Clinical management system enhances quality, restores physician withhold for Health New England.
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 IPA - International Phonetic Alphabet model HMO HMO health maintenance organization.
A corporation that is financed by insurance premiums and has member physicians and professional staff who provide curative and preventive medicine within certain financial, 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 HBOC HBO & Co of Georgia
HBOC Hereditary Breast and Ovarian Cancer
HBOC Hemoglobin-Based Oxygen Carrier
HBOC Hawke's Bay Orienteering Club (New Zealand)
HBOC Hunter Bird Observers Club
HBOC Horse Breeders and Owners Conference Payor Solutions Group (formerly HPR (High-Performance Routing) Extensions to IBM's APPN networking that enable SNA data to be sent over frame-based (Ethernet, etc.) and cell-based (ATM) networks. Inc.) Clinical Resource Management System (CRMS CRMS Colorado Rocky Mountain School
CRMS Customer Relationship Management System
CRMS Certified Residential Mortgage Specialist (National Association of Mortgage Brokers)
CRMS Castle Rock Middle School ), 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 HEDIS Health Plan Employer Data & Information Set Managed care An initiative by the National Committee on Quality Assurance to develop, collect, standardize, and report measures of health plan performances. 3.0 reporting: We are using HealthPlan Reporter to meet our HEDIS 3.0 reporting requirements.
$500,000 license fees for a three-year term for the software.
Hardware: Dual Pentium, 300 MHz (MegaHertZ) One million cycles per second. It is used to measure the transmission speed of electronic devices, including channels, buses and the computer's internal clock. A one-megahertz clock (1 MHz) means some number of bits (16, 32, 64, etc. , 128 RAM, and 9 GB hard drive
Software: Sybase SOL Anywhere client-server; HBOC Payor Solutions Group Clinical Resource Management System (CRMS) Networks: Novell
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
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 preventive treatment
See prophylactic 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 National Committee for Quality Assurance Medical practice A private, not-for-profit organization which has become the leading accreditor of managed care plans; in site visits, NCQA reviewers evaluate a managed care plan in terms of quality management, physicians' (NCQA NCQA National Committee on Quality Assurance, see there ) 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 employer group Association of employers Managed care An entity with a current group benefits agreement in effect with a health plan to provide covered health care services to its employee-subscribers and eligible dependents. . 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.