Sutter Medical Network

Sutter Medical Network Sutter Care Pattern Analyzer making the case for affordability Fifth National Pay for Performance Summit March 9, 2010 Michael van Duren, M.D., CMO Sutter Physician Services Colleen Thilgen, VP Ingenix Consulting Kristin Tschida, Consultant, Ingenix

Overview Sutter Medical Network Demonstration of Sutter Care Pattern Analyzer High level roll out plan Optimal Use Activities Low Back Pain Best Practice Alerts 2

Sutter Health & Sutter Medical Network

Sutter Health Vision Statement Sutter Health leads the transformation of health care to achieve the highest levels of quality, access and affordability Five priorities flow from the vision: Transparency 1. Quality 2. Affordability Transformation 3. Process Redesign & EHR 4. Prudent & strategic capital investment 5. Sutter Medical Network

Vision The purpose of the Sutter Medical Network, working in partnership with the overall Sutter Health network, is to provide consistently superb and affordable health care where, when and how patients want it.

Goals Consistently delivers top decile clinical quality and patient outcomes Enhances affordability by collaborating with hospitals to improve institutional performance and reduce the total cost of care and reducing variation and optimizing utilization management in physician care Aligns physician organizations to provide a convenient, organized care system Is preferred by customers, patients and health plans

Strategic Objectives Key Strategy Quality Patient Experience (Service) Disease Management/ Care Model Affordability Strategic Priority Pay for Performance Patient Online Access Ease of Referrals Reducing Patient Wait Times Patient Satisfaction Advanced Illness Management (AIM) Program Optimal Use of Clinical Services and Supplies

Why address these issues? Affordability For our patients, healthcare system, society Service Provide a consistent experience for all our patients Quality of Care Evidence based medicine Professional standards Avoid unnecessary radiation, risks, complications

National Health Expenditures and Their Share of Gross Domestic Product, 1960 2007 Dollars in Billions $2,500 $2,000 $1,500 $1,000 $500 $0 27.5 74.9 253.4 714.1 1,602.3 1,469.4 1,353.2 1,265.2 1,190.1 1,124.9 1,734.9 2,241.2 2,112.7 1,980.6 1,854.8 1960 1970 1980 1990 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 NHE as a Share of GDP 5.2% 7.2% 9.1% 12.3% 13.5% 13.6% 13.7% 13.8% 14.5% 15.3% 15.8% 15.9% 15.9% 16.0% 16.2% Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/nationalhealthexpenddata/ (see Historical; NHE summary including share of GDP, CY 1960-2007; file nhegdp07.zip).

Average Annual Premiums for Single and Family Coverage, 1999 2009 1999 $2,196 $5,791 Single Coverage 2000 $2,471* $6,438* Family Coverage 2001 2002 2003 2004 2005 $2,689* $3,083* $3,383* $3,695* $4,024* $7,061* $8,003* $9,068* $9,950* $10,880* 2006 2007 2008 2009 $4,242* $4,479* $4,704* $4,824 $11,480* $12,106* $12,680* $13,375* $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 * Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2009.

High Deductible Plans 11

The latest big idea Lower satisfaction with consumer driven plans Higher out of pocket costs More missed health care More cost conscious consumers Lack of information 12

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Physician driven utilization Can we measure it? # of Visits Specialty Referrals Ancillary testing (Imaging, Lab) Treatment choice (drugs, interventions) Decision to operate Can we manage it?

Reasons for over utilization Behavior driver Ability to influence Speed of results FFS payment system F F Self referral N/A N/A RVU physician comp system C D Professional identity C C Training, practice style F F I had no idea A A

So what can we do about this? Gather systemwide data in a standardized manner Solution: Sutter Health Enterprise Data Warehouse Led by Sutter Health IS Utilize a methodology that provides apples to apples comparisons between clinicians Solution: Implement episode grouper software (Ingenix) Led by Sutter Physician Services Methodology for changing individual physician behavior Solution: Engage physicians to examine, address and reduce variation in each specialty Led by Sutter Medical Network

Data Challenges Disparate systems Data not standardized Workflow variations producing varying data results Varying levels of discrete & detailed data available Varying technical database platforms Access to systems Inability to integrate and uniquely identify patients across multiple platforms 20

21 Sutter Connect Claims Sutter Connect Eligibility PAMF Claims Sutter North Claims PAMF Eligibility Pharmacy MiSys Lab Ext. Lab Sutter Select Claims Sutter Select Pharmacy Sutter Select Eligibility SCPA without SHEW standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize standardize SCPA Data Mart Claims Member Pharmacy Provider * will not work without Enterprise ID links across Provider, Member and transactions Lab * * * *

Sutter Connect Claims Sutter Connect Eligibility PAMF Claims SCPA with SHEW SHEW SCPA Data Mart Claims Sutter North Claims PAMF Eligibility Aggregate Member eid Pharmacy MiSys Lab Standardize Provider eid Match Pharmacy eid eid Ext. Lab Member eid Match Provider Sutter Select Claims Sutter Select Pharmacy Lab eid 22 Sutter Select Eligibility

Integrated Data Warehouse Advantages Centralized data standardizations and business logic Integration of Enterprise identification of patients & providers Synchronization of data loads across all environments to SCPA Normalization of data Ability to QA data quality in one place Reusability of all data stored in data warehouse for future projects and needs 23

Variation Reduction Implementation 1. Make variation visible 2. Safe environment 3. Physician led variation reduction 4. Reproducible Process 24

Sutter Care Pattern Analyzer Demonstration Exploration Process Select a clinical area High volume, high cost, ability to impact, curiosity Narrow to one Episode Treatment Group Drill down into all areas of variation; look for differences and patterns Ask questions; don t assume Link to Sutter Care Pattern Analyzer

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That doesn t look right Possible causes of underlying variation Coding patterns Data completeness Explainable patient characteristics Explainable provider characteristics Unexplained characteristics Ask, don t assume Probe for best practice, evidence based guidelines, or professional standards

Physicians identify an opportunity We should be able to fix that 1. Define standard / guideline 2. Define defect 3. Define metric for ongoing analysis 4. Generate ideas for possible improvement efforts 38

Possible methods for improvement efforts 1. Group discussion 2. Send out data by mail 3. Individual counseling (academic detailing) 4. Ongoing audit & feedback 5. Design Epic best practice alert

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Prioritize interventions EHR Alert Ongoing audit & feedback Group discussion Counsel Individuals Web portal with reports Mail out data 44

EHR Decision Support Inclusion: any low back pain dx Exclusion: cancer on problem list Trigger: any imaging ordered (regardless of first or recurrent episode) Frequency analysis: 1 9 x per mo. (highest utilizers: once per day)

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Results at Pilot Site 1

Results at Pilot Site 1

Results at Pilot Site 2

Results at Pilot Site 2

Variation reduction vs. follow standard care? Variation reduction Voice of the process No need to define standard of care Allows for clinical variation Can start immediately with variation exploration No clear endpoint (what is the right amount of variation?) Defect reduction Voice of the customer Must have evidence based guideline Must make sure all cases are very pure Must spend time to gather consensus Endpoint can be defined as percent compliance with guideline

Next steps Training for Medical Directors Navigating and exploring variation with the SCPA Tool Engaging physicians Identifying key leaders to drive initiative Identifying preliminary departments to engage Meeting with physicians to generate, evaluate and select concepts Determine best practices/guidelines Monitoring and quantifying improvement efforts

Risks Impact on revenue due to decreased utilization Affordability is a long run goal Provider satisfaction Professional autonomy Respectful communication Culture change Discussing practice patterns is new Potential for lack of engagement Biggest risk: doing nothing 53

Questions? Michael van Duren, MD, MBA 916-854-6613 vandurm@sutterhealth.org 54