Today we’re going to tour the ballpark and have a go in the batting cage. But first…

Shorter Bob Pearl, CEO Permanente Medical Group: Our docs are convinced we care about outcomes. Other people’s docs (other IPA and med groups) have doubts.

Chronic care management is an IT intensive, patient outreach intensive, 24/7/365 process that’s really tough, but need a whole system. We have to track and predict bad incidents. One example is tracking bi-polar people every day in order to predict a manic incident. But the system needs to track all patients –those with chronic illness and those at risk of getting one (which is everyone else!). The system needs to track everyone all the time and find the failures, and report them out for both intervention and later analysis.

Right now 500K in the KP system are being watched by a care manager, but that 500K is not a static population — and they are trying to get them out of that system back to baseline. Everyone everywhere needs constant prompts and that’s where KP’s heading. (Implication is that every one else needs to get on board or they won’t be around…)

Next session is on P4P in California, where 6 health plans are busy running a P4P program via the Integrated Healthcare Association. (Presentations are linked)

At the moment (Lance Lang, HealthNet) it’s only 0.5% of the dollars for those participating groups, but there’s a lot going on in terms of work being done for that 0.5% and it’s heading to 1% next year and maybe up to 20% (?) by 2009. He thinks that they need to ensure that groups that are not deserving of a bonus get the message that they are not going to be around in the longer term unless they change.

Greater Newport Physicians IPA med director Doug Allen had three main points. Even though his IPA was at 90% in all the metrics, the amount they got from different health plans in bonuses varied 6-fold. So what are they supposed to do?

With the P4P dollars they have created and improved their data warehousing, but there’s nowhere near enough for an EMR. There’s no new money for investment here–the P4P is a variation of a whithhold. Plus some plans are starting to play politics by witholding some of the amount as a bargaining chip for other negotiations.

Finally, he’s (rightfully) concerned that the whole HMO-IPA model is under threat. Even if they can prove they’re better quality, employers are going to other types of health plan (e.g. high deductible PPOs). So this may all go down the tubes anyway? Or at least come under a lot of pressure if they can’t figure out a model to take P4P to the PPO or high deductible world.

In the Medicaid plan world in California, the San Francisco Health Plan did improve its health scores, even though there are no groups and no IT at the physician level. (Michael van Duren, SF health plan) They used direct member intervention (bribes) and direct physician intervention (more and bigger bribes. But it also required visiting the bigger providers (on the 80-20 rule to get at the most patients) face-to-face to get them to do immunizations, etc. To do the visits they are imitating drug reps’ sales tactics. They serve food, and they show the data very quietly, and then start working on improvement by showing them into the live data on the warehouse (online) — then they go down to individual patient data (claims of course). So the incentives get you in the door, but it’s showing the doctors the transparent data as a tool to make them change — and of course most of it is fixing the coding which was done wrong in the first place! Now the plan is doing direct bribes to the physicians’ staff. The provider relations people are entitled to authorize anything that works up to a few thousand dollars,to get them to get their data better (including hiring a low level analyst, but also getting their Internet connection up, etc, etc.)

Of course, as W might say, this is really hard work.

Jeff Flick from CMS thinks that we’re heading from 33% of Californian seniors in Medicare Advantage to 50-60%. (Havent we seen this movie before–the private plans didn’t like the endsing and ran out before the end last time.) He wants to drive it there because he thinks that provate Medicare plans are easier to get to provide better quality care. Also worried about the impact of PPOs. HSAs and other higher deductible plans on shredding the community rating aspecy (as Alain Enthoven said to me in a quick corridor conversation).

In addition the CMS Docket program (seems not to have a Googleable web presence which may be why it’s not so popular!) Doqit program (thanks for the correction, Catherine) helps poorer and smaller practices get into information age, although it has not had much of an uptake so far. He does think that there’ll be a tipping point when doctors get the tech. He also thinks that the chronic care demonstration projects are part of Pay for Performance as they do mandate improved quality, satisfaction and guarantee savings. He said it: "We think that we are going to be able to figure out what works for disease management in Medicare" and it can then go into the main program with no further legislation needed. But in addition to focusing on chronic care, they are focusing on end of life issues which are very expensive and these people are getting no help from intensive case managmenet, or consumer support programs for those people. CMS is going to do a national demonstration for intensive case management. These are all forms of P4P that he thinks have a bright future in Medicare.

Finally CMS is also trying to figure out how to make claims data be useful for measuring quality and performance. As you can’t pay for perfomance if you can’t measure it, but they are working on this. (Ed’s Note. Going down this road will, you might suspect, be tricky given the reputation claims have for accuracy). But they also have to work out the payment issue on the FFS side. From 2006 there’ll be reductions in fees for the next four years. He thinks this needs to be fixed, but how will this be fixed legislatively? His personal hunch (not CMS dogma) that the solution is to increase fees for those physicians with quality information (and the IT to support it) and not for the rest.

In response to me asking him if we hadn’t seen this movie before (Plans launch into Medicare Advantage; rates go down plans so plans quit Medicare)  Jeff says that the Rx benefit, risk adjustment and quality indicators will drive people into Medicare Aadvantage — but of course politics may change this (i.e. the way the BBA reduced payment rates) and he can’t say that it won’t.