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 MI practices participating in Calculation of 10 claims- Propensity-score Physician Group matched derived outcome measures Incentive Program (demographics over time (2010-13) for target MI practices NOT & baseline year practices, relative to matched participating in outcomes) control Physician Group Incentive Program 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 Quality Composite Score visits Inpatient Admissions Preventive Care Composite Score Ambulatory care-sensitive Medication Management Inpatient Admissions 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 Managers 13 Physicians, NPs, PAs 6 Nurses 2 Medical Assistants/Techs 6 Care Managers 4  Practice respondents generally in consensus RE: what categorized patients as “high - need”  11 strategies identified across 3 domains of interest Motivation • Approach • Results • Discussion

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 Non-Improving Practices (n=7) Practices (n=7) Participation in external learning 5 3 collaboratives “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.” Motivation • Approach • Results • Discussion

Key Results - Learning Improving Non-Improving Practices (n=7) Practices (n=7) Participation in external learning 5 3 collaboratives Accessing online payer tools that provide 6 4 claims-based measures of patient utilization and care quality "Any day of the week I can pull up our quality summary report and see - for every measure – exactly where we’re at.” Motivation • Approach • Results • Discussion

Key Results - Motivation Improving Non-Improving Practices (n=7) Practices (n=7) Framing P4P participation as a 6 4 transformation opportunity “ 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 ." Motivation • Approach • Results • Discussion

Key Results - Motivation Improving Non-Improving Practices (n=7) Practices (n=7) Framing P4P participation as a 6 4 transformation opportunity Investment of earned incentive money in 4 2 an equitable, practice-centric way “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.” Motivation • Approach • Results • Discussion

Key Results - Resources Improving Non-Improving Practices (n=7) Practices (n=7) Employment of a care manager 6 3 “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.” Motivation • Approach • Results • Discussion

Key Results - Resources Improving Non-Improving Practices (n=7) Practices (n=7) Employment of a care manager 6 3 6 3 Use of external technical and administrative support for performance improvement “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.” Motivation • Approach • Results • Discussion

Key Results – Summary (1) Participation in external learning collaboratives Learning (2) Accessing online payer tools that provide claims-based measures of patient utilization and care quality (3) Framing P4P participation as a transformation opportunity Motivation (4) Investment of earned incentive money in an equitable, practice-centric way (5) Employment of a care manager Resources (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: Brought new knowledge in to the practice 1.  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