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Commitment to Quality Report for 2008 CareNet and Health Partners Report on Clinical Integration

MOUNT CARMEL Health Partners, Inc.


Contents Table of Contents

From the Executive Director ..........................................................................................................................2 From the Clinical Integration Committee ......................................................................................................3 Clinical Integration Defined ............................................................................................................................4 CareNet Systems and Mount Carmel Health Partners: Facts and Overview ................................................5 Mission and Vision ..........................................................................................................................................6 Clinical Integration and Quality Activities for 2008 ......................................................................................7 Clinical Integration Program Summaries ........................................................................................................8

Diabetes Care PROGRAM ONE: NCQA Diabetes Recognition Program ..............................................................................9 PROGRAM TWO: Diabetes Control in an Elderly Population ....................................................................13 PROGRAM THREE: Diabetes Control in a Commerical Health Plan ..........................................................15 NCQA Heart Stroke Recognition Program....................................................................................................17 Generic Antidepressant Initiative ..................................................................................................................19 Patient Satisfaction..........................................................................................................................................22 Electronic Medical Record and Information Technology Adoption ..........................................................24 Physician Credentialing and Board Certification..........................................................................................26

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Executive Director From the Executive Director

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008 is a very important year for the physician and hospital members of CareNet Systems and Mount Carmel Health Partners. While the organizations have worked closely together over the years, I am pleased to announce that CareNet and Health Partners are poised to become one physician hospital organization this year. CareNet and Health Partners Boards of Directors and staff have undertaken two years of education, deliberation and due diligence concerning the future of healthcare and how the 1,400 physician members and four acute care hospitals that form CareNet and Health Partners can best be prepared to excel in the future. This research with the assistance of healthcare experts, has shown that health plans, managed care companies, employers and the government are moving toward a model that rewards and reimburses physicians and hospitals based on quality measures, clinical outcomes and provider demonstration of quality care. In order to meet this challenge, primary care physicians, specialists and hospitals must work together using proven protocols and measures to demonstrate clinical and quality outcomes. This is the backbone of "Clinical Integration" — a strategy that the CareNet and Health Partners Boards of Directors have determined is vital to the success of our physician and hospital members. As a result of this due diligence and to meet the goals of Clinical Integration outlined in this document, the Boards of Directors of CareNet and Health Partners are taking the necessary steps to combine the two organizations to form one entity. When structured, Clinical Integration provides the platform needed to retain and potentially increase revenues for member physicians and hospitals. Similar organizations have been extremely successfully using this approach with health plans and payers responding positively to their efforts. Other exciting news in 2008 is that CareNet and Health Partners have developed the first edition of the Commitment to Quality Report. Throughout the past few years, our physician members have successfully launched and implemented numerous quality programs demonstrating that CareNet and Health Partners physicians provide high quality care and improve clinical outcomes while reducing cost. The Commitment to Quality Report for 2008 demonstrates these accomplishments. Together the CareNet and Health Partners’ Board of Directors thank the physicians and their staffs who invested their time and energy to achieve the successes documented in this report. The Commitment to Quality Report is designed to educate a broad audience, which includes patients, physicians, hospitals, employers and health plans, regarding the value CareNet and Health Partners physicians and Mount Carmel Health System bring to greater Columbus. It also outlines past quality programs, along with background information supporting the selection of these programs. I hope you find this document engaging and thought-provoking. The Boards of Directors, staff, and I look forward to working with you in the upcoming year as we embark on new opportunities and share more success stories. The Commitment to Quality Report will be updated as we go forward. — Michele Helbig Executive Director CareNet and Mount Carmel Health Partners July 2008

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Clinical Integration

From the Clinical Integration Committee of CareNet and Health Partners Boards

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areNet and Health Partners are pleased to present our first annual Committment to Quality Report highlighting the many programs being managed and implemented to improve patient care and to aid our 1,400 physicians in managing their patients. CareNet and Health Partners physicians have been leaders in quality care for years. We are now prepared to strengthen our market position through a concentrated effort utilizing the components of clinical integration to support and communicate with each other. Over the past two years, we have negotiated and administered Pay for Performance programs with a Medicare Advantage Plan, commercial health plans and an employer sponsored health plan. Member physicians have also had the opportunity to earn National Center for Quality Assurance (NCQA) recognition in diabetic care with CareNet and Health Partners coordinating and assisting in this process. As of this date, CareNet and Health Partners has 70 physicians who have earned NCQA diabetes recognition. In addition, our popular coding seminars, newsletters, and educational offerings help busy physicians and their staff stay up to date with trends in healthcare. CareNet and Health Partners will continue to serve as a quality improvement resource for our member physicians, by providing member physicians with access to quality improvement programs and services that they may not have available to them in their individual practices. Experts predict that "pay for performance" programs, grading of physician quality, and the concept of tiered payments for "underperforming" physicians will continue to grow. More of a physician's income will be tied to "performance". Now, more than ever, it is time for our organization to be the leaders in all quality initiatives and embark on new dimensions in healthcare. Our goal is to provide efficient patient-centered care, in the right setting, at the right time. Ultimately this is what is best for the patients and what employers and insurance companies require. This involves electronic health records, data gathering and analysis, and adopting evidence-based medicine guidelines. While it can take years to make some of this happen, our plan is to facilitate systems that can easily be accessed and utilized knowing that currently not all physicians are prepared to invest in electronic health records or similar systems. We believe there are alternatives that will work for most of our physician membership. In the coming year, we will continue to offer our current quality related services and programs and launch new industry driven programs. We think you will agree that CareNet and Health Partners are off to a great start. As you review this Commitment to Quality Report, your comments and suggestions are welcome and appreciated. These are "our" organizations. Your input is important and valued and your support imperative.

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What is Clinical Integration? Clinical Integration is the process of physicians and hospitals working together to improve patient care, improve patient outcomes and control healthcare costs. Unlike some healthcare initiatives, Clinical Integration is physician led and driven.

Clinical Integration is: • A physician led and driven quality improvement program. • Primary care physicians, physician specialists and hospitals working together to demonstrate and improve clinical and quality outcomes. • The collaboration among independent doctors and hospitals to increase quality and efficiency of patient care. • The adoption of a comprehensive and reportable program of inpatient and ambulatory quality improvement that allows physicians to set organizational benchmarks for quality and that provides resources to physicians to excel in care delivery. • Sharing our physicians’ and hospitals’ quality track records with health plans, employers and patients, thus making us the preferred physician network in central Ohio. • Building an infrastructure that supports quality and enables joint negotiations when beneficial to the parties.

We should become Clinically Integrated to: • Continually improve the quality of care our patients receive. • Demonstrate and prove to health plans, employers, the government and patients that we deliver high quality and costeffective care. • Reverse the tide of declining physician and hospital reimbursement.

We become Clinically Integrated through: • Physician leadership and involvement in CareNet and Health Partners programs which demonstrate high quality and positive clinical outcomes in the physician practice and hospital settings. • Physician leadership and involvement in health plan quality programs that demonstrate quality, improve care processes and clinical outcomes in a cost-effective manner. This demonstrates our willingness to work with our health plan partners to improve care. • Physician leadership and participation in the National Committee on Quality Assurance (NCQA) Physician Recognition Programs and other national and local physician and quality programs to demonstrate that CareNet and Health Partners physician members provide care at or above national standards. • Mount Carmel Health System and physicians forming partnerships in quality health plan programs that provide benefits to both physicians and the hospital.

Why must CareNet and Health Partners be merged together? • A united physician hospital organization will foster the necessary collaboration between primary care physicians, specialists and Mount Carmel Health System which is essential to Clinical Integration. • One organization will reduce redundancies and decrease cost incurred by two separate organizations. • One organization will allow us to share our physician-hospital partnership and Clinical Integration successes in a cohesive, positive manner.

Clinical Integration is not: • • • • • •

A loss of physician or practice autonomy A hospital or government mandate A means to "weed out bad physicians" A means to force a physician to purchase an electronic health record (EMR) "Cookbook medicine" Messenger model contracting

Simply put, Clinical Integration is CareNet and Health Partners member physicians and Mount Carmel Health System collaborating to improve patient care, improve patient outcomes and reduce healthcare costs. These are mutual goals that patients, physicians, hospitals, employers and health plans all agree upon.

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CareNet Systems and Mount Carmel Health Partners: Facts and Overview • Physician-hospital organization comprised of physicians throughout Central Ohio. • 600 primary care physician members in central Ohio. • 800 specialty physician members in central Ohio. • CareNet and Health Partners were formed in partnership with Mount Carmel Health System in 1994. • The organizations establish physician contracts with managed care plans on behalf of member physicians. • Physician credentialing (the in-depth review of a physician's training, expertise and experience) is performed for managed care plans contracted with CareNet and Health Partners. • Quality improvement initiatives are undertaken to raise the quality of healthcare in Central Ohio.

CareNet and Health Partners Executive Director Michele Helbig

CareNet Systems Board of Directors Michael J. Cooney, M.D., Chair, Cooney & Ricaurte James J. Barr, M.D., Dublin Family Care Inc William Buoni, M.D., Stonecreek Family Health Douglas Finnie, M.D., Southwestern Internal Medicine William J. Morris, M.D., Family Physicians of Columbus Daniel J. Wendorff, M.D., Grove City Internal Medicine Jackie Primeau, Mount Carmel Senior Vice President and CFO Cindy Sheets, Mount Carmel Senior Vice President and CIO Patty Callahan, Mount Carmel Director of Finance Teri Watson, Mount Carmel Vice President Planning & Marketing Michele Helbig, ex-officio, Executive Director

Mount Carmel Health Partners Board of Directors George Ho, M.D., Chair, Scioto Valley Urology Franklin Bressler, M.D. Bressler & Schaeffer Jason Keith, M.D, Metropolitan Surgery, Inc. Alan J. Murnane, M.D., Westar Obstetrics & Gynecology Thomas Archer, M.D., Columbus Cardiology Consultants Jackie Primeau, Mount Carmel Senior Vice President and CFO Cindy Sheets, Mount Carmel Senior Vice President and CIO Robert Martin, Mount Carmel Vice President Finance Ron Whiteside, Mount Carmel Senior Vice President and System COO Michele Helbig, ex-officio, Executive Director

CareNet and Health Partners 6150 East Broad Street Columbus, OH 43213 (614) 546-3000 www.carenetsystems.com www.mchp.com

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Mission and Vision Mission The mission of CareNet and Health Partners is for physicians and Mount Carmel Health System to venture collaboratively to provide high quality, cost effective, coordinated and innovative patient care in all healthcare settings and to be the premier healthcare provider network in central Ohio.

Vision Patients, employers, government agencies, healthcare providers and the community place a high value on the quality and cost of healthcare services provided in central Ohio. CareNet and Health Partners will utilize the expertise and knowledge of member physicians and the Mount Carmel Health System to develop innovative methods to continuously improve the quality and reduce the cost of healthcare provided in the central Ohio community. Through this innovation and excellence, CareNet and Health Partners will be the premier healthcare provider network in central Ohio. Through innovation and excellence, physician members along with Mount Carmel Health System’s hospitals will be recognized by the communities we share.

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Clinical Integration and Quality Activities for 2008 CareNet and Health Partners will be launching new quality programs and continuing many of the quality programs outlined in this Commitment to Quality Report for 2008. Continuous quality improvement requires a systematic examination of the operations of our physician and hospital network and focuses on identifying and implementing improvement in performance. Quality improvement is a participative, systematic approach to planning and implementing a continuous network improvement process (Deming, 1986).

National Committee on Quality Assurance (NCQA) Physician Recognition programs The National Committee for Quality Assurance (NCQA) has developed Diabetes and Heart Stroke Physician Recognition Programs. These are voluntary programs that were developed to help physicians use evidence-based measures to provide excellent care to their patients with diabetes and/or heart disease. CareNet and Health Partners have audited member physicians for the diabetes and heart stroke recognition programs, and will continue these audits with the goal of having the majority of our eligible physician membership recognized by NCQA. These programs are further explained in this report.

Diabetes Control in an Elderly Population CareNet and Health Partners primary care physicians have been participating in a diabetes quality improvement program with a Medicare Advantage Plan since 2005. This program has focused on diabetes control throughout the past three years and has resulted in an increasing number of physicians meeting the program's goal for diabetic care. This program will continue in 2008 focusing on diabetic and cardiac care. Measures will be based on NCQA guidelines. This program is further explained in this report.

Healthcare Quality Improvement and Cost Reduction in an Employer-Sponsored Health Plan CareNet and Health Partners, in collaboration with an employer-sponsored health plan, will launch multiple quality initiatives focusing on improving health outcomes and reducing costs in the health plan. The health plan has partnered with CareNet and Health Partners to launch a robust healthcare database that will give CareNet and Health Partners member physicians the ability to systematically evaluate their care delivery, network performance and ensure health plan members receive appropriate, cost-effective, high quality care. The quality initiatives are comprehensive in nature with a strong focus on working with health plan members to ensure they take the appropriate steps to improve their personal health.

Patient Satisfaction Improved patient experience can indicate high quality care and can lead to more satisfied staff, fewer preventable medical mistakes, fewer malpractice lawsuits and economic savings. Measuring and tracking patient satisfaction will continue to gain importance as healthcare becomes increasingly more consumer-driven. CareNet and Health Partners will continue to operate a patient satisfaction program that incorporates a self measurement tool to give physicians and practices the ability to learn of other practices’ strengths and learn of opportunities for improvement from their patients.This program is further explained in this report.

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Clinical Integration Program Summaries NCQA Diabetes Physician Recognition Program: A voluntary program that was developed to help physicians use evidence based measures to provide excellent care to their patients with diabetes. CareNet and Health Partners have 70 member physicians who have demonstrated high quality diabetic care and are currently recognized by NCQA. Bridges to Excellence estimates that recognized physicians save an estimated $1,059 in healthcare expenses per diabetic patient, per year.

Diabetes Control in an Elderly Population: The objective of the diabetes quality improvement program is to increase the number of diabetic elderly members who obtain appropriate diabetic screenings. Since the program was implemented in 2005, the number of CareNet physicians who have met the program's goals has increased by 133%. Elderly members have also benefited from this program by receiving proper diabetic preventive care that may reduce diabetic complications in the long run. Diabetes Control in a Commercial Health Plan: The program's goal was to improve health plan members' compliance with select diabetes measures. These measures are intended to prevent the onset of diabetes complications and to reduce the cost of diabetes due to complications. Three hundred and sixty (360) CareNet and Health Partners physicians participated in the program and were responsible for the treatment and care of over 5,700 health plan members with diabetes. Of the CareNet physicians who participated in the program, 214 met the program's measurement goals.

NCQA Heart Stroke Physician Recognition Program: A voluntary program that was developed to help physicians use evidence based measures to provide excellent care to their patients with cardiovascular disease. The economic cost of cardiovascular diseases and stroke in the United States for 2007 is estimated at $431.8 billion, and an estimated 79,400,000 American adults (one in three) have one or more types of cardiovascular disease. CareNet and Health Partners will initially audit 70 physicians for this program in 2008. Our intent is to grow the program in the future. Generic Antidepressant Initiative: Depression is among the most costly common medical conditions, and estimates indicate that depression costs US employers $24 billion annually in lost productive work time. Pharmaceuticals are a key cost in depression treatment. The program's goal was to increase the use of generic antidepressant medications prescribed to health plan members from 43% to 55% or greater. During the measurement period, 58% of all antidepressant medications prescribed to health plan members were generic, surpassing the goal.

Patient Satisfaction: Patients are increasingly demanding customer-friendly service along with the quality care they have always expected, both in physician offices and in the hospital. Understanding patients' needs and expectations is the first step in identifying the components of healthcare services that will lead patients to return or to recommend a physician or hospital — a situation in which both patients and providers benefit. The program's goal is to operate a patient satisfaction program that gives physicians the ability to evaluate their care processes, meet patient expectations and remove barriers that inhibit communication between patient and provider. Electronic Medical Record (EMR) and Information Technology Adoption: EMRs and advanced information technology such as billing and practice management software, support physicians' efforts to improve quality across all patients. CareNet and Health Partners will facilitate the adoption of EMRs and new information technology among member practices through education and by providing access to financial assistance through Mount Carmel Health System's EMR program. Physician Credentialing and Board Certification: Credentialing and re-credentialing is the process of formal recognition and attestation of current medical or technical competence and performance by evaluating and monitoring a physician's clinical or medical decision-making. The impact of credentialing physician members, along with setting board certification as a criterion for membership, further supports the establishment of a physician network that is high quality, minimizes risks to patients and provides the means to ensure physician quality is maintained and measured.

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Diabetes Care PROGRAM ONE: NCQA Diabetes Physician Recognition Program Medical and Economic Impact Definition Diabetes: a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes can lead to serious complication and premature death, but people with diabetes can take steps to control the disease and lower the risk of complications. There are many forms of diabetes but the disease takes three primary forms: 1. Type 1 diabetes: develops when the body's immune system destroys pancreatic beta cells, the only cells in the body which make the hormone insulin that regulates blood glucose. 2. Type 2 diabetes: accounts for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly.Type 2 diabetes is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity and race/ethnicity. 3. Gestational diabetes: a form of glucose intolerance diagnosed in some women during pregnancy. It is more common among obese women and women with a family history of diabetes.1 NCQA: The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving healthcare quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the healthcare system, helping to elevate the issue of healthcare quality to the top of the national agenda.7

Medical Impact The medical complications of diabetes include: heart disease and stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations, dental disease, complications of pregnancy, sexual dysfunction and illnesses such as pneumonia and influenza.2 Total prevalence of diabetes in the United States, all ages, 2005: • Total: 20.8 million people — 7.0% of the population — have diabetes • Diagnosed: 14.6 million people • Undiagnosed: 6.2 million people1 Total prevalence of diabetes among people aged 20 years or older, United States, 2005: • Age 20 years or older: 20.6 million or 9.6% of all people in this age group have diabetes • Age 60 years or older: 10.3 million or 20.9% of all people in this age group have diabetes • Men: 10.9 million or 10.5% of all men aged 20 years or older have diabetes • Women: 9.7 million or 8.8% of all women aged 20 years or older have diabetes1

Economic Impact Direct economic costs of diabetes: • Estimated at $92 billion in 2002, compared to $44 billion in 1997. • Diabetes alone represents 11% of US healthcare expenditures. • $40.3 billion was spent for inpatient hospital care and $13.8 billion for nursing home care for people with diabetes.3 Indirect economic costs of diabetes: • Estimated to be $40 billion in 2002. • In 2002, diabetes accounted for a loss of nearly 88 million disability days. • 176,000 cases of permanent disability were caused by diabetes, at a cost of $7.5 billion.3

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Diabetes Care NCQA Diabetes Physician Recognition Program cont’d CareNet and Health Partners Program Goals To provide primary care physicians and endocrinologists with tools to support the delivery and recognition of consistent, high quality care, the National Committee for Quality Assurance (NCQA) and The American Diabetes Association (ADA) developed the Diabetes Physician Recognition Program. This is a voluntary program developed to help physicians use evidence-based measures and provide excellent care to their patients with diabetes. Physicians who participate in the program enhance their delivery of high quality diabetic care through the use of a physician and practice evaluation tool and by individual physician benchmarking to national diabetic performance standards. Additional resources are provided to participating physicians to help them control diabetes in their patients.4 The program focuses on preventing diabetic complications by focusing on four main areas. When these four clinical areas are properly managed in diabetic patients, clinical outcomes are dramatically improved for diabetic patients. • Glucose control: In general, every percentage point drop in A1C blood tests results (e.g. from 8% to 7%) reduces the risk of microvascular complications (eye, kidney and nerve disease) by 40%. • Blood pressure control: Blood pressure control reduces the risk of cardiovascular disease (heart or stroke) among persons with diabetes by 33% to 50%, and the risk of mircovascular complications (eye, kidney, and nerve diseases) by approximately 33%. • Control of blood lipids: Improved control of cholesterol or blood lipids (for example, HDL, LDL and triglycerides) can reduce cardiovascular complications by 30% to 50%. • Preventive care practices for eyes, kidneys and feet: — Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50% to 60%. — Comprehensive foot care programs can reduce amputation rates by 45% to 85%. — Detecting and treating early diabetic kidney disease by lowering blood pressure can reduce the decline in kidney function by 30% to 70%.2

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The American Board of Family Medicine (ABFM) and NCQA recently announced an agreement under which ABFM Diplomates recognized for quality care through NCQA's diabetes or heart/stroke recognition programs will receive credit toward their Maintenance of Certification for Family Physicians. Maintenance of Certification for Family Physicians is the means by which ABFM continually assesses its more than 70,000 Diplomates to ensure that they meet the highest standards of accountability and clinical excellence. ABFM Diplomates who successfully complete NCQA's diabetes or heart/stroke physician recognition program are eligible to receive credit for the completion of a MC-FP Part IV Performance in Practice Module. Diplomates are required to complete one such module during each stage of the Maintenance of Certification process.6

CareNet and Health Partners Measurement and Results CareNet and Health Partners have used the NCQA Diabetes Physician Recognition Program to evaluate the diabetic care provided by over 100 primary care physicians in 2007. Each physician received a comprehensive evaluation of his or her diabetic care according to program standards. As of publication, 56% (70 of 126) of the recognized physicians in greater Columbus were CareNet or Health Partners physician members.

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Diabetes Care NCQA Diabetes Physician Recognition Program cont’d CareNet and Health Partners Program Impact To date, CareNet and Health Partners have 70 primary care member physicians who have demonstrated high quality diabetic care and are currently recognized by NCQA. In addition, CareNet and Health Partners have audited over 100 primary care physicians to qualify for the recognition. Even if NCQA recognition was not achieved by an individual physician, he or she had the opportunity to use the audit experience to improve diabetic care processes. Bridges to Excellence is a national not-for-profit organization developed by employers, physicians, healthcare providers, researchers, and other industry experts with a mission to create significant leaps in the quality of care. Bridges to Excellence noted the following about NCQA-recognized physicians who meet the standards of the NCQA diabetes program and who fully control diabetes in their patients: • Physicians who are NCQA-recognized save an estimated $1,059 in healthcare expenses per diabetic patient, per year.5 • When NCQA-recognized savings are applied to a typical patient population composed of over 100 diabetic patients, the NCQA-diabetes-recognized physician savings can be in excess of $100,000 per year. By improving the care diabetic patients receive, CareNet and Health Partners physicians are contributing to reducing healthcare expenditures associated with diabetes and are improving clinical outcomes for their patients with diabetes. References 1. 2. 3. 4. 5. 6. 7.

The Centers for Disease Control and Prevention. National Diabetes Fact Sheet, 2005. The American Diabetes Association, Complications of Diabetes in the United States, www.ada.org The American Diabetes Association, Direct and Indirect costs of diabetes in the United States, www.ada.org The National Committee on Quality Assurance, The Diabetes Physician Recognition Program, www.ncqa.org Bridges to Excellence, Diabetes Care Analysis — Savings Estimate. www.bridgestoexcellence.org The National Committee on Quality Assurance, NCQA, ABFM Align Physician Measurement Standards, www.ncqa.org The National Committee on Quality Assurance, www.ncqa.org

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Diabetes Care PROGRAM TWO: Diabetes Control in an Elderly Population Scope of Diabetes in an Elderly Population In 2005, there were 10.3 million or 20.9% of all people aged 60 years or older with diabetes. CareNet primary care physicians have been participating in a diabetes quality improvement program with a Medicare Advantage Plan since 2005. The medical impact of diabetes is especially burdensome among individuals 60 years or older, which is the vast majority of Medicare Advantage Plan's member population.

CareNet and Health Partners Program Goal The objective of the diabetes quality improvement program is to increase the number of elderly diabetics who obtain appropriate diabetic screenings. As stated in the previous diabetic section, the proper management of glucose, blood lipids, eye disease and kidney disease will dramatically improve clinical outcomes for diabetic patients. This program also established a bonus program that financially rewarded physicians who met three of the four measures listed on the next page. The financial bonus was intended to reward physicians who took extra time and effort to more effectively manage their diabetic patients.

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Diabetes Care PROGRAM TWO: Diabetes Control in an Elderly Population cont’d CareNet and Health Partners Measurement and Results The CareNet diabetes quality improvement program measured physicians on the following measures: • Greater than 50% of a participating physician's diabetic patients must have obtained an annual eye exam • Greater than 85% of a participating physician's diabetic patients must have obtained an HbA1c less than 9 • Greater than 85% of a participating physician's diabetic patients must have obtained an LDL-C less than 130 • Greater than 20% of a participating physician's diabetic patients must have obtained an annual microalbuminuria screen Since the program was implemented in 2005, the number of CareNet physicians who have met the program's goals has increased by 133%. The program has increased the awareness of proper diabetic control. Elderly members have also benefited from this program by receiving proper diabetic preventive care that may reduce diabetic complications in the long run.

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Diabetes Care PROGRAM THREE: Diabetes Control in a Commercial Health Plan Pay for Performance: The rewarding of providers (i.e., hospitals, medical groups, and/or physicians depending on the program) according to the attainment of a predetermined level of performance or according to improvement. Paying according to the level of performance is common to the majority of pay-for-performance programs.1

CareNet and Health Partners Program Goal CareNet primary care physicians have been participating in a local health plan's diabetes pay for performance programs since 2005. The program goals are to improve health plan members’ compliance with select diabetes measures. These measures are intended to prevent the onset of diabetes complications and to reduce the cost of diabetes due to complications. The elements of the diabetes program for the measurement period were the following: 1. HbA1c Testing: a minimum of one HbA1c test 2. Lipid Profile Testing: a minimum of one Lipid Profile Test 3. Dilated Eye Exam: a minimum of one Dilated Eye Exam 4. Nephropathy Monitoring: a minimum of one Microalbuminuria test, unless patient already has confirmed Microalbuminuria or is receiving either ACE and/or ARB therapy. 5. Diabetes Advantage Program: Increased participation in this program by referring eligible patients to a diabetes control and education program.

CareNet and Health Partners Measurement and Results CareNet performance in the diabetes program is demonstrated below. CareNet was able to meet four out of the five measures that were established under this program. Three hundred and sixty (360) CareNet physicians participated in the program and were responsible for the treatment and care of over 5,700 health plan members with diabetes. Of the CareNet physicians who participated in the program, 214 met the program’s measurement goals and had the minimum number of health plan members (CareNet set the program participation level at 6 or more diabetic patients during the measurement period in order to simplify the administration of this program). In total, there were: • 2,567 individuals who received appropriate HbA1c testing, • 2,456 individuals who received appropriate lipid profiles, • 1,145 individuals who received appropriate dilated eye exams, • 2,473 individuals who received appropriate nephropathy screenings.

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Diabetes Care PROGRAM THREE: Diabetes Control in a Commercial Health Plan

This program demonstrates a willingness of CareNet physicians to participate in a pay for performance program with a major health plan and the achievement of diabetic measures that prevent the onset of diabetic complications. 1. Rosenthal, Grank, Li, Epstein. Early Experience with Pay for Performance, JAMA, Vol 294, No 14.

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Heart & Stroke NCQA Heart Stroke Physician Recognition Program

Definition Cardiovascular disease: the conditions and illnesses that affect the cardiovascular system. Cardiovascular can be defined as those body systems that pertain to the heart and blood vessels. ("Cardio" means heart, "vascular" means blood vessels.) The circulatory system of the heart and blood vessels is the cardiovascular system.1 NCQA: The National Committee for Quality Assurance (NCQA) is a private, 501(c)(3) not-for-profit organization dedicated to improving healthcare quality. Since its founding in 1990, NCQA has been a central figure in driving improvement throughout the healthcare system, helping to elevate the issue of healthcare quality to the top of the national agenda.6

Medical and Economic Impact Economic Impact The economic cost of cardiovascular diseases and stroke in the United States for 2007 is estimated at $431.8 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital and nursing home services, the cost of medications, home healthcare and other medical durables) and lost productivity resulting from morbidity and mortality (indirect costs).

Medical Impact An estimated 79,400,000 American adults (one in three) have one or more types of cardiovascular disease, of whom 37,500,000 are estimated to be age 65 or older. Mortality data shows that cardiovascular disease is the underlying cause of death for 36.3% of all 2,398,000 deaths (870,500 deaths attributed to cardiovascular disease) in 2004, or one of every 2.8 deaths in the United States. Nearly 2,400 Americans die of cardiovascular disease each day, an average of one death every 36 seconds. Over 147,000 Americans killed by cardiovascular disease in 2004 were under age 65. In 2004, 32 percent of deaths from cardiovascular disease occurred prematurely (i.e., before age 75, which is close to the average life expectancy).3 Also, the presence of cardiovascular diseases in individuals with certain conditions such as diabetes contributes significantly to co-morbidities and co-mortalities.

CareNet and Health Partners Program Goal In order to provide primary care physicians and cardiologists with tools to support the delivery and recognition of consistent, high quality care, the National Committee for Quality Assurance (NCQA) and the American Heart Association/American Stroke Association developed the Heart/Stroke Recognition Program. This is a voluntary program that was developed to help physicians use evidence-based measures as a basis to provide excellent care to their patients with cardiovascular diseases. Physicians who participate in the program enhance their delivery of cardiovascular care through the use of a physician and practice evaluation tool. Physicians are also benchmarked to national cardiovascular performance standards. Additional resources are provided to participating physicians to help them control cardiovascular diseases in their patients.4 The program focuses on preventing cardiovascular complications by focusing on five main areas: 1. Maintaining a patient’s blood pressure control of less than 140/90mmHG 2. Ensuring each patient receives a complete lipid profile 3. Maintaining a patients’ cholesterol control (LDL) of less than 100 mg/dL 4. Use of aspirin or another antithrombotic 5. Smoking status and cessation advice or treatment4

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Heart & Stroke NCQA Heart Stroke Physician Recognition Program cont’d The American Board of Family Medicine (ABFM) also recognizes NCQA’s heart/stroke physician program as credit towards their maintenance of certification for family physicians. Please see page 11 for more information.

CareNet and Health Partners Measurement and Results CareNet and Health Partners will use the NCQA Heart/Stroke Recognition Program to evaluate the cardiovascular care provided by primary care physicians and cardiologists beginning in 2008. Each physician will receive a comprehensive evaluation of his or her cardiovascular care according to recognition programs standards. At the time of this publication, there are no physicians in Central Ohio who have been recognized by NCQA under the Heart/Stroke program. CareNet and Health Partners will audit a minimum of 75 physicians for the recognition program.

1. The American Heart Association, the Heart and How it Works, www.americanheart.org 2. The American Heart Association, Economic Cost of Cardiovascular Diseases, www.americanheart.org 3. The American Heart Association, Cardiovascular Diseases, www.americanheart.org 4. The National Committee on Quality Assurance, Heart-Stroke Recognition Program, www.ncqa.org 5. The National Committee on Quality Assurance, NCQA, ABFM Align Physician Measurement Standards, www.ncqa.org

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Antidepressant Generic Antidepressant Initiative

Definition Depression: A temporary mental state or chronic mental disorder characterized by feelings of sadness, loneliness, despair, low self-esteem and self-reproach; accompanying signs include psychomotor retardation or less frequently agitation, withdrawal from social contact, and vegetative states such as loss of appetite and insomnia.1 Generic Pharmaceuticals: A generic drug is a copy that is the same as a brand-name drug in dosage, safety, strength, how it is taken, quality, performance and intended use.2

Medical and Economic Impact Economic Impact Estimates indicate that depression costs US employers $24 billion annually in lost productive work time.3 Employees with depression, on average, reported significantly more lost productive time than those without depression (depressed employees lost an average 5.6 hours of productive time per week versus non-depressed employees who lost 1.5 hours of productive time per week due to health-related concerns). Depression is one of the most costly common medical conditions among employee because it is highly prevalent and comorbid with other conditions. Furthermore, although workers with depression are usually present at work, their performance can be substantially reduced.3 Spending in the U.S. for prescription drugs was $188.5 billion in 2004, over 4½ times more than the $40.3 billion spent in 1990.4 The economic and cost savings generated from switching from brand name pharmaceuticals to generic pharmaceuticals is tremendous. Health Plan data shows brand name antidepressants cost 3 times more per day than generic antidepressants cost per day.

Medical Impact Depression is classified as a mood disorder. Mood disorders include major depressive disorder, dysthymic disorder, and bipolar disorder. Depression and related mood disorders are prevalent in the United States and affect a large number of individuals. Some statistics include: • Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15-44.5 • Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year.5 • While major depressive disorder can develop at any age, the median age at onset is 32.5 • Major depressive disorder is more prevalent in women than in men.5

CareNet and Health Partners Program Goal CareNet, in collaboration with an employer sponsored health plan, launched a quality initiative focused on the medical treatment of depression. The decision to focus on depression included: 1. The employer sponsored health plan has seen a dramatic increase in the cost of healthcare associated with depression for employees and their dependents. A focus on managing depression can also reduce employee absenteeism which can result in additional cost savings to the employer.

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Antidepressant Generic Antidepressant Initiative cont’d 2. The employer sponsored health plan members were also heavy utilizers of brand name pharmaceuticals. 56% of all antidepressants prescribed during the baseline measurement period were brand name. Health Plan data shows brand name antidepressants cost $3.51 per day while generic antidepressants cost $1.29 per day during the program timeframe. By moving a substantial number of prescriptions from brand name to generic, a cost savings for the Health Plan and the members can be achieved through reduced copays. The goals of the depression initiative were to: 1. Increase the use of generic antidepressant medications prescribed to health plan members to 55% or greater from 43%. Baseline results were taken from July 1, 2005 through December 31, 2005. This data showed that 43% of antidepressants prescribed to all health plan members were generic. A new measurement period took place from July 1, 2006 through December 31, 2006. 2. Encourage appropriate screening and appropriate treatment of depression.

CareNet and Health Partners Measurement and Results During the measurement period, 58% of all antidepressant medications prescribed to health plan members were generic, resulting in the program's goals being achieved. Physician participation details include: • 313 CareNet primary care physicians participated in the program. • 180 primary care physicians (58% of participating physicians) had a 55% or greater generic antidepressant prescribing rate • 154 primary care physicians (49% of participating physicians) had a 65% or greater generic antidepressant generic prescribing rate *Rates are not accumulative

Percent of Generic Antidepressants Prescribed by CareNet Physicians

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CareNet physicians were successful at driving down the costs of brand name antidepressants by prescribing effective generic equivalents when appropriate, resulting in: • 11.3% decrease in brand name antidepressant costs for the health plan • 4.6% decrease in brand name antidepressant costs for the employee • 19.6% decrease in brand name antidepressant days prescribed Overall, the total cost of antidepressants (brand name and generic) for the Health Plan increased by 4.3%, which was primarily fueled by a 6.4% increase in antidepressant utilization (increased antidepressant prescribing/days of medication). While this was an overall increase, when compared to the average pharmaceutical cost increase of 10.7% which was experienced nationally from 2000 to 2005, this program was effective in implementing appropriate use of antidepressants, resulting in a trend lower than the expected and lower than the national trend. 1. 2. 3. 4. 5. 6.

Stedman's Concise Medical Dictionary for the Health Professions, 3rd Edition. Frequently Asked Questions about Generic Drugs, www.fda.gov Stewart, et al. Cost of Lost Productive Work Time Among US Workers With Depression, JAMA, Vol 289, No. 23 Kaiser Family Foundation, Prescription Drug Trends, www.kff.org The National Institute of Mental Health, www.nimh.nih.gov The Common Wealth Fund, Slowing the Growth of U.S. Health Care Expenditures: What are the Options? January 2007, www.commonwealthfund.org

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Satisfaction Patient Satisfaction

Definition Patient satisfaction: the perceived quality of service provided to patients. Along with other measures of quality, significant attention has been devoted toward the measurement of patient satisfaction. Employer groups view patient (employee) satisfaction as an important indicator for assessing the performance of health plans, hospitals and physician organizations.1

Medical and Economic Impact An improved patient experience has many rewards and benefits including the following: • Outcomes and compliance: Patients who have positive interaction during their visits are more likely to follow the physician's medical instructions, resulting in more effective treatment. • Perceived credibility: Physicians who are able to gain the respect of their patients during the visit are more likely to be perceived as credible sources of medical advice. • Skill: A patient's perception of the physician's skill is often skewed based on whether or not the patient was content with the physician's interpersonal communication skills. • Choice: Patients identify the ability to choose their physician as a top concern in determining healthcare service satisfaction. • Loyalty: Patients who are treated with respect and compassion are more likely to return to that physician or hospital for subsequent treatment.3 Other benefits from improved patient satisfaction include a more satisfied office staff, few malpractice lawsuits, economic savings, and increased visits.

CareNet and Health Partners Program Goal Measuring and tracking patient satisfaction will continue to gain importance as healthcare becomes increasingly more consumer-driven. Patients are demanding customer-friendly service along with the quality care they have always expected, both in physician offices and in the hospital. Understanding patients' needs and expectations is the first step in identifying the components of healthcare services which will lead patients to return or to recommend a physician or hospital — a situation in which both patients and providers benefit. Patients gain the advantage of continuity of care while providers benefit from patients returning and recommending the physician or hospital.2 Physician-patient interactions are the most influential factor regarding patient satisfaction. Patients who experience trouble during the admission or registration processes, dislike the atmosphere of a facility, or have difficulty with the nursing staff may still report high satisfaction with their healthcare experience if their physician treats them well.3 CareNet and Health Partners’ patient satisfaction program goal is to develop a selfmeasurement tool that gives physicians and practices the ability to evaluate their care processes, determine if they meet patient expectations and enable them to remove barriers that inhibit communication between patient and provider. If this can be accomplished, a partnership between the patient and physician is certain to succeed.

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CareNet and Health Partners Measurement and Results CareNet and Health Partners have been measuring physician patient satisfaction with a group of physician practices. CareNet and Health Partners' patient satisfaction survey contains 15 questions with "Likelihood of you recommending our practice to others" being the key question. Over the past six years, over 95% of patients surveyed have indicated they are very likely to recommend the practice to other patients. 1. Stephen J Williams and Paul R Torrens, Introduction to Health Services, fifth edition. 2. Reinventing the Patient Experience, Tequia Burt, Health Care Executive 21:3, May/June 2006. 3. Key Drivers of Patient Satisfaction, The Advisory Board Company, Washington DC.

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Technology Electronic Medical Record and Information Technology Adoption Definition Electronic Medical Records (EMR): all clinical data and records for a patient, complemented by a set of tools that completely replace the paper patient charts. The U.S. Department of Health and Human Services defines EMRs as: "A digital collection of a patient's medical history that could include items like diagnosed medical conditions, prescribed medications, vital signs, immunizations, lab results and personal characteristics like age and weight."

Medical and Economic Impact Medical Impact • Electronic Medical Records (EMRs) support physicians' efforts to improve quality across all patients. EMRs help ensure that health maintenance — things like mammograms or tetanus shots — being performed. EMRs can also check for drug interactions when prescriptions are written. • Practice-wide, EMRs can assist physicians with population-based medicine looking, for example, at diabetic patients by LDL or Hemoglobin A1c. • The EMR system provides the documentation and reporting to demonstrate compliance with quality initiatives, such as the NCQA Diabetes and Heart/Stroke Physician Recognition programs as well as with quality pay for performance programs.

Economic Impact • Reduced costs for paper-based medical records and associated resources needed to support them • Decreased transcription expenses • Improved workflow and intra-office communication (office visits, prescription refills, processing of test results, etc). • Reduced malpractice insurance premiums (Some malpractice carriers now offer discounts of 5-10 percent for using EMRs).

CareNet and Health Partners Program Goal CareNet and Health Partners will link physician members to Mount Carmel Physician Information Systems, a vendor for NextGen EMR, and, if need be, with third party vendors that support EMRs. CareNet and Health Partners will provide education, return on investment resources and contacts to assist practices with implementing EMRs regardless of the vendor. Mount Carmel Physician Information Systems is a division of Mount Carmel Health System and has been supporting and operating information technology for physicians offices for over fifteen years. In addition, CareNet and Health Partners will provide information to our member physicians to help them purchase modern practice management systems. Many CareNet and Health Partner physicians are currently using practice management systems that are archaic, no longer supported by the product's vendor and which do not contain tools or processes that allow physicians to participate in quality improvement activities. The transition to a modern practice management software from obsolete systems will ensure practice survival and facilitate a physician's participation in quality improvement activities.

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CareNet and Health Partners Measurement and Results EMR adoption among CareNet and Health Partners practices has been limited. A number of factors influence a physician's decision to purchase and implement an EMR: years to retirement, available physician practice capital, comfort with information technology, practice specialty, practice setting (hospital based physician versus non-hospital-based physician), practice cash flow/debt, etc. A number of large practice groups in CareNet and Health Partners have implemented EMRs and others are in the planning stages. An increasing number of practices are using the NextGen Practice Management System, a state-of-the-art practice management system which greatly benefit a physician practice both in operations and quality improvement. Physician members of CareNet and Health Partners do not have to select or operate NextGen. Rather, the organization is interested mainly in physicians adopting a state-of-the-art practice management software. NextGen adoption is only used as a benchmark for EMR adoption. At the same time, we will be exploring other means to collect and evaluate quality so that our member physicians can participate in quality programs.

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Credentialing Physician Credentialing and Board Certification

Definition Credentialing or re-credentialing is the process of formal recognition and attestation of current medical or technical competence and performance by evaluating and monitoring a physician's clinical or medical review decision-making by adherence to the applicable professional standard for direct medical care or peer review. In addition, credentialing verifies an individual's license, experience, certification, education, training, malpractice and adverse clinical occurrences, clinical judgment, technical capabilities, and character by investigation and observation.1 Board certification demonstrates a physician's expertise in a particular specialty and/or subspecialty of medical practice. Certification by a board involves a rigorous process of testing and peer evaluation that is designed and administered by specialists in the specific area of medicine.

Medical and Economic Impact Medical Impact Credentialing and Board Certification of physicians ensures that patients served through contracts held by CareNet and Health Partners receive care from physicians who are appropriately qualified and experienced in their medical specialties and whose past performance and behavior are in keeping with acceptable medical professional standards.

Economic Impact Credentialing and ensuring Board Certification of physicians may assist in the reduction of medical malpractice, reduction of medical errors and ensuring community medical standards are upheld, all of which contribute to reducing healthcare costs.

CareNet and Health Partners Program Goal CareNet and Health Partners Credentialing Committees, which are composed of practicing member physicians, perform a complete review of physicians applying to join the organizations, and review all member physicians periodically. The committees obtain meaningful advice and expertise from participating physicians when making credentialing decisions. The committee reviews: • each physician's medical education and residency completion dates, medical licensure expiration date • DEA expiration date • Medicare/Medicaid sanctions • hospital privileges to ensure they are in good standing • malpractice limits with expiration date • settlements reported to the National Practitioner Data Bank • work history and education gaps to determine a physician's ability to deliver care. • reasons for physician’s inability to perform the essential functions of the position, with or without accommodation • history of substance abuse (alcohol or drugs) • history of felony convictions • history of loss or limitation of privileges or disciplinary activity (hospital, professional society, group practice, managed care organization). CareNet and Health Partners utilize the National Committee on Quality Assurance (NCQA) credentialing policies to ensure national credentialing standards are met. Each physician’s personal and professional information is protected and accessed only by appropriate individuals. The organizations also serve as the delegated credentialing agent for the managed care plans they contract with.

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CareNet and Health Partners Measurement and Results The impact of credentialing of physician applicants and periodic re-credentialing of physician members of CareNet and Health Partners, along with setting Board Certification as a criterion for membership, is the establishment of a physician network that is high quality, minimizes risks to patients and establishes the means to ensure physician quality is maintained and measured. The credentialing process ensures that patients are treated by physicians who meet a national standard of care and that physicians are continuously held to these standards.

570 total physicians 1. The American College of Medical Quality, www.acmq.org

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832 total physicians


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July 2008

MOUNT CARMEL Health Partners, Inc.

Mount Carmel Commitment to Quality Report - 2008  

Mount Carmel Commitment to Quality Report - 2008

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