Clinical management system enhances quality, restores physician withhold for Health New England.

SOURCE:

Donald Burt, M.D. Vice President and Medical Director Health New England, Inc. One Monarch Place Springfield, Mass. 01144-1006

PROBLEM: In 1995, Health New England, Inc., (HNE) a 75,000 member IPA model HMO in Springfield, Mass. began to experience areas of over utilization, mandated high-cost benefit increases (i.e., bone marrow transplants), and reduced premiums due to market pressures. As a result, we were unable to return any of our physician withhold in 1996, jeopardizing our relationships with the physicians.

SOLUTION: We wanted to offer our physicians information to improve quality of care, control costs, and financially reward them for appropriate care.

We initiated a Physician Excellence Committee to identify reporting strategies and methodologies that would be meaningful to practicing physicians. The committee requested clinically adjusted (age/gender, case mix, and co-morbidity) data, based on sound clinical methodology.

We identified the HBOC Payor Solutions Group (formerly HPR Inc.) Clinical Resource Management System (CRMS), including Episode Profiler, Quality Profiler, Referral Profiler, and HealthPlan Reporter, as the best solution.

PLANNING: After an exhaustive 12-month review of the analysis products in the market. HNE has successfully implemented two separate initiatives.

HNE physician incentive program: We developed a new physician incentive program based on data derived from the HBOC Payor Solutions Group CRMS. We worked with our participating physicians to help them understand and become familiar with the clinical criteria and methodology used in the HBOC Payor Solutions-Group applications. Next, we provided historical overviews of each physician's performance. They were then able to identify areas for improvement and to take proactive corrections prior to rolling out the physician incentive program in mid-1997, targeted at 230 primary care physicians. HEDIS 3.0 reporting: We are using HealthPlan Reporter to meet our HEDIS 3.0 reporting requirements.

COSTS:

$500,000 license fees for a three-year term for the software.

COMPONENTS:

Hardware: Dual Pentium, 300 MHz, 128 RAM, and 9 GB hard drive

Software: Sybase SOL Anywhere client-server; HBOC Payor Solutions Group Clinical Resource Management System (CRMS) Networks: Novell

INSTALLATION:

In December 1996 we began building the underlying data warehouse. The first module, HealthPlan Reporter, was up and in full production March 1997.

STAFF OR PATIENTS

SERVED: 230 primary care physicians

BENEFITS:

Savings: We returned over 80 percent of the withhold in 1997 -- compared to none in 1996 -- because of improved performance.

Productivity: Historical overview of each physician's performance helped identify areas for improvement. The IS department had productivity gains as they were not responsible for building an internal HEDIS reporting capability and were able to support the CRMS applications.

Patient care or service: Combined use of Quality Profiler and Health Plan Reporter allows us to identify patients who have not received a specific preventive treatment, such as children who have not been immunized, thereby increasing the quality of care.

Others: Health Plan Reporter took in our internal code specifications, compared them with the National Committee for Quality Assurance (NCQA) definitions and automatically adjusted the data to meet the NCQA mandated HEDIS 3.0 specifications. As a member of the New England HEDIS Coalition, we participated in an audit of our HEDIS reporting capabilities conducted by Coopers -- Lybrand. They reported no deficiencies related to the use of the software. We were able to submit our HEDIS 3.0 reports to NCQA on schedule. The software goes beyond the HEDIS requirements to break down quality results by individual employer group. We can use this information to identify geographic areas where we need improvement and to demonstrate the quality of our service at contract renewal time.