WHIO Symposium
May 13, 2011
Goals of WHIO
 To aggregate health care data from sources across
Wisconsin to create a single reliable data source to
be used by multiple stakeholders to examine
variations in efficiency, quality, safety and cost
 To improve the quality, cost, safety and efficiency
health care in Wisconsin by sharing the results
with providers, purchasers and consumers
 To support provider quality improvement
initiatives
 To encourage value-based health care choices by
consumers
WHIO Members and Subscribers
 The Alliance
 Anthem Blue Cross and Blue Shield
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of Wisconsin
Greater Milwaukee Business
Foundation on Health
Humana
United Healthcare of Wisconsin
WEA Insurance Trust
WPS Health Insurance
Wisconsin Collaborative for
Healthcare Quality
Wisconsin Hospital Association
Wisconsin Medical Society
Wisconsin Department of Employee
Trust Funds
Wisconsin Department of Health
Services
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Aspirus
Aurora Health System
Bellin Health
Dean Health Plan
Group Health Cooperative South
Central Wisconsin
Gundersen Lutheran Health Plan
Health Tradition Health Plan/Mayo
MercyCare Insurance
Network Health Plan
Physicians Plus Insurance
Prevea Health Plan
Security Health Plan
ThedaCare
Unity Health Plan
UW – Population Health Institute
Using the Data:
Wisconsin Payment Reform Initiative
Launched with the premise that:
 Aligning the incentives of payers, providers, employers
and patients,
 Measuring quality and cost of care at a granular level,
and
 Publicly reporting outcomes
Will:
 Improve the quality of care delivered and reduce its cost
by rewarding those who reduce waste and develop more
effective, efficient processes
And This is Important Because…
 Health care spending now tops 18% of US GDP
 Premium growth crowds out wage increases, is
unsustainable for employers
 1:6 (50+ million) Americans is enrolled in Medicaid
 1:6.5 (47+ million) Americans is enrolled in Medicare
 1:6 (50+ million) Americans is uninsured
History of WPRI
 November 2009 – WHIO creates WPRI Steering
Committee
 April 2010 – Steering Committee hosts WPRI Leadership
Summit
 170 “C – Level” leaders from stakeholder organizations
 Agreed to form Acute, Chronic, Preventive Care
Workgroups to develop pilot projects
 Hypothesis: The outcomes for patients treated for a specific
condition will improve, and costly complications or
exacerbations of the patient’s condition will be avoided, if
the payment system fosters competition among providers at
the level of the medical condition based on the quality of
care delivered and the total cost of services.
Pilot Conditions
 Acute Care chose total knee replacement
 Chronic Care chose adult diabetes
 Preventive Care chose composite measure of
screenings for:
 Breast Cancer
 Cervical Cancer
 Colorectal Cancer
Partnership for
Healthcare Payment Reform
Our Mission:
The Partnership for Healthcare Payment Reform
supports the voluntary engagement of Wisconsin’s
diverse healthcare stakeholders in assessing,
designing, testing and implementing innovative,
comprehensive approaches to healthcare payment
reform in order to improve the quality and
affordability of healthcare in Wisconsin and advance
the health status of Wisconsin residents.
Guiding Principles/Values
Collaboration: We rely on shared sense of purpose among
participants
Openness/Transparency: Communicate learnings, engage
all parties.
Patient Centeredness: Payment reform should enhance
patient experience of care.
Synergy: PHPR will provide relevant, Wisconsin-based
leadership, building on national trends
Guiding Principles/Values
Evidence-based: Use data to select high value projects;
assess promising practices
Continuous Learning: Our understanding of what
best supports value in healthcare continues to evolve
Impact: Pilot approaches that are both replicable and
scalable
Why Are 60+ Organizations
Participating in Design Efforts?
 Opportunity to align incentives among payers
 Maximize purchasing strategies
 Collaborative nature of the work—building on
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Wisconsin’s tradition and healthcare assets
Shared learning
Commitment to quality
Opportunity to test “what we know we have to do”
Sense of responsibility/duty to sustainable healthcare
system
Current Status: Acute Care Pilot
 Bundled payment for total knee replacement (single
knee)
 Commercially insured patients ages 18 – 64
 Includes 90 day warranty period to cover
complications, device failure
Why Pilot Bundled Payments?
 Bundled payments have been shown to improve
quality and efficiency of care*
 Medicare scheduled to pilot episode of care bundled
payments beginning January 1, 2013
 Few multi-payer bundled payment efforts in the
country—Wisconsin can lead the way
 Participation in PHPR bundled payment pilot allows
manageable testing of larger payment reforms to come
*See, e.g., http://www.gao.gov/new.items/d11126r.pdf; Cromwell J, et al., Cost savings and
physician responses to global bundled payments for Medicare heart bypass surgery.
Health Care Financ Rev. 1997 Fall;19(1):41-57.
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Acute Care Pilot Overview
What Services?
• Bundled payment for Total Knee Replacement (one knee)
• Episode period begins at admission and concludes 90 days
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from hospitalization
Revision procedure performed during episode period
resulting from patient complications or device failure
Patient complications arising during anchor admission
Treatment of complications related to either anchor or
revision admission (any service setting)
Readmission during the 90-day episode period for listed
DRGs
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Acute Care Pilot Overview, cont’d.
Who’s Included?
 Patients presenting for the index procedure without:
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Clinical history that demonstrates a clinical condition of
active cancer, HIV/AIDS, or End Stage Renal Disease
Body Mass Index (BMI) of 40 or greater
 Over age 18 and under age 65 on the date of surgery
 Covered (as primary plan) by a participating employer
and health plan at the time of admission
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Acute Care Pilot Overview, cont’d.
How Will Bundled Payments Work?
 “Bundler” (hospital, IPA, PHO) negotiates bundled
payment
 Provider bills upon patient discharge and at end of
episode period
 Payer pays negotiated amount to “bundler”
 “Bundler” distributes payment to TKR bundle team
members
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Measure
Who
Collects and
Reports
To
Whom
How
Often
SCIP Cardiology 2
Hospital
CMS/
PHPR
Quarterly
SCIP VTE 2
Hospital
CMS/
PHPR
Quarterly
Length of Stay
Hospital
PHPR
Quarterly
Readmission/Revision Rates for TKR
Payers/WHI
O
PHPR
6 months
Complications (infection rates, DVT,
PE)
Payers/WHI
O
PHPR
6 months
Patient Satisfaction
Hospital
HCAHP
S/
PHPR
Quarterly
Outcomes Measure (WOMAC, KSS,
KOOS, etc.) depending on what
provider uses
Provider
PHPR
Quarterly
Patient facility with activities of daily
living – pre-op vs. post-op (being
developed)
Provider
TBD
TBD
TKR Bundle Quality Measures
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Acute Care: Next Steps
 Expressions of interest requested by May 20 or as soon
as feasible
 Targeting go-live of September 1, 2011
 Workgroup meeting this afternoon open to potentially
interested pilot participants
Current Status:
Chronic Care Pilot Project
 Adult diabetics covered by commercial plans
 WCHQ quality measures
 Begin with shared savings and transition to global
payment over time
 Payers retain insurance risk; providers take
clinical/performance risk
 Consider opportunities to work on local
community engagement around nutrition,
physical activity, obesity prevention/reduction
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Why Pilot Shared Savings/
Episode of Care Payments?
 Condition-based, episode of care payments are expected to
improve quality and efficiency of care*
 Pilots propose to start with shared savings and transition to
full global payment
 Participation in PHPR chronic care payment pilot allows
manageable testing of larger payment reforms to come
 Few multi-payer episode of care payment efforts in the
country—Wisconsin can lead the way
*See, e.g., http://www.ncbi.nlm.nih.gov/pmc/articles/PMC554918/;
http://www.commonwealthfund.org/Content/Publications/Issue-Briefs/2008/Jun/EvidenceInformed-Case-Rates--Paying-for-Safer--More-Reliable-Care.html?doc_id=689893
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Diabetic Services Bundle
 Adults 18-64 with diabetes
 Without HIV, cancer, suicide, ESRD, pregnancy
 Include the following ICD-9-CM codes:
 250.xx, v45.85, v53.91, v58.67, v65.46
 Establish outliers to exclude expensive surgical claims
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Chronic Care: Payment Model
Diabetic Pilot Outcomes Measures
Measure
Who Collects
and Reports*
To
Whom
How
Often
Good Control Hemoglobin A1C
(target < 7.0% or <8% for high risk
patients)
Provider
WCHQ
/
WPRI
At least
annually
Blood Pressure Control (target
<130/<80)
Provider
WCHQ
/
WPRI
At least
annually
LDL Cholesterol Control (target
<100mg/dl)
Provider
WCHQ
/
WPRI
At least
annually
Uncontrolled Hemoglobin A1C
(>9%)
Provider
WCHQ
/
WPRI
At least
annually
*electronic reporting to WCHQ assumed
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Chronic Care Pilots and Three-Part Aim
 Three goals for health as defined by IHI, National Quality
Strategy, etc. (sometimes called the “Triple Aim” or threepart aim):
 Better Care: Improve the overall quality, by making health
care more patient-centered, reliable, accessible, and safe.
 Healthy People and Communities: Improve the health of
the population by supporting proven interventions to address
behavioral, social, and environmental determinants of health
in addition to delivering higher-quality care.
 Affordable Care: Reduce or at least control the cost of
quality health care for individuals, families, employers, and
government.
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Chronic Care Pilots and Three-Part Aim, cont’d.
 Local communities may have prevention efforts (e.g.
nutrition/physical activity plans) in place—pilot
participants can leverage existing efforts
 PHPR welcomes the opportunity for further discussion
with interested pilot participants
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Chronic Care Next Steps
 Finalize service package, pilot materials
 Expressions of interest requested by June 1 or as soon
as feasible
 Targeting go-live of October 1, 2011
 Workgroup meeting this afternoon open to those
potentially interested in being pilot participants
Current Status:
Preventive Care Pilot Project
 Commercial patients
 Eligible for routine screenings for breast, cervical and
colorectal cancer
 In December, WHIO Board asked Preventive
Workgroup to explore suitability as a payment reform
project
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Preventive Care Deliberations
 Whose behavior most needs to be influenced
(Provider? Patient?) to increase compliance?
 What incentives or other strategies are best employed
to increase rates of cancer screenings?
 Now that cancer screenings are provided at no cost to
patients under the ACA, what barriers remain?
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What Gets in the Way of 100% Compliance?
Courtesy of WPS Insurance
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Major Screening Barrier
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Had bad experience in the past (n=70, 17 percent)
Unable to get a convenient appointment time (n=50, 12 percent)
Don’t want to think about the possibility of breast cancer (n=33, 8 percent)
“Cost” factor issue is a minimal barrier (n=2, <1%)
Source: Managed Care, April 2009: Barriers to Breast Cancer Screening In a Managed Care Population
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Preventive Care Next Steps
 WHIO Board direction:
 Early detection of cancer is important but falls outside of original purpose of
payment reform initiative
 Pend further development of Preventive Care cancer screening payment reform
pilot until results of no-cost screenings under ACA are better understood
 In 2011, WPS and partners will further explore:
 Lessons learned with military
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What education, incentives are needed to improve patient compliance?
 Relative cost of screenings; centers of excellence?
 How is total cost of care affected by more asymptomatic screenings
 Attend workgroup meeting this afternoon to learn more
 Volunteers welcome
What Are We Learning From Others?
 Integrated Healthcare Association, California
 http://www.iha.org/
 Mission: To create breakthrough improvements in
health care services for Californians through
collaboration among key stakeholders.
 Blue Cross/Blue Shield Alternative Quality Contract,
MA
 http://www.bluecrossma.com/visitor/pdf/alternative-
quality-contract.pdf
What Will It Take to Succeed?
1. Full CEO engagement
2. Commitment by all participants to prioritize pilot,
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including understanding that resources will need to
be committed, and there are costs and benefits to
participation
Clean, complete claims and eligibility data
Timely, actionable data feedback
EMR
Sense of urgency
Meaningful incentives
Reliable, accepted measures
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PHPR Support for Pilots
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Bundle definition
Quality measures and reporting processes
Model contract language
Resources from other payment reform efforts around the
country
 Initial interface between pilots and WHIO/Ingenix, other
technology vendors
 Support (if requested)of activities pilot participants may
wish to engage in, including:
 Steering Committee of representatives of participants in each
pilot site
 Best practice sharing across pilot sites; hosting “learning
laboratory” opportunities
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What Else Will It Take to Succeed?
 Leadership:
 No external imperative
 Lots of other things to do
 Future is uncertain
 Not just about the choir, but the parishioners too
 Sense of Urgency:
 Could be in design mode forever
 Easy for small pilot project to get lost in the shuffle
What Else Will It Take to Succeed?
 Honesty:
 Not a conversation about scarcity and threat, but holistic look
at overuse, underuse, misuse
 Patient engagement
 Stewardship: Stepping up to opportunity to influence
complex, multi-faceted problem
 It is not all about the _______ (physicians, drug companies,
insurance companies, patients, medical technology
vendors….)
 It’s about everyone accepting responsibility for a sustainable
health care system
What’s Next for PHPR?
Phase 1:
 Implement
 Track results
 Make adjustments
 Promote wider adoption
What’s Next for PHPR?
Phase 2 Options Include:
 Apply payment models to other conditions
 Map other payment models that can apply across
conditions
 Identify ongoing initiatives where payment reform would
be useful strategy
 Explore ACO options
“Health Policy Brief: Update - Accountable Care Organizations. Health Affairs, August 13, 2010
http://www.healthaffairs.org/healthpolicybriefs/
The Partnership for Healthcare Payment Reform
Thanks Its Sponsors…
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The Alliance
Anthem Blue Cross Blue Shield of
Wisconsin
The Business Health Care Group of
Southeast Wisconsin
Dean Health System
Greater Milwaukee Business Foundation
on Health
Gundersen Lutheran Health System
Hayward Area Memorial Hospital and
Waters Edge
Hospital Sisters Health System
Humana
Meriter Health Services
MetaStar, Inc.
Monroe Clinic
Network Health Plan
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Prairie du Chien Memorial Hospital
ProHealth Care
Rural Wisconsin Health Cooperative
Sacred Heart Rehabilitation Institute
Security Health Plan
ThedaCare Center for Healthcare Value
UnitedHealthcare of Wisconsin
University of Wisconsin Population Health
Institute
WEA Trust
WHEFA
Wisconsin Academy of Family Physicians
Wisconsin Department of Health Services
Wisconsin Manufacturers & Commerce,
Inc.
Wisconsin Hospital Association
Wisconsin Medical Society
WPS Health Insurance
…And Its Volunteers
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Acuity
The Alliance
Amery Regional Medical Center
Anthem Blue Cross Blue Shield
Appleton Cardiology Associates
Aspirus
Aurora
Briggs & Stratton
Business Healthcare Group
Children’s Community Health Plan
City of Milwaukee Health Department
Columbia St. Mary’s Hospital
Dean Health Plan
Family Health Center of Marshfield, Inc.
Greater Milwaukee Business Foundation
on Health, Inc.
 Group Health Cooperative of South
Central Wisconsin
 Mile Bluff Medical Center
 Holy Family Memorial, Inc.
 The HOPE of Wisconsin
 Hospital Sisters Health System
 Hufcor, Inc.
 Humana, Inc.
 Ingenix
 Journal Communications
 Lakeshore Medical Clinic
 Lakeview Specialty Hospital &
Rehabilitation
 Literacy Network
 Manpower Group
 Marshall & Ilsley Corporation
 Marshfield Clinic
…And Its Volunteers
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Medical College of Wisconsin
Medical Society of Milwaukee
MetaStar, Inc.
Ministry Health Care
Ministry Medical Group
Ministry St. Joseph’s Hospital
Monroe Clinic
Network Health Plan
New London Family Medical Center
Northeast Wisconsin Health Value Network
Oconomowoc Memorial Hospital
Orthopedic Associates of Wisconsin
Prairie du Chien Memorial Hospital
ProHealth Care, Inc.
Robert W. Baird & Company
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Rural Wisconsin Health Cooperative
Sacred Heart Hospital
St. Joseph’s Hospital
Seats, Inc.
St. Mary’s Hospital
ThedaCare Center for Healthcare Value
Trilogy Insurance
United Healthcare of Wisconsin
Unity Health Plans Insurance Corporation
University of Wisconsin – Milwaukee
University of Wisconsin Hospitals and Clinics
WEA Trust
Wheaton Franciscan Healthcare
Wisconsin Academy of Family Physicians
Wisconsin Collaborative for Healthcare
Quality
…And Its Volunteers
 Wisconsin Department of
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Health Services
Wisconsin Health
Information Exchange
Wisconsin Health
Information Organization
Wisconsin Hospital
Association
Wisconsin Manufacturers
& Commerce
Wisconsin Medical Society
WPS Health Insurance
Zimbrick, Inc.
For More Information:
Karen Timberlake
ktimberlake1@gmail.com
(608) 268-1802
Tim Higgins
tim.higgins@chirhoservices.com
(920) 716-8596