and Associates, LLC (205) 999-8064 bcockrell@caahms.com www.caahms.com