Consumer Driven Healthcare Summit 2007 Second National Consumer

Consumer Driven Healthcare Summit 2007 Second National Consumer

Consumer Driven Healthcare Summit 2007 Second National Consumer Driven Healthcare Summit Developing Key Performance Indicators for Consumer-Directed Health Care and PayFor-Performance David Hammer McKesson Provider Technologies Ft. Lauderdale, Florida Session 2.06 Wednesday, September 26, 2007 Developing CDHC and P4PEastern Time 5:15 pmKPIsfor6:15 pm 1 Consumer Driven Healthcare Summit 2007 Agenda Key Performance Indicators Definition Purpose Benefits

Consumer-Directed Health Care Why Dont Employees Care? Why Do Employers Care? The Presidents Plan Backlash Financial Ramifications Keys to Success Under CDHC Developing KPIs for CDHC and P4P 2 2 Consumer Driven Healthcare Summit 2007 Agenda (contd) Pay-For-Performance

Costs of Errors and Variation How Can They Pay Us for Quality? Challenges Ahead Backlash Keys to Success Under P4P KPIs for CDHC and P4P Scheduling Pre-Registration / Pre-Authorization Insurance Verification Patient Access / Registration Developing KPIs for CDHC and P4P 3 3 Consumer Driven Healthcare Summit 2007 Agenda (contd) KPIs for CDHC and P4P (contd)

Financial Counseling Health Information Management Billing / Claim Submission Clinical / Decision Support / Finance Appendices 34 CMS / Premier Hospital Quality Measures 2. Organizations Interested in Healthcare Quality 3. Provider Scorecard Information 4. 50 Clinically-Relevant, yet Difficult, Questions 1. Developing KPIs for CDHC and P4P 4 4 Consumer Driven Healthcare Summit 2007 Whats Going On in This Picture?

Tiger Woods 2005 Masters Tourname nt Developing KPIs for CDHC and P4P 5 Consumer Driven Healthcare Summit 2007 Even the VERY BEST Keep Score! In business, words are words, explanations are explanations, promises are promises, but only performance is reality. Harold S. Geneen Former President and CEO of ITT Developing KPIs for CDHC and P4P 6 Consumer Driven Healthcare Summit 2007 Even the VERY BEST Keep Score! Ten Top Issues for 2006

1. Balancing clinical and financial issues 2. Getting ready for pay-for-performance 3. Implementing the EHR 4. Making pricing transparent 5. Boosting the revenue cycle 6. Developing new capital-access strategies 7. Increasing financial-reporting transparency 8. Updating charity care policies and procedures 9. Improving leadership skills 10.Dealing with staffing shortages SOURCE: Veach, M., Whats on Your Plate?, hfm, Jan 7 06 Developing KPIs for CDHC and P4P Consumer Driven Healthcare Summit 2007 Wheres Your Focus? Developing KPIs for CDHC and P4P 8 8 Consumer Driven Healthcare Summit 2007 Lets Define Terms

Key Performance Indicators Developing KPIs for CDHC and P4P 9 Consumer Driven Healthcare Summit 2007 What is a Key Performance Indicator? Numerical factor Used to quantitatively measure performance Activities, volumes, etc. Business processes Clinical processes Financial assets Functional groups Service lines The entire enterprise

SOURCE: BearingPoint, Key Performance Indicators Developing KPIs for CDHC and P4P 10 Consumer Driven Healthcare Summit 2007 Purposes of KPIs View a snapshot of performance at an individual, group, department, hospital, or regional level Assess the current situation and determine root causes of identified problem areas Set goals, expectations, and financial incentives for any individual, group, or enterprise Trend the performance of the selected individual, group, or enterprise over time SOURCE: BearingPoint, Key Performance Indicators Developing KPIs for CDHC and P4P 11 11 Consumer Driven Healthcare Summit 2007

Benefits of Using KPIs Increases management awareness Focuses attention on improvement opportunities Increasing Cash Flow Improving Clinical Quality Reducing Costs Benchmarkin Developing Consistent Processes and g Outcomes Illustrating Developing Best Trends Practices Scoring Performance Improving / Accelerating Reducing Management Denials Reporting Identifying Problem

SOURCE: BearingPoint, Key Performance Indicators Monitoring Staffing Areas 12 Developing KPIs for CDHC and P4P Consumer Driven Healthcare Summit 2007 Consumer-Directed Health Care A Whole New Ballgame! Developing KPIs for CDHC and P4P 13 Consumer Driven Healthcare Summit 2007 Medical Consumerism Coming Managed care was designed to put control where there was none. Todays trend towards consumerism attempts to inject something thats been missing from health benefits a consumer who cares more about cost and quality. SOURCE: Take Care of Yourself Employers Embrace Consumerism to Control Healthcare Costs, PricewaterhouseCoopers Health Research Institute, 2005

Developing KPIs for CDHC and P4P 14 Consumer Driven Healthcare Summit 2007 Why Dont Employees Care? Many have chosen unhealthy lifestyles, which drive up spending Can rarely shop for health plans, because 90% of plans lack a choice of benefits Few shop for providers Fewer still are aware of rating services for MDs, hospitals, or health plans SOURCE: Take Care of Yourself, PwC, 2005 Developing KPIs for CDHC and P4P 15 Consumer Driven Healthcare Summit 2007 Why Dont Employees Care? Almost all are at least four steps away from cost of, and payment for, medical care Have little access to information Thus, most know little or nothing about quality or true cost of what theyre buying SOURCE: Take Care of Yourself, PwC, 2005

Developing KPIs for CDHC and P4P 16 Consumer Driven Healthcare Summit 2007 Why Do Employers Care? More than 75% believe they can reduce benefit costs by making employees pay a greater share Nearly 67% fear that increasing deductibles could cause employees to defer needed care or risk long-term health problems This could reduce productivity and lead to higher catastrophic costs later 80% believe most-promising option is to provide financial incentives for employees to adopt healthier lifestyles (carrot vs. stick) Developing KPIs for CDHC and P4P SOURCE: Take Care of Yourself, PwC, 2005 17 Consumer Driven Healthcare Summit 2007 Why Do Employers Care? 72% state that CEOs are encouraging employees

and dependents to adopt healthy lifestyles Financial incentives Education Innovative healthcare programs Divided on whether to require employees with unhealthy lifestyles to pay a greater share of their healthcare costs (self-inflicted wounds) Think price + quality info could change behavior and reduce costs, but hard to obtain / distribute Developing KPIs for CDHC and P4P SOURCE: Take Care of Yourself, PwC, 2005 18 Consumer Driven Healthcare Summit 2007 Why Do Employers Care? SOURCE: Kauffman, V. and L. Smith, Centering on the Consumer: The Health Insurers Key to Unlocking the Healthcare Cost Crisis, DiamondCluster International, 2005 Developing KPIs for CDHC and P4P 19 Consumer Driven Healthcare Summit 2007 Why Do Employers Care?

What If They Didnt Offer Health Benefits? Per a recent Kaiser Family Foundation annual Employer Benefits Survey Survey tracked five-year trend Employers offering health coverage fell from 69% to 60% 13% decline in five years Healthcare premium costs grew precipitously between 1999 and 2004 5.5 times the rate of inflation 2.3 times the rate of business income growth SOURCE: Klepper, B. and P. Salber, The Business Case for Reform, Modern Healthcare, Oct 10, 2005 Developing KPIs for CDHC and P4P 20 Consumer Driven Healthcare Summit 2007 Why Do Employers Care? Glossary of Consumer-Directed Products Plans

Descriptions Tax Benefits FSAs: Flexible Spending Accounts Employer bookkeeping accts for medical expenses, funded by employee pre-tax dollars Often offered as separate components of cafeteria plans Unspent balances may not be rolled over from year to year or cashed out Use it or lose it HDHPs: High- Health insurance plans with a deductible of at least Deductible $1,000 Health Plans Must meet certain legislative

and regulatory requirements for participants to contribute to HSAs and MSAs HRAs: Health Medical plans funded entirely by employers, that Reimburseme reimburse employees for Developing KPIs for CDHC and P4P nt Tax benefits same as other employer plans Premiums are tax deductions for employers and are not considered taxable income for employees Unspent balances may be rolled over from year to year but there is only limited 21 Consumer Driven Healthcare Summit 2007 Why Do Employers Care? Glossary of Consumer-Directed Products

Plans Descriptions Tax Benefits HSAs: Health Savings Accounts Portable, personal accounts for payment of medical expenses Individuals must be covered by HDHPs ($1,000 indv / $2,000 family) to contribute to HSAs Unavailable to Medicareeligibles, tax dependents, or anyone covered by non-HDHP plans Can be funded by employers, employees, or other individuals Requires a trust or custodian account Contributions are excludable or deductible and may be rolled over from year to year

if unused for payment of qualified medical expenses Accounts earnings are not taxable Available to small-business employees covered by High Deductible Health Plans Developing KPIs for CDHC andNo P4Pnew accounts may be MSAs: Medical Savings Requires a trust or custodian account Contributions are excludable 22be or deductible and may Consumer Driven Healthcare Summit 2007 The President Has a Plan Developing KPIs for CDHC and P4P 23

Consumer Driven Healthcare Summit 2007 The Presidents Plan Allow people who buy HSA-related highdeductible policies outside their workplace to deduct premiums from their taxes Offer tax credits to offset payroll taxes paid on these premiums Have owners of HSA accounts and their employers make contributions to offset outof-pocket costs, as well as deductibles Make out-of-pocket expenses taxdeductible, but cap at $5,250 indv / $10,500 family SOURCE: Newkirk, W. and J. Graham, Chicago Tribune, Feb 16, 2006 Developing KPIs for CDHC and P4P 24 Consumer Driven Healthcare Summit 2007 The Presidents Plan Refundable tax credit to help uninsured Americans purchase high-deductible policies in connection with HSAs Maximum credit $1,000 for one adult $2,000 for two adults $3,000 for two adults with children

Credit would phase out at $30,000+ income for individuals $60,000+ income for families SOURCE: Newkirk, W. and J. Graham, Chicago Tribune, Feb 16, 2006 Developing KPIs for CDHC and P4P 25 Consumer Driven Healthcare Summit 2007 The Presidents Plan President Bush spoke during a panel discussion at DHHS on Thursday, February 16, 2005 Argued that U.S. patients should pay more-directly for their care Postulated they will become comparison shoppers whose interest in a good deal will drive costs down Bush said current system makes individuals less engaged in the cost of the procedures they get SOURCE: Reichman, D., Bush Urges More Direct Health Care Choices, Associated Press, Feb 16, 2006 Developing KPIs for CDHC and P4P

26 Consumer Driven Healthcare Summit 2007 The Presidents Plan Bushs statements at DHHS headquarters included When somebody else pays the bills, rarely do you ask price or ask the cost of something The problem with that is that there's no kind of market force, there's no consumer advocacy for reasonable price when somebody else pays the bills One of the reasons why we're having inflation in health care is because there is no sense of market Bush also repeated his calls for tax-advantaged Health Savings Accounts SOURCE: Reichman, Associated Press, Feb 16, 2006 Developing KPIs for CDHC and P4P 27 Consumer Driven Healthcare Summit 2007 The Presidents Plan Comparison Shopping a Myth, or Dream? Government Accountability Office study released September 2005 GAO found no rhyme or reason to

Prices charged by hospitals or physicians Prices paid by health insurers for hospital or physician services SOURCE: Evans, M., Modern Healthcare, Oct 3, 2005 Developing KPIs for CDHC and P4P 28 Consumer Driven Healthcare Summit 2007 Consumer-Driven Health Care Backlash Developing KPIs for CDHC and P4P 29 Consumer Driven Healthcare Summit 2007 Consumer-Driven Health Care Backlash One of the greatest public-relations coups in the history of the healthcare industry is the creation of the term consumer-driven health care. Anyone that follows healthcare knows that consumers had nothing to do

with this latest cost-saving invention from the minds of employers and health insurers. David Burda Editor, Modern Healthcare Oct 10, 2005 Developing KPIs for CDHC and P4P 30 Consumer Driven Healthcare Summit 2007 Consumer-Driven Health Care Backlash Many employees dont like the HSA, to be quite frank. Had my position been an elected one, I would have been voted out of office this year. It feels like theyre paying more up front. The perception is, this is a very expensive type of plan. Even though there is money in employee accounts to cover these expenses, people end up feeling theyre paying more out of pocket. Larry Lutey

VP, Human Resources Social Services, Elgin, IL Developing KPIs for CDHC and P4P Lutheran 31 Consumer Driven Healthcare Summit 2007 Match the Headline to the Organization Headline Organization Majority of working adults prefer employer-selected health plans to employerfunded accounts. Blue Cross and Blue Shield Organization Large U.S. employers are changing benefit plans to control costs and improve quality.

PricewaterhouseCoopers Commonwealth Fund Survey shows high rate of satisfaction with HSAs. SOURCE: Burda, D., Connect the Dots Employers and Insurers are Behind the Wheel on Consumer-Driven Healthcare, Modern Healthcare, Oct 10, 2005 Developing KPIs for CDHC and P4P 32 Consumer Driven Healthcare Summit 2007 What Does This Mean for You? Developing KPIs for CDHC and P4P 33 Consumer Driven Healthcare Summit 2007 Possible CDHC Financial Ramifications Desirable Questionable

Potentially-better results More net revenue Higher profits Improved cash flow Potentially-worse results More bad debt Worsened aging Higher cost-to-collect Patients w/ HDHPs will have to use cash or credit for care, at least initially Growing pressure to publicly disclose prices and details of reimbursement Patients w/ HDHPs may be paying full charges, not discounted rates charged to HMOs and PPOs Developing KPIs for CDHC and P4P Patients w/ HSAs may deplete funds by spending on health

convenience items and/or 34 SOURCE: Burda, Modern Healthcare, Oct 10, 2005 non-traditional care Consumer Driven Healthcare Summit 2007 Possible CDHC Financial Ramifications Rising pressure to increase financial transparency Summer 2005 McKinsey & Company study of 2,500 insured people (1,000 in CDHC plans) showed CDHC-plan members felt they lacked sufficient info to make meaningful healthcare-choice decisions Wondered about how much MDs and hospitals get paid Yet, McKinsey study also showed CDHC plan members were 50% more likely to ask about cost 33% more likely to independently find alternative care 300% more likely to have chosen a less extensive, lessexpensive treatment SOURCE: Snowbeck, C., Pittsburgh Post-Gazette, Sep 18, 2005 Developing KPIs for CDHC and P4P

35 Consumer Driven Healthcare Summit 2007 Keys to Success Under CDHC Developing KPIs for CDHC and P4P 36 Consumer Driven Healthcare Summit 2007 CDHC Thoughts to Ponder CDHC initiatives will continue to accelerate, and proliferate, over time Initiatives will require an increased focus on Pre-registration Ins verification Financial counseling The need to collect, retrieve, and report data about CDHC-related patients will increase Developing KPIs for CDHC and P4P 37 Consumer Driven Healthcare Summit 2007

CDHC Thoughts to Ponder Self-pay exposure will increase as more employers offer, and more employees take, CDHC plans Provider / payor negotiations may be needed to sort out whether patients will be responsible for gross or net charges Individual patient encounters may be subject to one-off price negotiations, requiring considerable management time Up-front payment policies and enforcement may have to become stricter, to forestall bad debt 38 Developing KPIs for CDHC and P4P Consumer Driven Healthcare Summit 2007 P4P: Pay for Performance Another Whole New Ballgame! Developing KPIs for CDHC and P4P 39 Consumer Driven Healthcare Summit 2007 Costs of Errors and Variation

High costs associated with medical errors and variations in treatment are drivers for P4P Developing KPIs for CDHC and P4P 40 Consumer Driven Healthcare Summit 2007 What Factors Contributed to Economic Focus on Patient Safety? 1999 Medical Errors 2001 Evidence-Based Medicine, increased use of IT 2001 Safety, effectiveness, patientcenteredness, timeliness 2004 Keeping Patients Safe: Developing KPIs for CDHC and P4P Transforming the Work

Environment of Nurses 41 What Do We Know About Medical Errors? Most Common Errors per 1,000 Visits Consumer Driven Healthcare Summit 2007 65 incidents due to adverse drug events 60 incidents due to hospitalacquired infections 51 incidents due to procedural complications 15 incidents due to falls SOURCE: Advisory Board Company, Washington, DC Developing KPIs for CDHC and P4P 42 Consumer Driven Healthcare Summit 2007 Problems with Paper-Based Manual Systems Handwritten MDs Orders 24% incomplete 20% illegible

SOURCE: National Committee on Vital and Health Statistics (NCVHS) A small piece of paper doesn't look like a deadly weapon. SOURCE: Developing KPIs for CDHC and P4P Turner, R., U.S. News & World Report, Aug 2, 2004 43 Dartmouth Study Spotlights Variances More Care Is Not Better 90,616 Medicare patients treated for cancer, CHF, and COPD at 77 top U.S. hospitals Patients with large amounts of care did no better than those with less care Extra MD visits, longer LOS, and more tests / consults appear to hasten death SOURCE: Wennberg, et al, The Dartmouth Study, Journal of Health Affairs, Oct, 2004

Hospital Length of Stay Mayo Rochester 11.6 St. Louis Univ Hospital 12.9 Duke Medical Center 13.5 UCLA Medical Center 16.1 John Hopkins 16.1 Massachusetts General 16.5

Mount Sinai Med Ctr, NYC 22.8 Consumer Driven Healthcare Summit 2007 Problem Is Not Simply Variances Care Often Does Not Match Quality Standards Adherence to quality indicators by condition 0% 20% 40% 60% 80% 65% care of HTN 68% care of CAD 45%

B-Blocker after AMI 61% ASA w / AMI 64% Pnemococcal Vac 38% Colorectal screen 57% Osteoarthritis 25% Atrial fib 23% Hip fracture EtOH dependence 11%

SOURCE: Clinical Quality Guidelines, New England Journal of Medicine, 348:2635-45, Jun 26, 2003 Developing KPIs for CDHC and P4P 45 Consumer Driven Healthcare Summit 2007 When Does Care Match Quality Guidelines? Only 55% of the Time! Adherence to Quality Indicators, According to 0% 10% 20% 30% 40% 50% 60% 70% 80% Mode 73% Encounter/Intervention 69%

Medication 66% Im m unization 63% PE 62% Lab/Radiology 57% Surgery 43% History Counseling/Education 18% SOURCE: Clinical Quality Guidelines, NEJM, 348:2635-45, Jun 26, 2003 Developing KPIs for CDHC and P4P 46

Consumer Driven Healthcare Summit 2007 How Can They Pay Us for Quality? Developing KPIs for CDHC and P4P 47 Consumer Driven Healthcare Summit 2007 How Have We Approached Healthcare Pmt? 1. Financial 2. Administrative 3. Clinical Developing KPIs for CDHC and P4P 48 Consumer Driven Healthcare Summit 2007 Financial and Administrative Approaches More Trouble Than Theyre Worth? Financial Payors controlling costs, via

DRGs Managed care contracting Etc. Administrative Payors controlling access, via Gatekeepers Capitation Etc. Clinical Payors attempting to reward care that adheres to quality standards Developing KPIs for CDHC and P4P 49 Control Access and Institute Risk Sharing? Some MDs Dont Tell Patients About Options Consumer Driven Healthcare Summit 2007 33% of MDs declined to offer "useful" medical services to some patients because the services weren't covered under their patients' health insurance. SOURCE: Health Affairs, Jul 2003

Developing KPIs for CDHC and P4P 50 What Do We Know About Medical Errors? Some Payors No Longer Pay For Them! Consumer Driven Healthcare Summit 2007 HealthPartners (Minnesota) recently became the first to penalize for errors In January 2005 HealthPartners stopped paying for errors that appear on a list of nevers surgery performed on the wrong body part surgery performed on the wrong patient leaving a foreign object in a patient after surgery SOURCE: Modern Healthcare, Oct 06, 2004 Developing KPIs for CDHC and P4P 51 Consumer Driven Healthcare Summit 2007 Payors Want Savings When Errors Reduced

Medical errors are responsible for 30% of healthcare expenditures More than 50% of the $17 - $29 billion national cost of medical errors is preventable Medical errors cost 10 - 15% of hospitals annual budgets SOURCE: Task Force on Healthcare Cost Control, Mar 2002 ADEs are responsible for $2 billion per year nationwide in hospital costs alone SOURCE: Bates D. W., et al, JAMA, 1997;277(4):307-11 One ADE adds more than $2,000 on average to the cost of hospitalization SOURCE: Classen D. C., et al, JAMA, 1997;277:301-306 52 Developing KPIs for CDHC and P4P Consumer Driven Healthcare Summit 2007 If No Proper Care Now, Who Pays Later? Welcome to Medicare! In 1999, seniors (13% of the population) accounted for $387 billion ($11,089 per capita / 36%) of U.S. healthcare spending

SOURCE: CMS Office of the Actuary, Dec 6, 2004 By 2014, CMS says government will pay 50% of healthcare costs SOURCE: Heffler, et al, Health Affairs, Feb 23, 2005 53 Developing KPIs for CDHC and P4P 53 Consumer Driven Healthcare Summit 2007 Medicare Using Its Leverage CMS / Premier Demonstration Project Three-year program linking payment with quality 278 participating hospitals Up to 2% of Medicare dollars at risk across five clinical areas Minimum payout of $25 million across top 20% of participants SOURCE: Toward the Data-Driven Clinical Enterprise, Advisory Board Company, 2005 Developing KPIs for CDHC and P4P 54 Consumer Driven Healthcare Summit 2007

Medicare Using Its Leverage In five to ten years I would like to see 20% 30% of Medicare payments tied to performance. Mark McClellan CMS Administrator 2004 SOURCE: Advisory Board Company, 2005 Developing KPIs for CDHC and P4P 55 Consumer Driven Healthcare Summit 2007 More Scrutiny on Practice Variation Tell MDs This is Improving Quality o Care Highmark Blue Cross and Blue Shield (PA) a 1,100-physician network Launched a program in 2000 to provide physician-specific data Pinpoints practice variation from accepted clinical guidelines In July 2005 Highmark began to offer financial support for EMR development SOURCE: Healthcare Informatics, Mar 2005

Developing KPIs for CDHC and P4P 56 Hospitals Now Have Company Doctors CMS Launches Pilot P4P Program for MDs Consumer Driven Healthcare Summit 2007 Pays bonuses to MDs at 10 participating clinics who achieve standards for more-efficient and better-quality care Focuses on 32 quality measures for preventive care and chronic disease management, for example Vaccination for patients at high risk for influenza Blood pressure control for diabetics Use of cholesterol-lowering medication by patients with heart disease Provides payments based on services delivered SOURCE: CMS Press, 31, 2005 bonus payments of up to MDs eligible

forJan annual 5% Developing KPIs for CDHC and P4P 57 Consumer Driven Healthcare Summit 2007 Challenges Ahead On That, We All Likely Agree... Developing KPIs for CDHC and P4P 58 Consumer Driven Healthcare Summit 2007 C-Suite Executives View P4P Differently Stakeholder Current Perception CEOs/ COOs

Concerned about public perception See P4P as marketing tool CFOs / CROs Worried about ROI Believe P4P requires labor-intensive data gathering Think payors will use P4P to drive down reimbursement CMOs / CNOs Dislike CMS Feel measures do not accurately represent quality Believe P4P requires labor-intensive data gathering CIOs / DSS Directors See P4P as a nuisance Do not see as a top priority compared to clinicals Resistant to one more request for data Developing KPIs for CDHC and P4P 59

Consumer Driven Healthcare Summit 2007 Data Collection and Measurement Challenges Ahead Over 400 publicly-defined indicators based on clinical evidence and industryrecognized metrics Process measures (~90%) Right treatment / drug, at the right time Appropriate patient assessment, education, and instruction Outcomes measures Mortality Post-operative complications Readmissions Developing KPIs for CDHC and P4P 60 Consumer Driven Healthcare Summit 2007 Data Collection and Measurement Challenges Ahead JCAHO Measurement Sets ORYX initiative (1997) is required for

accreditation, and Medicare participation requires accreditation JCAHO partnered with CMS so ORYX would encompass CMSs Pay For Performance measures Core measures (ORYX + CMS) Acute myocardial infarction (AMI) Heart failure (HF) Community acquired pneumonia (CAP) Pregnancy and related conditions (PR) Surgical infection prevention (SIP) Developing KPIs for CDHC and P4P 61 Consumer Driven Healthcare Summit 2007 Data Collection and Measurement Challenges Ahead JCAHO Measurement Sets

Hospitals must report on a varying combination of core and non-core measure sets, depending on their ability to collect the data Two core and three non-core measure sets OR One core and six non-core measure sets OR Nine non-core measure sets Data are publicly reported at www.qualitycheck.org Developing KPIs for CDHC and P4P 62 Consumer Driven Healthcare Summit 2007 Data Collection and Measurement Current CMS / Premier Reporting Acute Myocardial Infarction (AMI) ASA on admission ASA on D/C ACEI for LVSD Adult smoking-cessation instructions Beta Blocker ordered at D/C

Beta Blocker within 14 hours of admission Time to Thrombolysis (30 min.) Time to PTCA (120 min.) Inpatient mortality Med record abstract Discharge Instructions Charge code + Dx code + imaging result Nursing activity Discharge instructions Drug administration time Drug administration time Procedure start times Discharge status BLUE Currently-captured revenue cycle data GREEN Not currently captured. Requires manual record review RED Time-stamped clinical activity. Requires manual review of nontraditional data sources Developing KPIs for CDHC and P4P 63 Consumer Driven Healthcare Summit 2007 Data Collection and

Measurement Challenges Ahead Reporting Numerator Statement: AMI patients whose time from hospital arrival to thrombolysis is 30 minutes Arrival date Arrival time Thrombolytic administration date Thrombolytic administration time Virtually all study populations apply extensive inclusion / Denominator Statement exclusion criteria Included populations - discharges with: These require complex data combinations Clinical Demographic Diagnosis

BLUE revenue cycle data Currently-captured Procedure Not currently captured. Requires manual record review RED Time-stamped clinical activity. Requires manual review of non-traditional data sources Developing KPIs for CDHC and P4P GREEN An ICD-9-CM principal diagnosis code for AMI as defined in Appendix A, Table 1.1 AND ST segment elevation or LBBB on the ECG performed closest to hospital arrival AND Thrombolytic therapy within 6 hours after hospital arrival Excluded Populations: Patients less than 18 years of age

Patients received in transfer from another hospital including another emergency department Data Elements: Admission date Admission source Birthdate ICD-9-CM principal diagnosis code Initial ECG interpretation Thrombolytic administration 64 Consumer Driven Healthcare Summit 2007 Data Collection and Reporting Financial Burden Data Collection Over 90% of the measures require data not readily available in current hospital data sets Thus, data collection will require manual chart review Developing KPIs for CDHC and P4P

Cost to Report Performance Measures COST $100M $200M OE FACTORS OE Chart Review Time Reqd 1,000 Hours/Yr 1,250 Hours/ Yr 3 RNs / 4 RNs $240,000 $320,000 $50,000 $50,000

$295,00 0 $380,000 Data Analyst Annual Total Revenue Impact of CMS P4P (.4%) ASSUMPTIO N $100M OE CMS $200,00 Revenue 0 Totals 50% Net Financial Impact $200M OE

$400,000 Net Financial Impact of CMS P4P GAIN / $100M $200M OE (LOSS) After costs of OE ($95,00 0) 65 $20,000 Consumer Driven Healthcare Summit 2007 Data Collection and Reporting Need Two Views: Patient + Aggregate Integrated View of Clinical Process Compliance & Perf Measures HBI

Decision Support Data Aggregatio n Monitoring HEO, Measuremen HED, t Reporting HPM HARx, HCR, User HAC, Education Reporting & HEC, Baseline Presentatio HSM Data Transformati on

n Patient-level Process Improvement Developing KPIs for CDHC and P4P Population-level Process Improvement SOURCE: McKesson Provider Technologies 66 Consumer Driven Healthcare Summit 2007 Pay for Performance Backlash Developing KPIs for CDHC and P4P 67 Consumer Driven Healthcare Summit 2007 Pay For Performance Backlash Too often managers and non-clinical personnel make profound decisions about how we practice medicine.

I hope this conference allows us to shape future payment policies in ways that those of us who actually see patients believe will work best. Sidna M. Scheitel, MD, MPH Mayo Clinic SOURCE: Outcomes-Based Compensation Pay-for-Performance Design Principles, 4th Annual Disease Management Outcomes Summit, Nov 11-14, 2005 Developing KPIs for CDHC and P4P 68 Consumer Driven Healthcare Summit 2007 Data / Methods for MDs Scores Questioned Performance measurement is still in its very rudimentary stages. There are a number of challenges to measuring quality and efficiency. It remains difficult to generate accurate provider report cards. MD group threatens to terminate its contract with United by August 2005 unless United suspends or alters its Performance Designation Program Program gives stars next to MDs names on Uniteds website Stars purportedly indicate high quality and lower-cost care

Claims data from 2002 - 2003 used SOURCE: Armstrong, Developing KPIs for CDHC and P4P J. (AMA), Modern Healthcare, Apr 4, 2005 69 Consumer Driven Healthcare Summit 2007 Data / Methods for MDs Scores Questioned MD groups concerns: Only 4 of 1,144 (0.3%) of full-time faculty received stars MDs bill in groups, but United unable to break down claims individually 40% of MDs ineligible due to of insufficient sample size (not enough claims submitted to analyze) MDs evaluated on cost, because evidence-based standards for their specialties had not been established SOURCE: Armstrong, J. (AMA), Modern Healthcare, Apr 4, 2005 Developing KPIs for CDHC and P4P 70

Consumer Driven Healthcare Summit 2007 Outcomes of P4P Programs Questioned Compared California and Pacific Northwest MD groups on three clinical quality process measures, based on 2001 to 2004 data Cervical cancer screening Mammography Hemoglobin A1c testing For all three measures, MDs with baseline performance at or above threshold improved least but got biggest share of P4P bonuses SOURCE: Rosenthal, M. et al, (Harvard School of Public Health), JAMA, Oct 12, 2005 Developing KPIs for CDHC and P4P 71 Consumer Driven Healthcare Summit 2007 Interpretation Challenges Variable definitions: Not all agencies and initiatives agree on measurement definitions. This creates varying results, and confusion Same facility, same conditiondiff erent results. As a consumer, do I use this facility for my bypass surgery?

THCI C Report* CABG mortality is significantly higher than expected Expected result General Hospital Observed result 8.4 ** * * indicates diff erence in observed and expected results are sta tistically significant * Texas Healthcare I nformation Council HealthGrades.com Report General Hospital Five stars indicates significantly better then expected Three stars indicates average Developing KPIssignifi for CDHC and P4P

One star indicates cantly worse than expected CABG mortality is at the expected level 72Council SOURCE: Texas Healthcare Information Consumer Driven Healthcare Summit 2007 P4P a Nightmare or Will Reason Prevail? Jack Bovender Jr. (HCAs CEO) calls for Congress to create a special board to develop a standard set of quality measures for P4P programs Without an organized approach, healthcare providers face high administrative costs as they try to comply with different P4P requirements We have all these silos going Leapfrog, individual consulting companies, government agencies, employer groups all starting down different paths. Karen Ignagi, CEO Americas Health Insurance Plans Developing KPIs for CDHC and P4P SOURCE: Modern Healthcare, Jun 29, 2004

73 Consumer Driven Healthcare Summit 2007 Keys to Success Under P4P Developing KPIs for CDHC and P4P 74 Consumer Driven Healthcare Summit 2007 P4P Thoughts to Ponder P4P initiatives will continue to accelerate, and proliferate, over time Initiatives will require, at both patient and aggregate levels Data collection Data retrieval Data reporting Clinical information systems will become an economic necessity as the ability to collect, retrieve, and report process / outcomes data increases Developing KPIs for CDHC and P4P

75 Consumer Driven Healthcare Summit 2007 P4P Thoughts to Ponder Revenue cycle + clinical informatics professionals will play key roles in evolving information systems towards efficacious care Financial and clinical data will become moreclosely integrated The HIPAA claims attachment rule (coming in 2006, hopefully) will require clinical documentation Do not limit yourself to a reactive approach to outside influences establish your own quality and outcomes goals and measures Developing KPIs for CDHC and P4P 76 Keys to Success Under P4P People, Process, and Technology 1. Automate and Support Patient-Facing Workflow How do we do the work electronically? Clinical Data Repository Results Viewing + Notification 3. Improve Outcomes Clinician Decision Support Clinical Order Entry + Documentation How can we do it better? Nurse MAR

Pharmacy-to-Lab Integration Workflow Rules Intelligent Medical Devices On-Line References Integration Clinical Protocols Integrated Structured Documentation Mandatory/Optional Support Charge Capture + Billing and Coding 2. Measure Aggregate Outcomes How well did we do it? Health Status Patient Satisfaction Cost & Utilization Analysis Clinical Results Analysis Level of resource commitment

Consumer Driven Healthcare Summit 2007 Components Required to Fully Addre P4P Definitions Day-to-day MD / RN clinical processes surrounding patient care Data acquisition, either automated (via clinical process) or manual, to support needed metrics Transformation of discrete data points into a comprehensive set of measures that goes beyond P4P and core measures Submission of data to key stakeholders (CMS, JCAHO, etc.) typically by a CMV Presentation of metrics and scorecards to internal audiences Improvement of business & clinical process to enhance patient safety, financial health, and market perception In the context of P4P, payment based on measured quality of care Developing KPIs for CDHC and P4P Components

Clinical workflow Data collection Data transformation Issues Full adoption of clinical systems is not yet widespread Supplemental data collection is mostly manual; hard to automate Heavy automation required to minimize cost Data submission Internal reporting Often requested to present a fair and accurate picture of quality Improving process Industry leaders will leverage core measures/ P4P to implement TQM Reimbursement An increasing % of reimbursement will be performance-based

78 Consumer Driven Healthcare Summit 2007 So, How Do You Measure Success? Use Proven KPIs in a New Context, and Consider Some New Ones Developing KPIs for CDHC and P4P 79 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Scheduling KPI Description 1. Overall scheduling rate of potentially-eligible patients: Scheduling rate for elective and urgent inpatients Scheduling rate for ambulatory surgery patients Scheduling rate for hi-$ outpatient diagnostic patients Standar

d 100% 100% 100% 100% 2. Scheduled patients pre-registration rate Developing KPIs for CDHC and P4P 95% 80 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Scheduling KPI Description Process 1. Use on-line scheduling software house-wide? Yes 2. Have central scheduling unit? Yes

3. Central scheduling answers to Chief Revenue Officer? Yes 4. Surgery uses same scheduling software as other depts? Yes 5. Scheduling system interfaced with registration system? Yes 6. Use on-line OP medical necessity system prior to service? Yes 7. Pre-certification requirements shared with MDs offices? Yes Developing KPIs for CDHC and P4P 81

Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Scheduling KPI Description Proces s 8. MDs offices able to make on-line appointment requests? Yes 9. Non-emergency services scheduled 12+ hours in advance? Yes 10. Process and IT integrated between scheduling and pre-reg? Yes 11. Services postponed if not pre-authorized in advance? Yes

12. Financial counseling part of scheduling process? Yes Patient balances and payment obligations discussed? Yes Hospital policy explained for point-of-service payment? Yes Reminder given Developing KPIs for CDHC and P4Pto bring required payment & insurance 82 Yes Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Pre-Registration / PreAuthorization

KPI Description Standar d 1. Overall pre-registration rate of scheduled patients 95% 2. Overall insurance verification rate of preregistered patients 95% 3. Deposit request rate for co-pays and deductibles 95% 4. Deposit request rate for elective admissions / procedures 100% 5. Deposit request rate for prior unpaid balances 95% 6. Data quality compared to pre-established dept

standards 98% Developing KPIs for CDHC and P4P 83 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Pre-Registration / PreAuthorization KPI Description Proces s 1. Have dedicated pre-registration / pre-authorization unit? Yes 2. Process and IT integrated between scheduling and pre-reg? Yes 3. Services postponed if not pre-authorized in

advance? Yes 4. Financial counseling part of pre-reg / pre-auth process? Yes Patient balances and payment obligations discussed? Yes Hospital policy explained for point-of-service payment? Yes Reminder given to bring required payment & insurance cards? Yes Developing KPIs for CDHC and P4P 84 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P

Insurance Verification KPI Description Standa rd 1. Overall insurance verification rate of scheduled patients 95% 2. Overall ins verification rate of pre-registered patients 95% 3. Ins verf rate of unscheduled IPs w/ in one business day 95% 4. Ins verf rate of unscheduled hi-$ OPs w/ in one business day 95% 5. Data quality compared to pre-established dept standards

98% Developing KPIs for CDHC and P4P 85 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Insurance Verification KPI Description Proces s 1. Have dedicated insurance verification unit? Yes 2. Process and IT integrated between ins verf / patient access? Yes 3. Use on-line insurance verification system? Yes 4. Financial counseling part of insurance verification

process? Yes Alternate arrangements for non-covered patients explored? Yes Hospital policy explained for point-of-service payment? Yes Reminder given to bring required payment & insurance cards? Yes Developing KPIs for CDHC and P4P 86 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Patient Access / Registration KPI Description Standar

d 1. Average registration interview duration 10 min 2. Average patent wait time 10 min 3. Average IP registrations per registrar / per shift 35 4. Average OP registrations per registrar / per shift 40 5. Average ER registrations per registrar / per shift 40 6. Data quality compared to pre-established dept standards 98% 7. ABNs / MSPQs obtained when required

100% 8. MPI duplicates created daily as a % of total registrations 1% Developing KPIs for CDHC and P4P 87 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Patient Access / Registration KPI Description Proces s 1. Patient access reports to Chief Revenue Officer? Yes 2. All registrars report to patient access or within rev cycle? Yes

3. Use on-line document imaging system? Yes 4. Financial counseling part of patient access process? Yes Patient balances and other payment obligations collected? Yes Policy explained for payment alternatives (credit cards, etc.)? Yes Copies obtained of required payment & insurance cards? Yes Developing KPIs for CDHC and P4P 88 Consumer Driven Healthcare Summit 2007

KPIs for CDHC and P4P Patient Access / Registration KPI Description Proces s 5. Registrars incentive compensation tied to quality indicators? Yes 6. Registration system integrated / interfaced to PFS system? Yes 7. Use on-line / web-enabled patient self-registration system? Yes 8. Use on-line OP medical necessity system prior to service? Yes 9. Use on-line registration data quality tracking

system? Yes 10. Have CDHC-specific insurance plans? Yes Developing KPIs for CDHC and P4P 89 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Financial Counseling KPI Description 1. Collection of elective services deposits prior to service Standar d 100% 2. Collection of IP patient-pay balances prior to discharge 65%

3. Collection of OP patient-pay balances prior to service 75% 4. Collection of ER patient-pay balances prior to departure 50% 5. Screening of uninsured IPs and hi-bal OPs for fin assist 95% 6. Pmt arrangements for non-charity eligible IPs / hibal OPs 95% Developing KPIs for CDHC and P4P 90 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Financial Counseling KPI Description

Proces s 1. Financial counseling reports to Chief Revenue Officer? Yes 2. Uninsured IPs and high-balance OPs screened for fin assist? Yes Medicaid eligibility? Yes State, local, and hospital charity programs? Yes Grants / studies, etc.? Yes 3. Financial counselors interview patients in their rooms? Yes

4. Prompt payment discounts offered? Yes Developing KPIs for CDHC and P4P 91 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Financial Counseling KPI Description Proces s 5. Fin counselors incentive compensation tied to collections? Yes 6. Discuss pmt alternatives w/ non-charity eligible patients? Yes Credit cards?

Yes Bank-loan financing? Yes Interest-bearing hospital-funded payment arrangements? Yes 7. All IPs cleared thru financial counselors before discharge? Yes 8. Proof of income / assets obtained from charity applicants? Developing KPIs for CDHC and P4P Yes 92 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Health Information Management

KPI Description Standar d 1. IP charts coded (or reviewed for P4P) per coder / per day 23 - 26 2. OBSV charts coded per coder / per day 36 - 40 3. AMB SURG charts coded (or reviewed for P4P) per coder / per day 36 - 40 4. OP charts coded per coder / per day 150 - 230 5. ER charts coded (or reviewed for P4P) per coder / per day 150 - 230 6. Chart delinquency greater than 30 days (JCAHO

definition) 7. Total chart delinquency Developing KPIs for CDHC and P4P 5% 10% 93 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Health Information Management KPI Description Standar d 8. HIM DRG development hold greater than late charge hold 2 A/R days 9. Copies of medical records pursuant to payors requests 10. Transcription rate per line 11. Transcription backlog 2 work

days 08 12 1 work day 12. Chart retrieval pursuant to MDs requests 90 minutes 13. MPI duplicates as a % of total MPI entries .5% Developing KPIs for CDHC and P4P 94 Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Health Information Management KPI Description Proces s 1. Health Info Management reports to Chief Revenue Officer?

Yes 2. Use on-line DRG and APC groupers? Yes 3. Use on-line, bar-code enabled chart location system? Yes 4. Use on-line, scanning-enabled HIM records imaging system? Yes 5. Use on-line and/or voice-recognition transcription system? Yes 6. Use on-line clinical abstracting system ? Yes 7. MDs able to view and/or e-sign records outside the hospital? Developing

KPIs for CDHC and P4P 95 Yes Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Health Information Management KPI Description Proces s 8. Use on-line, up-to-date coding compliance system? Yes 9. Storage / retrieval / release of records HIPAAcompliant? Yes 10. All P4P coders / technicians receive payor-specific training? Yes 11. All coding done by employees reporting to HIM

Director? Yes 12. All coding done by certified coders who are retrained often? Yes 13. All coding done in descending balance order, not FIFO ? Yes 14. AllKPIs coding done Developing for CDHC and P4P when info is sufficient, not 100% 96 Yes Consumer Driven Healthcare Summit 2007

KPIs for CDHC and P4P Health Information Management KPI Description Proces s 15. Receive and discuss P4P info provided by Finance or others? Yes 16. Provide and discuss P4P info with MDs? Yes 17. P4P discussed / monitored in multi-disciplinary meetings? Yes 18. Have effective tracking system to locate missing records? Yes 19. Have appropriate staffing to prevent process backlogs?

Yes 20. Consistently monitor / control D-N-F-B A/R due to HIM? Yes 21. Perform internal Developing KPIs for CDHC and P4P quality-control audits at least 97 Yes Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Billing / Claim Submission KPI Description 1. HIPAA-compliant electronic claim submission rate Standar d 100%

2. Final-billed / claim not submitted backlog 1 A/R day 3. Medicare supplement ins billing following adjudication 2 bus days 4. Non-Medicare COB-2 ins billing following COB-1 payment 2 bus days 5. Medicare RTP (Return To Provider) denials rate 3% 6. Outsourced guar stmt cost to produce / mail (w/out stamp) Developing KPIs for CDHC and P4P 20 - 25 98

Consumer Driven Healthcare Summit 2007 KPIs for CDHC and P4P Billing / Claim Submission KPI Description Proces s 1. Use Patient Friendly Billing concepts for guarantor billing? Yes 2. Use proration to bill ins and guarantor simultaneously? Yes 3. Guarantor stmts include credit / debit / MSA card option? Yes 4. Guarantor stmts clearly communicate payment policies? Yes

5. Guarantor stmts provide customer service phone number? Yes 6. Guarantor stmts provide customer service web address? Yes Developing KPIs for CDHC and P4P 99 KPIs for CDHC and P4P Clinical / Decision Support / Finance Consumer Driven Healthcare Summit 2007 KPI Description 1. P4P Demonstration Project percentile ranking 2. P4P Demonstration Project bonus achievement Standar d 80% 1%

3. Length of stay, by DRG DRG avg 4. Readmission rate, by DRG DRG avg 5. Adherence to quality indicators, by condition 80% 6. Adherence to quality indicators, by mode 80% 7. Overall P4P program ROI Developing KPIs for CDHC and P4P 0% 100 KPIs for CDHC and P4P Clinical / Decision Support / Finance

Consumer Driven Healthcare Summit 2007 KPI Description Proces s 1. Use advanced clinical systems to support patient care? Yes 2. Use electronic medical record system to support patient care? Yes 3. Use advanced decision support / performance mgt system? Yes 4. Use executive information (scorecard) system? Yes 5. Use data warehouse system to support DSS / EIS capabilities?

Yes 6. Participate in CMS Demonstration Project, if eligible? Yes 7. Have clinical improvement teams in data-enabled depts?KPIs for CDHC and P4P Developing Yes 101 Consumer Driven Healthcare Summit 2007 Wheres Your Focus? Developing KPIs for CDHC and P4P 102 Consumer Driven Healthcare Summit 2007 Appendices Developing KPIs for CDHC and P4P

103 Consumer Driven Healthcare Summit 2007 Appendix 1 34 CMS / Premier Hospital Quality Measures Five Diagnosis Focus Areas Acute myocardial infarction Coronary artery bypass graft Heart failure Community-acquired pneumonia Hip and knee replacement Developing KPIs for CDHC and P4P 104 Consumer Driven Healthcare Summit 2007 Appendix 1 34 CMS / Premier Hospital Quality Measures

Condition Measure Acute Myocardial Infarction 1. ASA on arrival 2. ASA at discharge 3. ACEI for LVSD 4. Smoking cessation advice / counseling 5. Beta blocker on arrival 6. Beta blocker at discharge 7. Thrombolytic w/ in 30 minutes of arrival Developing KPIs for CDHC and P4P 8. Percutaneous Coronary Intervention w/ in 30 minutes of 105 arrival Consumer Driven Healthcare Summit 2007 Appendix 1 34 CMS / Premier Hospital Quality

Measures Condition Measure Coronary Artery Bypass Graft 10. ASA at discharge 11. CABG using internal mammary artery 12. Prophylactic antibiotic 1 hour before surgery 13. Prophylactic antibiotic for surgical pts 14. Prophylactic antibiotic dcd w/ in 24 hours post-op 15. Inpatient mortality rate 16. Post operative hemorrhage or hematoma Developing KPIs for CDHC and P4P 17. Post operative physiologic and 106 Consumer Driven Healthcare Summit 2007

Appendix 1 34 CMS / Premier Hospital Quality Measures Condition Measures Heart Failure 18. Left ventricular function (LVF) assessment 19. Detailed discharge instructions 20. ACEI for LVSD 21. Smoking cessation advice Developing KPIs for CDHC and P4P 107 Consumer Driven Healthcare Summit 2007 Appendix 1 34 CMS / Premier Hospital Quality Measures Condition Measures

Community Acquired Pneumonia 22. Oxygenation assessment 23. Initial antibiotic 24. Blood culture prior to antibiotic 25. Influenza screening / vaccination 26. Pneumococcal screening / vaccination 27. Initial antibiotic timing 28. Smoking cessation advice Developing KPIs for CDHC and P4P 108 Consumer Driven Healthcare Summit 2007 Appendix 1 34 CMS / Premier Hospital Quality Measures Condition Measures Hip and Knee Replacement

29. Prophylactic antibiotic one hour prior to surgery 30. Prophylactic antibiotic selection for surgical patients 31. Prophylactic antibiotic dcd w/ in 24 hours after surgery 32. Post-operative hemorrhage or hematoma 33. Post-operative physiologic and metabolic derangement 34. Readmissions 30 days post-discharge Developing KPIs for CDHC and P4P 109 Consumer Driven Healthcare Summit 2007 Appendix 2 Organizations Interested in Healthcare Quality Organization Focus Area ACHP: Alliance of Community Health Plans

Performance measurement initiatives AHRQ: Agency for Healthcare Research and Quality Performance measurement initiatives AMIA: American Medical Informatics Association Data collection and standardization CHI: Consolidated Health Informatics Initiative Data collection and standardization CHT: Center for Health Transformation Healthcare quality initiatives CMS: Centers for Medicare and Medicaid Services

Public reporting initiatives eHI: KPIs e-Health Initiative Developing for CDHC and P4P Data collection and 110 Consumer Driven Healthcare Summit 2007 Appendix 2 Organizations Interested in Healthcare Quality Organization Focus Area FACCT: Foundation for Accountability Healthcare quality initiatives FDA: Food and Drug Administration

1. Nov 02: Look-alike / soundalike drugs to be stored on different shelves + comprehensive review of soundalike drug names 2. Mar 03: Bar code with NDC number required + reporting of blood reactions and potential medication errors FHCQ: Foundation for Health Care Quality Healthcare quality initiatives HIMSS: Healthcare Information Developing for CDHC and P4P and KPIs Management Systems Society Data collection and standardization 111 Consumer Driven Healthcare Summit 2007 Appendix 2

Organizations Interested in Healthcare Quality Organization Focus Area IHA: Integrated Healthcare Began to pay physicians for Association. Composed of seven documented performance in CA health plans (Aetna, BC of 2003 California, Blue Shield of CA, CIGNA CA, Health Net, PacifiCare, Western Healthcare Advantage) IHI: Institute for Healthcare Improvement Healthcare quality initiatives ISMP: Institute for Safe Medical Practice Healthcare quality initiatives IsQua: International Society of Quality Assurance Healthcare quality initiatives

Developing KPIs for CDHC and P4P 112 Consumer Driven Healthcare Summit 2007 Appendix 2 Organizations Interested in Healthcare Quality Organization Focus Area JCAHO: Joint Commission for Accreditation of Healthcare Organizations Hospital core measures (average survey cost is $29,191 for 2005) LFG: Leap Frog Group Patient safety initiatives NCC MERP: National Coordinating Council for Medication Errors Reporting and Prevention

Medication safety initiatives NCQA: National Committee for Quality Assurance 2005 Health Plan Employer Data and Information Set (HEDIS) tracked Medicare beneficiaries for Glaucoma Beta-blocker long term 113 usage for 6 months Developing KPIs for CDHC and P4P Consumer Driven Healthcare Summit 2007 Appendix 2 Organizations Interested in Healthcare Quality Organization Focus Area NHIN: National Health Information Network (supported by National Committee on Vital and Health

Statistics NCVHS) Data collection and standardization NICHQ: National Initiative of Childrens Healthcare Quality Childrens health initiatives NPSF: National Patient Safety Foundation Patient safety initiatives NVHRI: National Voluntary Hospital Reporting Initiative (Now replaced by Hospital Quality Initiative) Uses CMSs 7th Scope of Work Developing KPIs for CDHC and P4P 114 Consumer Driven Healthcare Summit 2007 Appendix 2 Organizations Interested in Healthcare

Quality Organization Focus Area PSI: Patient Safety Initiative Patient safety initiatives QIO: Quality Improvement Organization (American Health Quality Association) Medicares state review organization, f/k/a PRO: Peer Review Organization UCLA CPSQ: UCLA Center for Patient Safety and Quality Patient safety initiatives Developing KPIs for CDHC and P4P 115 Appendix 3 Provider Scorecard Information Agency for Healthcare Research

and Quality www.ahrq.gov/consumer/qnt Guide to choosing quality care. Includes guide on judging MD quality, including checklists The National Committee on Quality Assurance www.ncqa.org Joint ventures with disease societies. Includes guide on finding best MDs for heart / stroke, by state Qualitycheck www.jcaho.org/quality+check Provides quality reports on hospitals, ambulatory care centers, and officebased surgery centers Heathgrades www.healthgrades.com Rates more than 5,000 hospitals by procedure. Also sells detailed reports on hospitals and MDs American Medical Association MD Select dbapps.ama-assn.org/aps/

amahg.htm Info on 690,000 physicians Center for Medicare and Medicaid Services www.medicare.gov Quality reports about Medicare managedcare plans and providers Federation of State Medical Boards www.docinfo.org Reports on disciplinary action against MDs Administrators in Medicine www.docboard.org Free info on licensing, background, and disciplinary action Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Resource Planning 1. When do most patients come in with the flu? 2. When are physicians taking vacation?

3. Which Medicare patients are about to exceed their DRGallowable LOS? 4. What % of Mrs. Greens previous ED visits resulted in admission? 5. What is our relative margin on CAP cases w/ and w/out vent assist? 6. What are the true costs of kyphoplasty? 7. How many complex cases are accurately reimbursed? 8. What are the marginal cost and LOS reductions, and improved outcomes, for patients treated on our CAP 117 protocol those not on the protocol? Developing KPIs for CDHCvs. and P4P Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Chronic Disease Management 9. Which female diabetics, ages 60-65, had eye exams in the last year? 10. What % of Dr. Smiths patients maintain HbAIc below 7? 11. How many patients with high cholesterol received angiograms last month? 12. What intervention seems to help prostate CA patients

most? 13. What % of Dr. Joness CHF patients were prescribed ACE inhibitors? 14. How many HIV+ patients did not have viral-load checks last year? Developing KPIs for CDHC and P4P 118 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Inpatient Management 15. How many bariatric surgery patients have co-morbid diabetes, hypertension, and/or depression? 16. Which MDs have treated this patient on this, or any previous, visit? 17. How many current IPs have two glucose values >200 but no diabetes Dx? 18. What is the distribution of vancomycin orders by patient condition? 19. What is the post-op cardiac rehab treatment variation between community hospitals across our health system? 20. How many ED patients are hospitalized due to inappropriate treatment of alcohol withdrawal?

Developing KPIs for CDHC and P4P 119 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Quality Control 21. How many CHF patients returned to the ED w/in 72 hours of discharge? 22. How were the most-recent 100 patients diagnosed with COPD treated? 23. How did this COPD treatment vary by MD? 24. What MD-nurse combinations cause higher ED mortality / complications? 25. How many pneumonia patients were readmitted for pneumonia w/in six months? 26. How many of those patients were vaccinated? 27. How many patients were misdiagnosed, leading to extended LOS, w/in the most-recent six months? Developing KPIs for CDHC and P4P 120 Consumer Driven Healthcare Summit 2007 Appendix 4

50 Clinically-Relevant, Yet Difficult, Questions Preventing Adverse Events 28. What types of catheters were used in all central-line infection cases w/in the most-recent six months? 29. What is the most common error caused by CPOE? 30. How many patients on heparin have experienced a platelet count drop of 15% in the last 24 hours? 31. How often do pharmacists intervene when renal failure patients are prescribed potentially-toxic doses of renallyexcreted drugs? 32. How many coronary angioplasty patients received appropriate prophylaxis against contrast-mediated renal toxicity? 33. What % of total-joint replacement patients receive DVT prophylaxis? Developing KPIs for CDHC and P4P 121 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Preventing Adverse Events (contd) 34. What is the most common combination of caregiver and patient condition, for patients who fall? 35. Which nurses have the most contact w/ patients w/ positive MRSA tests?

36. How often does each resident internist ignore drug interaction alerts? Developing KPIs for CDHC and P4P 122 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Surveillance 37. What is the distribution of patients presenting with stomach pains, by zip code? 38. What is the distribution of positive blood cultures, by nursing unit? 39. Where do most inpatients die? 40. Have we experienced a spike in the number of ED patients complaining of shortness of breath, in the last week? Developing KPIs for CDHC and P4P 123 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult,

Questions Physician Credentialing 41. What is the most common reason for failing to give beta blockers to AMI patients? 42. What is the average length of stay, by MD? 43. Which MDs have the highest readmission rates, on a severity-adjusted basis? 44. What is the compliance rate for standing orders, by MD? 45. Which MD group is referring the sickest patients? Developing KPIs for CDHC and P4P 124 Consumer Driven Healthcare Summit 2007 Appendix 4 50 Clinically-Relevant, Yet Difficult, Questions Physician Credentialing 46. What is the distribution of admitted patients, by primary care MD? 47. Are Dr. Blacks patients actually sicker? 48. What is the distribution of cesarean deliveries, by day of week, and by MD? 49. How frequently do MDs treat patients for conditions outside of their credentialed fields? 50. Which MDs keep patients on IV antibiotics for more than three days, post-procedure?

APPENDIX 4 SOURCE: Toward the Data-Driven Clinical Enterprise, Advisory Board Company, 2005 Developing KPIs for CDHC and P4P 125 Consumer Driven Healthcare Summit 2007 Questions? Comments? Presenters Resume David Hammer, Vice President, McKesson Mr. Hammer is a Vice President in McKessons Business Performance Solutions group. He focuses on receivables and health information management for hospitals, health systems, and related entities. In his more than 21 years of health care industry experience, Mr. Hammer has held a variety of positions with leading notfor-profit and proprietary health systems, Big Four accounting firms, information systems vendors, and health care A/R management companies. Background and Affiliations Mr. Hammer received an MBA in Management and an MHS in Health Care Administration from the University of Florida in 1987. He also received a BBA in Accounting with a minor in Information Systems (Magna cum Laude) from the University of North Florida in 1985. Mr. Hammer is certified by HFMA as a Fellow (FHFMA) and as a Certified Healthcare Finance Professional (CHFP). He has been named an HFMA Distinguished Speaker for four consecutive years, and has received HFMAs Gold, Silver and Bronze service awards. Recent Publications

Mr. Hammer authored the July 2007 cover story in HFMAs healthcare financial management journal, entitled The Next Generation of Revenue Cycle Management, as well as the July 2005 hfm cover story, entitled Performance is Reality: Is Your Revenue Cycle Holding Up? His most-recent article, UPMCs Metric-Driven Revenue Cycle, appeared in the September 2007 issue of hfm, and Data and Dollars: How CDHC is Driving the Convergence of Banking and Health Care was published in hfms February 2007 issue. His article Black Space Versus White Space The New Revenue Cycle Battleground appeared in the January 2007 issue, and Customer Service Adapts to CDHC appeared in the September 2006 issue. He also publishes regularly in McKesson Provider Technologies Answers magazine. Contact Information Mr. Hammer can be reached by telephone at (954) 648-4764 and/or by e-mail Developing KPIs for CDHC and P4P at [email protected] 126

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