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January 2013
Innovative Policies: Using ACO Principles and Financial Incentives to Improve Health Outcomes
AHRQ's Health Care Innovations Exchange held a Web seminar on Innovative Health Care Policies: Using ACO Principles and Financial Incentives to Improve Health Outcomes on January 29, 2013.

Participants

Host:

Judi Consalvo, Program Analyst at AHRQ Center for Outcomes and Evidence

Presenters:

Stephen Rosenthal, MBA, MS, has been a leader in the development of care management programs and initiatives. He is the President and Chief Operating Officer for The Care Management Company, LLC (CMO), a wholly owned for-profit subsidiary of Montefiore Medical Center and Corporate Vice President for Network Care Management for Montefiore’s Integrated Delivery System. Mr. Rosenthal developed and managed Montefiore’s Faculty Practice of over 1,000 physicians. Prior to that he developed over a half a million square feet of ambulatory practice programs. He currently chairs the network-wide implementation of Montefiore’s Ambulatory Clinical Information Systems.

David A. Share, MD, MPH, is the Senior Vice President of Value Partnerships at Blue Cross Blue Shield of Michigan and serves as Vice Chair of the Board of Directors of the Michigan State Medical Society (MSMS). He serves as an Executive Councilor of the Michigan Antibiotic Resistance Reduction Coalition, and a Director and Secretary of the Washtenaw Health Plan, a county health insurance program for indigent people with no other source of health insurance. Dr. Share serves on the Commission for a High Performance Health System of the Commonwealth Fund and is a Fellow of the American College of Preventive Medicine. He served for 30 years as founding Medical Director of The Corner Health Center in Ypsilanti, a community-based health center for teenagers and their children, where he still practices medicine.

Lauren Henrikson-Warzynski, MPA, is a Health Care Analyst at Blue Cross Blue Shield of Michigan (BCBSM). She is currently part of the Collaborative Quality Initiatives (CQI) team in the Value Partnerships department, where she works to develop and provide administrator oversight to CQI programs with the overarching goal of improving health care delivery and outcomes. Prior to joining BCBSM, Ms. Henrikson-Warzynski was a researcher and crime analyst at the Center for Urban Studies and worked on several community and economic development initiatives.

Respondent:

Xavier Sevilla, MD, MBA, FAAP is Vice President for Clinical Quality for Catholic Health Initiatives in Denver, Colorado. Until August 2012, Dr. Sevilla practiced pediatrics on the West Coast of Florida in a full-functioning Patient Centered Medical Home. In 2010, Dr. Sevilla participated in the Federal subcommittee that chose the Initial Core Set of Child Health Quality Measures for the CHIPRA legislation. He was appointed in 2009 the Chair of the Steering Committee of Quality Improvement and Management for the American Academy of Pediatrics. In 2009, he was also appointed to the National Advisory Council of the Agency for Healthcare Research and Quality. He also served on the Steering Committee of Quality Improvement and Management of the American Academy of Pediatrics in 2006. Dr. Sevilla received the Award for Excellence in Health Care Improvement from the Florida Children’s Quality Improvement Initiative.

Moderator:

Gerry Fairbrother, PhD, is a Senior Scholar at AcademyHealth, an Adjunct Professor of Health Policy at the George Washington University, and Adjunct Professor of Pediatrics at the University of New Mexico and the University of Cincinnati. Dr. Fairbrother is an experienced health services researcher and evaluator, whose work has emphasized measurement of quality of care, policy research and evaluation, and health information technology and its effects on quality of care. Dr. Fairbrother serves on Centers for Medicare and Medicaid Services (CMS) Technical Expert Panel on National Impact Assessment of CMS Quality Measures and on the National Policy Advisory Committee of the National Institute of Children’s Healthcare Quality. She received the “Best Ohio Health Policy Award for Independent Scholar or Practitioner” from the Health Policy Institute of Ohio.

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Panel Slides

Download PowerPoint Presentation Slides (PPT, 4.7 MB). (PowerPoint Viewer External Web Site Policy)

Jump to Slides:
Judi Consalvo 1 2 3 4 5 6 7 8 58
Gerry Fairbrother 9 10 11 28 45 57
David A. Share 12 13 14 15 16 17 18
Lauren Henrikson-Warzynski 19 20 21 22 23 24 25 26 27
Stephen Rosenthal 29 30 31 32 33 3435 36 37 38 39 40 41 42 43 44
Xavier Sevilla 46 47 48 49 50 51 52 53 54 55 56

Slide 1

Text Description Follows

Innovative Health Care Policies: Using ACO Principles and Financial Incentives to Improve Health Outcomes

Web Seminar
January 29, 2013
Follow this event on Twitter
Hashtag: #AHRQIX

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Slide 2



Today’s Host
Judi Consalvo


Picture of Judi Consalvo
Program Analyst at AHRQ Center for Outcomes and Evidence

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Slide 3



Using the Webcast Console

• Speakers or headphones are required for the audio portion of the Web Seminar
• Having difficulties with audio-stream?
Dial (888)-632-5061 and enter Conference ID number: 51722494 followed by the # sign. Or click on “help”
Figure shows arrow pointing to the help button on the bottom of the Webcast console.

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Slide 4



Submitting Questions

• Click on “Ask a Question”, complete the form and click “Submit”
• Technical questions? Click on “Answered Questions”
• Substantive questions will be answered during the Q&A portion of the Web Seminar

Figure shows arrows pointing towards the “Ask a Question” and the “Answered Questions” buttons on the Webcast console. There is also a text field box on the right hand side with an arrow pointing towards the “Submit” button.

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Slide 5



Accessing Presentations

• Slides used during this Web Seminar may be downloaded
• Click on “Supporting Material” for slides
Figure shows an arrow pointing towards the “Supporting Material” on the bottom of the Webcast console.

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Slide 6



What Is the Health Care Innovations Exchange?

• Publicly accessible, searchable database of health policy and service delivery innovations
• Searchable QualityTools
• Successes and attempts
• Innovators’ stories and lessons learned
• Expert commentaries
• Learning and networking opportunities
• New content posted to the Web site every two weeks
Sign up at http://www.innovations.ahrq.gov under “Stay Connected”

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Slide 7



Innovations Exchange Web Event Series

How to find archived materials
Go to http://www.innovations.ahrq.gov to the Events & Podcasts tab. A transcript of this event along with the slides will be available within two weeks

Next Events
Join our Tweetchat – February 27, 2013
Chats on Change: Supporting Priority Populations

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Slide 8



Today’s Event Moderator
Gerry Fairbrother, PhD


Picture of Gerry Fairbrother
Senior Scholar at AcademyHealth

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Slide 9



Identifying Health Care Policy Innovations

• AcademyHealth is pleased to work with Westat and AHRQ on identifying health care policy innovations

• Major policy innovations in 2013: Accountable Care Organizations, payment reforms, quality improvement initiatives

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Slide 10



Innovations Presented Today

• The Blue Cross Blue Shield of Michigan and Montefiore Medical Center
• A payer driven quality improvement initiative and an ACO
• Both timely and cutting edge innovations

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Slide 11



Blue Cross Blue Shield of Michigan

On the left side of the slide:
David Share, MD, MPH
Picture of David Share
Senior Vice President of Value Partnerships

On the right side of the slide:
Lauren Henrikson-Warzynski, MPA
Picture of Lauren Henrikson-Warzynski
Health Care Analyst

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Slide 12



Improving Healthcare Through Collaborative Partnerships

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Slide 13



What are Collaborative Quality Initiatives?

• Structure of Collaborative Quality Initiatives (CQIs): developed and administered by Michigan physician and hospital partners, funded by BCBSM and its HMO, Blue Care Network
• Support continuous quality improvement and the development of best practices
• Leverage inter-institutional data registries
• Why? Reduce avoidable adverse events, provide incentives and track performance

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Slide 14



Why Do We Need CQIs?

• Quality of health care remains suboptimal, with wide variations in performance across institutions and avoidable adverse events
• Suboptimal quality affects patients’ health; drives up costs
• Regional collaborations can provide incentives and infrastructure to systematically track and improve performance

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Slide 15



Overall Goals of the CQI Program

• Examine the link between care processes and outcomes in complex, highly technical areas of care
• Measure the quality of care within and across systems
• Create a feedback loop for continuous quality improvement with participating institutions
• Identify “clinical champions” at each participating hospital
• Implement fast-track quality improvement initiatives targeted at specific, high-leverage procedures
• Continue to demonstrate to consumers and purchasers of care that CQIs positively impact systems of care

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Slide 16



The Beginning

• Collaborative study on the variation in angioplasty procedures and treatment (1997)
• Resulted in decreases in mortality, kidney failure, emergency bypass surgeries and other complications
• Fostered development of a culture in which stakeholders pool efforts and best thinking to optimize practices, systems and outcomes of care
• Collaboration was necessary for real change

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Slide 17



Current CQI Programs


BCBSM/BCN Collaborative Quality Initiatives:
Hospital-based = 12
New Hospital-Based (2013) = 2
Hospital/Provider-based = 1
Professional = 5

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Slide 18



CQI Program Framework

This figure shows that the Collaborative Quality Initiatives work with Blue Cross Blue Shield of Michigan, coordinating centers and participating sites. The figure indicates that participating sites contribute to the all-payer registry and share and learn from best practices. It shows that Blue Cross Blue Shield Offer neutral ground for collaboration, program funding and incentive payment design. It also shows that coordinating centers provide clinical leadership, analytic and quality improvement support. The figure also shows that the efforts of the Collaborative Quality Initiatives include data collection, data analysis, data reporting and developing best practices.

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Slide 19



CQI Financial Support

Hospital CQIs:
•Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs)
•The CQI Coordinating Center

Professional CQIs:
•Registry-based CQIs: Data collection for BCBSM/BCN, Medicare and Medicaid, and uninsured members (estimated 80% of data collection costs)
•Non-registry-based CQIs: a portion of staff resources for CQI-related processes
•The CQI Coordinating Center

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Slide 20



CQI Incentive Payment

Hospital CQIs:
•Active participation and improved outcomes are rewarded through BCBSM’s incentive program
•Engaged physicians for select CQIs may receive a recognition payment through service codes beginning February 2013

Professional CQIs:
•Active participation and improved outcomes as reflected in the metrics through the Physician Group Incentive Program

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Slide 21



CQI Participation

High levels of participation throughout Michigan
•95% of eligible hospitals participate in at least one Hospital CQI
•73% of hospitals participate in all of the Hospital CQI programs for which they are eligible
•Over 329 physician practices participate in at least one Professional CQI

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Slide 22



Angioplasty CQI-Outcomes

This bar chart shows that between 2002 and the third quarter of 2011, death has declined by 20%, contrast induced nephropathy (CIN) by 38%, transfusions by 38%, vascular complications by 44%, emergency coronary artery bypass grafting (CABG) by 92% and revascularizations by 17%.

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Slide 23



Hospital CQI Savings

•Over 2-3 years, 4 participating programs produced $232.8 million in health care cost savings
•Complications and mortality rates lowered for thousands of patients
•Michigan Surgical Quality Collaborative (general surgery) 2009-2010: $ 85.9 million statewide savings; $49.2 million BCBSM savings
•Michigan Society of Thoracic and Cardiovascular Surgeons (cardiac surgery) 2009-2010: $30.3 million statewide savings; $2.4 million BCBSM savings
•Michigan Cardiovascular Consortium - Percutaneous Coronary Intervention (angioplasty) 2008-2010: $102 million statewide savings; $13.8 million BCBSM savings
•Michigan Bariatric Surgery Collaborative (bariatric surgery) 2008-2010 : $14.6 million statewide savings; $4.7 million BCBSM savings

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Slide 24



Award Winning Partnerships

Best of Blue Clinical Distinction Award
•Michigan Surgical Quality Collaborative (2011)
•Michigan Bariatric Surgery Collaborative (2011)
•Quality Oncology Practice Initiative (2011)
•BMC2 – Percutaneous Coronary Intervention (2012)
•PGIP – “Fee for Value” (2012)

Michigan Cancer Consortium Spirit of Collaboration Award (2011)
•Quality Oncology Practice Initiative
•Michigan Breast Oncology Quality Initiative
•Michigan Oncology Clinical Treatment Pathways

Cancer Innovator Award (2011)
eValue8 Health Plan Innovation Award (2008)

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Slide 25



CQI Model: Why It Works

•Empowering the provider community to use comparative effectiveness research in a collaborative context
•Measurement to inform is more powerful than measurement to judge; BCBSM does not see individual hospital data
•Intrinsic motivation of professionals is harnessed when the work is owned and conducted by them
•Incentives focused on:
-Participation to help pay for the cost of data collection; and
-Performance, to reward active and results-oriented participation catalyzes engagement and improved results.
•Focus on long-term transformation of care processes improves systems of care

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Slide 26



Key Takeaways

•CQIs support continuous quality improvement and development of best practices for areas of care that are highly technical, rapidly-evolving, and associated with scientific uncertainty.
•Collaborating across institutions accelerates improvement; more can be learned from variation in care processes and outcomes across groups than within groups.
•CQIs target common clinical conditions and procedures associated with high costs per episode.
•CQIs gather data on patient risk factors, processes and outcomes of care. Use data to generate risk adjusted comparative performance analyses and guide quality improvement interventions.
•CQIs help to further BCBSM's social mission of cultivating a healthier future for all Michigan residents.
•Patients, regardless of payer, benefit from improved care processes developed through an all-patient approach to practice transformation.

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Slide 27



The Future of CQIs

Ongoing CQI and Overall Program Evaluation including NIH-funded ROI analysis
•Michigan Spine Surgery Improvement Collaborative
Aims: To improve the quality of care of spinal surgery by enhancing patient-reported outcomes following spine surgery; reduce surgical complications; reduce average costs of surgeries and episodes of care; and reduce the rate of repeat spine surgeries.
•Michigan Value Collaborative
Aims: To profile approximately 20 common inpatient conditions and procedures; to partner with existing CQIs to present findings and lead discussions; and collaborate in designing and evaluating improvement interventions.

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Slide 28



Montefiore Medical Center
Stephen Rosenthal, MBA, MS


Picture of Stephen Rosenthal
President and Chief Operating Officer at the
Montefiore Care Management Organization (CMO)

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Slide 29



Montefiore: More than a Hospital

This figure shows that Montefiore works with the community, health system and academic institutions to provide services to patients and other members of the community. Montefiore works with the community to impact population health outcomes: including obesity prevention and lead poisoning prevention efforts. Montefiore works through the health system by providing services in hospitals, employing primary and specialty care providers, and providing services in clinics and through home care programs. Under hospitals, there are 3 campuses, 4 hospitals, and 1,491 beds. Primary and specialty care providers includes medical groups and outpatient. Clinics include satellite, mobile and school clinics. Home care includes the home health agency and house call program. Montefiore works with academic institutions to conduct basic, clinical, translational, and health services research and teach 1,200 residents and fellows, 750 medical students, 500 multidisciplinary students, 1,200 nursing students and offer health professional education and CME.

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Slide 30



Where We Are: High-Cost, High-Volume Environment

High Volume:
Over 90,000 admissions annually
3.5 million ambulatory care visits annually
500,000 home care agency visits annually

Bronx, New York:
1.4 million people, 31% poor (vs. 21% across New York) and 90% Hispanic and/or Black
Higher prevalence of diabetes, obesity, asthma, other chronic conditions than New York City
20% higher per capita medical expense than US
8% of population account for 50% medical expense

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Slide 31



Our Structure

Montefiore IPA
Integrated Provider Association

•Formed in 1995
•MD/ Hospital Partnership
•Contracts with managed care organizations to accept and manage risk
•Over 2,400 physician members
-Over 500 PCPs
-Over 1,900 Specialists

CMO
Care Management Company

•Established in 1996
•Wholly-owned subsidiary of Montefiore Medical Center
•Performs care management delegated by health plans, other administrative functions, (e.g. claims payment, credentialing)
•Licensed Utilization Review agent and certified claims adjustors

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Slide 32



MIPA and CMO Cont.

This figure shows that insurance premiums from patients are sent to the insurance companies which then pay the Care Management Company of Montefiore and the Montefiore Integrated Provider Association to work with primary and specialty care providers and hospitals to create savings.

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Slide 33



How We Got Started: Catalysts for Innovation

•Reality of population Montefiore serves: low income, with chronic illnesses
•Early advent of managed care and the need for Montefiore to manage the premium
•Significant competition among insurance companies led to insurers saw partnering with us as opportunity to grow market share
•Also substantial competition among provider groups

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Slide 34



How We Got Started: Early Questions

Why Fill the Care Management Gap:
•Dominant presence in the Bronx
•Developed diverse set of primary care practices through which to serve beneficiaries
•Improved relationships with providers in the community

Decision Points:
•Determining the structure - combination of legal parameters and financial considerations
•Seeking risk arrangements with payers vs. becoming a payer
•Focusing on particular care management and network support functions
•Which payers to target initially and longer term

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Slide 35



Implementation

Worked with a few key partners:
• Collaborated with healthcare leaders to brainstorm
• Participated in National IPA coalition to learn about practices used across the country

Developed agreements with payers:
• First needed to understand their populations
• Getting the correct payment was critical
• Used a consistent model (full risk)

Getting up and running:
• Cultivated a dedicated workforce
• Focused on transactional aspects of the business e.g. timely claims payment
• Understood the benefit packages and what employers expected of insurance companies
• At start, systems limitations were challenging

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Slide 36



Our Current Portfolio

Initiative 2012 Population 2012 Est. Revenue 2013 Population 2013 Est. Revenue
Risk Contracts 140,000 $850 m 185,000 $1,085 m
Shared Risk 78,000 $490 m 80,000 $685 m
Medicaid Health Home
 (Care Coordination)
10,000 $10 m 10,000 $18 m
TOTAL 228,000 $1,350 m 270,000 $1,788 m

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Slide 37



Strategic Approach: Population Stratification

This figure shows that using self-identification, data mining, sentinel events and physician referrals the patient population is screened and stratified into three risk categories: 1) well and worried well; 2) functional chronically ill; and 3) frail ill/high utilizers. The types and intensity of care management provided to patients depends on which risk stratification category they are assigned to. Well and Worried Well members access information as needed including My Montefiore, General Health Information and PHR (personal health records). Functional Chronically Ill members access information as needed, receive health education and interventions targeted to members including self-management/empowerment tools and customized assessments. Frail Ill/High Utilizers receive interventions targeted to members, health information accessed by caregivers as needed including intensive/complex case management, palliative care and transitional case management.

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Slide 38



Care Guidance Model in Action

This figure shows that the care guidance model involves the patient centered medical home team and accountable care management team working together to create individualized care plans. There are 10 different types of care management programs, including intensive case management, chronic care management, palliative/end of life care, behavioral care, SNF management, telemonitoring, medical house calls, pharmacist review, care transitions, and ED case management. Accountable Case Management Team includes an Accountable Care Manager, nurse, social worker, patient educator, and a behavioral care manager. A pharmacist and physician are in a supporting role.

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Slide 39



Outcomes: Post-Discharge Call Program Readmission Rate Decreased 33%

This bar chart shows that the 30-day readmission rates have decreased from 24.9% at baseline in 2008, to 21.5% for the high-risk not reached group and 14.1% for the high-risk reached/assessed in 2009-2010.
At-risk patients defined as: age >69; having had a readmission in past 60 days; or having had home care services prior to admission

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Slide 40



Outcomes: Effective Management of Diabetes has resulted in a 12% Drop in Total Costs


The line graph shows that from 2006 to 2010, projected healthcare costs steadily increased from $11,251 to $13,676, while total healthcare costs decreased from $11,251 to $9,897. Total healthcare cost did not steadily decline during the 2006 to 2010 time period, with total healthcare cost rising between 2007 and 2008, before declining in 2009 and 2010.
Note: Rx costs not available. Note: Projected Costs Estimated using healthcare inflation trend of 16%.

References:
CMO Paid Claims; Author: H. Shao.

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Slide 41



Key Takeaways: Care Coordination

Individual level:
•Focus assessments on medical and psychosocial issues
•Expand capability to work with participants face to face
•Incorporate tools to support individual behavior change

Provider level:
•Improve access and availability
•Expand PCMH infrastructure
•Incorporate behavioral health expertise into care management

System level:
•Support organizational behaviors that reduce preventable utilization
•Partner to identify vulnerable patients and create comprehensive care plans
•Develop IT infrastructure to support cross-organizational communication and data exchange

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Slide 42



Key Takeaways: Promoting an Accountable Delivery System

•Organizational governance, structure, alignment, and data are the foundation
•Must define and understand the population
•<20% of the population determine the costs 100% determine the quality of care
•Sustainable cost reduction, improve performance and patient-centered care only with delivery system transformation

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Slide 43



Key Takeaways: Setting the Stage for Growth

•Use empirical evidence to support the spread of your best practice
•Develop or engage in forums for sharing information (like AHRQ’s Innovation Exchange) to engage new champions
•Leverage technology to advance your success; need technology to move information to the right people at the right time and to enable staff to practice at the top of their license

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Slide 44



What's Next?

•New targeted interventions for select groups
•Additional interventions for skilled nursing facility (SNF) residents
•Expand linkage with community-based providers
•Expand strategies for beneficiary engagement
•Focus on patient satisfaction (33 ACO quality measures)
•Expand current programs

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Slide 45



Respondent
Xavier Sevilla, MD, MBA, FAAP


Picture of Xavier Sevilla
Vice President for Clinical Quality
Catholic Health Initiatives, Denver, Colorado

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Slide 46



Quality Health Policy Background

•2000 To Err is Human: Call to improve the delivery system as a whole
•2001 Crossing the Chasm: 6 Quality Dimensions, 10 Rules for Redesign of Health Care
•2007 Joint Principles of the Patient Centered Medical Home
•2007 IHI Triple Aim

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Slide 47



Quality Health Policy Background

New approach to measuring quality: National Quality Strategy April 2011
•Better care
•Healthy communities
•More affordable care

ACO Medicare Shared Savings Program 2012

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Slide 48



Current Landscape in Health Care Policy/Quality

•Using data to build a culture of quality: Slow improvement in quality (2.5% per year)
•Delivery system transformation
•Aligning payment policies with quality
•Bending the cost curve: $2.7 trillion, $1 out of every $6 in the economy

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Slide 49



Using Data to Build a Culture of Quality

Pediatrix Medical Group

Clinical Data Warehouse
•Automated data extraction from EHR
•Accessible and easy to use at the bedside
•Extensive data validation

Decreased clinical variation
•Data down to individual clinician
•Change culture to ongoing continuous quality improvement

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Slide 50



Delivery System Transformation

HealthPartners in Minnesota
•“Prepared practice teams interacting with informed, activated patients through continuous healing relationships supported by ongoing availability of health information”
•Care Model Process (Delivery System)
-Team based care
-Primary care based system
-Reliable, timely and actionable data
-Change of clinician’s culture

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Slide 51



Aligning Payment Policies with Quality Improvement

• Zero sum game between payers / providers: wrong kind of competition, shifting costs, increase bargaining power, restrict choice
• Competition should be on creating value
• Shift from pay for performance to pay for value

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Slide 52



Status of Pay for Performance

Quality and Outcomes Framework Britain’s National Health Service (2004)
•“Overall only a modest improvement in quality”
•“Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes”
--BMJ 2011;342:d108

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Slide 53



Alternative Quality Contract BCBS of Massachusetts

•Unique Contract Model: Accountability for quality and utilization, long term - 5 years
•Controls Cost Growth: Global payment, payment to adjust for inflation, incentive to eliminate overuse
•Improved Quality and Outcomes: Bonus payments up to 10% of the total contract, used widely accepted quality measures, outcome had more weight than process, frequent performance reports

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Slide 54



Bending the Cost Curve

•Bellin Health (Wisconsin): decreased health cost, health care costs below the national average for external employers
•Health knowledge of the population: health risk assessments for all patients
•Care management for at risk patients
•Integrated system of care coordination: nurse call line entry point, primary care
•Created a culture of health

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Slide 55



Conclusion

•Reform of the health care system is not only possible, but is flourishing in a number organizations such as Montefiore and BCBS Michigan
•Visionary leaders are not waiting to see what the new healthcare environment will look like but are innovating to improve their organizations today and position them for the future

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Slide 56



The Future of Health Care Policy Innovations

•Partnerships and collaboration
•The new roles for patients
•Sick care versus wellness
•Health versus healthcare

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Slide 57



Question and Answer

•Click on “Ask a Question” below this presentation. Complete the form and click “Submit.”

Figure shows arrows pointing towards the “Ask a Question” and the “Answered Questions” buttons on the Webcast console. There is also a text field box on the right hand side with an arrow pointing towards the “Submit” button.

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Slide 58



The Innovations Exchange

• Visit our Web site:
http://www.innovations.ahrq.gov/

• Follow us on Twitter:
#AHRQIX

• Send us email:
info@innovations.ahrq.gov
Listen to the audio file (Flash player download External Web Site Policy)

Transcript

Judi Consalvo:

Good afternoon, everyone. On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to our Web event entitled, "Innovative Health Care Policies: Using Accountable Care Organization Principles and Financial Incentives to Improve Health Outcomes."

I'm Judi Consalvo and a program analyst in AHRQ's Center for Outcomes and Evidence. We're very excited about today's topic and glad to see that you share our enthusiasm.

We have more than 1,200 registered for this event today. Before we begin, I would like to remind you that if you experience any technical problems, please call 888-632-5061 for support and assistance. There is a conference ID number listed on the slide that you will be asked to enter followed by the pound sign. Another option for technical assistance is to click on the "Help" button at the bottom of your screen.

We welcome your questions and comments on the upcoming presentation. To submit content related or technical questions, simply click on the "Ask a question," button at any time. If your question is technical in nature, the support and assistance staff will respond to you as soon as possible.

The last portion of this Web seminar will focus on a discussion based on the content questions you submit. We will do our best to address as many of them as we can during the Web seminar. To ensure your questions get answered, please submit them early during the presentation.

The slides from today's Web event can be downloaded to your computer. To access and download these slides, please click on the "Supporting Material," tab at the bottom of your screen.

The presenters that you will hear from today are innovators from AHRQ's Health Care Innovations Exchange. For those of you who are new to the Innovations Exchange, I'd like to take just a minute to give you an overview before I introduce today's moderator.

AHRQ created the Innovations Exchange to speed the implementation of new and better ways of delivering health care. The Exchange offers busy health professionals and researchers a variety of opportunities to share, learn about and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations.

The Innovations Exchange Web site includes a searchable data base of QualityTools and service delivery innovations and, more recently, the Exchange has been expanded to include policy innovations such as the ones that you will hear about today. The Innovations Exchange also contains both successes and attempts, innovator stories and lessons learned and expert commentaries. To assist you in implementing these innovations, AHRQ also supports learning and networking opportunities, such as the Web seminar we are doing today, TweetChats and podcasts.

We post new content to the Web site every two weeks on a range of topics and hope that you will sign up to stay connected with us if you have not already done so. We also invite you to take a look at archived materials from our most recent Web events, which can be found on our Web site, www.innovations.ahrq.gov.

Notifications of future events are also found at the same location. For example, this is the site to learn more about our upcoming TweetChat that will take place on Wednesday, February 27.

OK, so let's turn to our agenda for today. It is my pleasure to introduce our moderator, Gerry Fairbrother, PhD. Dr. Fairbrother is a senior scholar at AcademyHealth and is an adjunct professor at the George Washington University. She has over 20 years of experience leading health services research and evaluation projects and leads several quality improvement projects. Gerry also serves on the CMS Technical Expert Panel on National Impact Assessment of CMS Quality Measures and on the National Policy Advisory Committee of the National Institute of Children's Health Care Quality.

Gerry Fairbrother:
Thank you, Judi. AcademyHealth is pleased to be working with Westat and AHRQ to identify health care policy innovations. This has been interesting work for us. We certainly have seen the need for policies that improve both quality and, today especially, lower costs. We will continue to identify the major initiatives including ACOs, payment reform initiatives and quality improvement initiatives. Check back to the Innovations Exchange to see some of these policy initiatives profiled throughout 2013 and beyond.

Today, we'll be highlighting the innovative work done by Blue Cross Blue Shield of Michigan and the Montefiore Medical Center. The first is a regional, collaborative quality improvement initiative that's driven by a health plan - at the health plan level. And, the second, is a vertically integrated hospital system. It's actually an ACO developed well before we were using the term, "ACO."

And, on a personal note, I'd like to say that I was at Montefiore at the time this was being launched and worked with Stephen Rosenthal on that effort. So, both of these initiatives are on the cutting edge of initiative practice, and they're directions that the health care system is moving in.
So, without further ado, I'd like to introduce our first two speakers who will be discussing the initiative by Blue Cross Blue Shield of Michigan. This will be presented by David A. Share, MD, MPH and Lauren Henrikson-Warzynski, MPA.

Dr. David Share is Senior Vice President of Value Partnership at Blue Cross Blue Shield of Michigan and serves as vice chair of the Board of Directors of the Michigan State Medical Society. He also serves as the director and secretary of the Washtenaw Health Plan, a county health insurance program for indigent people with no other source of health care. David also serves on the Commission for a High Performance Health System of the Commonwealth Fund in addition to a number of other duties and responsibilities.

Lauren Henrikson-Warzynski, MPA, is a healthcare analyst at Blue Cross Blue Shield of Michigan. She's currently part of the collaborative Quality Initiative Team in the Value Partnerships Department where she works to develop and provide administrative oversight to the CQI programs with the overarching goal of improving health care delivery and outcomes.

David, can you start us off?

David A. Share:
I can. Thanks very much, Gerry. And, we're having some technical challenges logging in to the Web site or staying logged in, so I'm going to ask someone else to advance the slides because we can't see them any longer, and I apologize for that.

So first, what I want to do is place the Collaborative Quality Initiatives in context, and it may seem, as you listen to these two presentations, that what we're going to describe in Michigan is very different from what you'll hear from the Montefiore folks. But, actually, the context is quite similar because relevant to that program, our collaborative quality initiative programs sit in the context of what we call an organized system of care program. We call it an "OSC program," which you can think of as being very much like an ACO program.

And, we have 38 OSCs around the state which are comprised of 995 patient-centered medical home primary care practices and another 2,000 practices that are actively working towards patient-centered medical home designation status. And then, about 10,000 specialist physicians who are affiliated with those medical homes in the context of these organized systems of care in a patient-centered medical home neighborhood program.

And then, the circle broadens to include facilities, all of which collaborate to create within their communities of care, clinically integrated systems and share responsibility for population level results on cost and quality.

And then, the CQI programs that I'm going to discuss along with Lauren, sit in that context, and we think of them as enablers or capabilities that help to augment the efficiency and effectiveness of hospital-based care. Also, we've expanded this model in to the ambulatory settings that are here.

Simply, these CQI programs are provider-owned, but the data collected is owned by the collaborative participants. They also own the armamentarium of collective quality improvement. And, one important fact is that by joining forces and pooling data, what is not possible at any individual site because of problems with low numbers of observation, in terms of being able to discern the lengths between process and outcomes that determine in a rigorous scientifically valid way what works in practice. It becomes possible, when dozens of hospitals pool their data in a common analytic environment.

Blue Cross and Blue Shield of Michigan, it has clearly been necessary to convene and catalyze these otherwise somewhat competitive providers to come together to guide and to provide resources, but it's the providers themselves that do the work. So, if we could move to 14, please.

It's clear why we need to address quality inefficiency in care. There's no - I don't need to convince anyone of that, but the third bullet refers to a key signing that we have made which is that, rather than through competition, through collaboration, the context of our collaborative quality initiatives and also our broader organized system of care and patient-centered medical home program, regional collaboration combined with resources and incentives provided by the health plan have catalyzed accelerations of improvement and both - importantly, the building of systems of care and restructuring processes of care in the achievement of improved results of a better system.

We're moving to slide 15. Probably the most important thing I'm going to say today is that what we've done through these programs is put the workings of comparative effectiveness research in to the hands of providers throughout the state who, through their collective experience, rigorously study the links between processes and outcomes using very sophisticated research methods. They generate new knowledge about what works in health care and have a systematic collective approach to disseminating that widely throughout the state and systematically implementing it in the care process.

But, the focus of our core CQI programs is on high cost, high complexity, high volume services where technology is changing and evolving rapidly and where the evidence base is thin, so absent that, follows literature that helps to guide practice to only focus on efficient and effective services and processes of care.

We have, using comparative effectiveness research in real time collaboratively throughout the entire state, we found a way to have a continuous flow of scientific evidence guiding continuous improvement and transformation processes. The CQI model includes having a coordinating center which generates comparative performance data, guides the collaborative quality improvement work, ensures the data validity and then, it's a context in which each participating site or usually hospital, has a parallel structure of clinical and administrative champions data coordination, collaboration throughout its micro community with continuous improvement and self-assessment being the focus.

We'll continue to 16. This model, the CQI model, began in 1997 inspired by the Northern New England Cardiovascular Disease study group which started an analogous multi-state effort, but this has never been done in the context of a state amongst competing providers, and we started with what we call the Blue Cross Blue Shield of Michigan Cardiovascular Collaborative which focused on cardiac angioplasty with six hospitals and their interventional cardiologists in the first four years starting in 1997, after developing the data registry, beginning to pool data. By the end of that four years, after the whole process of using comparative performance reports to examine variation in practice, identify better practices, implement them. There was a dramatic reduction in death rates, kidney failure, CABG surgery after angioplasty and other important variables which all led to better outcomes for patients with substantial savings.

And we were able to show very conclusively that collaboration on data sharing and this robust approach to cross institutional analysis led to tangible improvements in care, better and faster dissemination of those improvements and dramatic improvements in actually the life experience of the patients who were receiving that care.

As one simple example, everyone had known before that, using contrast dye for angioplasty, carried a risk of causing kidney damage including kidney failure requiring dialysis, but it was always considered an infrequent occurrence and something that was hard to prevent, but yet by pooling data across all these sectors, they were able to amass enough cases to discover what were the patient's case risk factors that were important and what processes of care were important and that guided structured approaches to transforming the way care was provided for those high-risk patients which, over that 4-year period of time, led to a 60 percent reduction in the occurrence of nephropathy requiring dialysis and a 25 percent reduction in mortality for the overall consortium, something that was completely unanticipated at the beginning but quite dramatic and it fueled our enthusiasm substantially.

So moving to 17, this slide simply shows that, at the present time, we now have 20 CQI projects, most of which are hospital-based, but several are now in the professional environment. For example, we're studying prostate cancer care amongst 20-some large urology practices across the state and, actually, that project is an interstate project as well. And that involves a lot of office-based practices as our breast cancer care projects.

Moving to slide 18, this is a schematic which really simply is trying to capture the broad outlines of our model, so simply put, Blue Cross Blue Shield of Michigan and its HMO Blue Care network worked together to - sorry, with the clinical leadership of each of these CQI projects, to create a coordinating center, to convene, otherwise, competing facilities and their staff, who would be reluctant to come together on their own, creating a neutral ground with a third party payer convenor helps immeasurably and then we fund the data collection in the coordinating center and the generation of reporting, so that the participants can get over the barrier of not having enough resources to do this important and very difficult work. The coordinating center is responsible for establishing the registry or using a nationally available one where there's one that's appropriate, generating the comparative performance reports, guiding a consortium-wide quality improvement agenda as well as supporting each participating site, needs developing and implementing its own QI agenda.

And, finally, assuring that the data are complete, accurate and valid in a very systematic structured audit based manner which doesn't happen in other contexts. The participants clearly are the ones that have to contribute the data to the central registry to actively participate in the collaboration, not just to work at their own site, they could actually come together in a collaborative fashion, share best practices, learn from others, engage in site visits or where folks from different centers along with the coordinating center staff, come and visit one another and can all take ownership of the responsibility to accelerate the pace of improvement across the state.

So, I'll turn it over to Lauren now to continue.

Lauren Henrikson-Warzynski:
As Dr. Share mentioned, one of the important ways that we support the CQI program is through funding for each CQI coordinating center, as well as its participating site. Coordinating center funding supports coordinating center staff as well as registries, meetings and other operational costs. And, site payments are designed to minimize a hospital or a physician offices cost barriers through participation and are intended to support the costs of a nurse data abstractor or other staff resources. For registry-based CQIs, we support sites by covering 80 percent of the salary of a nurse data abstractor. For non-registry based professional CQIs, we cover a portion of staff resources for CQI related processes.

Next slide, please, slide 20. There are three opportunities for CQI participants through three incentive payments. In addition to data abstraction costs, active participation and improved outcomes resulting from hospital CQI involvement are rewarded through Blue Cross' Pay for Performance Hospital Incentive program. Engaged physicians for select CQIs may also receive a recognition payment through increased payments for selected evaluation and management service codes beginning in February 2013.

Some physician types and professional CQI programs will also be eligible for recognition payments beginning this year.

The CQI program has received incredible buy-in from the Michigan physician community. Blue Cross' 20 CQI programs reach over 810,000 Michigan patients throughout the state. Furthermore, 95 percent of eligible hospitals participate in at least one hospital CQI. Seventy-three percent of hospitals participate in all of the hospital CQI programs for which they're eligible and over 329 physician practices participate in at least one professional CQI.

Next slide, please. We've had some really excellent results from our program. One such example comes from our Cardiovascular Consortium Percutaneous Coronary Intervention, or as we fondly refer to it, BMC squared PCI. BMC squared PCI is designed to improve care for patients with coronary disease who undergo angioplasty by reducing complications, such as, kidney damage, the need for blood transfusions and the need for open heart surgery.

As you can see from the graph, as a result of the collaborative's efforts to reduce complications between 2002 and 2011, death declined by 20 percent. Contrast-induced nephropathy by 38 percent, transfusions by 38 percent, vascular complications by 44 percent, CABG by 92 percent, and revascularization by 17 percent.

Next slide, please. As a result of the collaborative quality improvement work, we've had incredible benefit cost savings from four CQIs which were evaluated and actuarial certified. From 2008 to 2010, these four CQIs resulted in over $232 million in benefit cost savings through lowering complications and mortality rates for thousands of patients across Michigan.

Now, keep in mind that these savings are from our four most developed CQIs only and just represent a few of their respective quality improvement interventions.

Next slide, please. Blue Cross has received local and national recognition for the CQI program. The program has won several Best of Blue Clinical Distinction awards from the Blue Cross Blue Shield Association for its surgical, bariatric, oncology practice and cardiovascular CQIs. In 2011, our surgical and bariatric CQIs won two Blue Works awards which are awarded by the Blue Cross Blue Shield Association in collaboration with the Harvard Medical School Department of Healthcare Policy.
The CQI program has also been recognized by the Michigan Cancer Consortium and by the National Business Coalition. Next slide, please.

As you can see, we've had some really amazing results from our program. We believe that the CQI programs are so successful because they are provider led. They have focused and drive toward achieving continuous quality improvement in the real world. Physicians throughout Michigan are leading the quality improvement agenda through a model of data collection and data analysis. Through this data, they're identifying best practices, sharing insights and applying continuous quality improvement.

A fundamental foundation to this model is that the collaborative owns the data. As a result, there is strong buy-in from the providers. They trust the data. Blue Cross doesn't see site-level data, only sees it in an aggregate, and we don't judge. This has allowed for a rapid change in a physician practice. What typically takes a decade or longer, is accomplished in a quarter to a year. For instance, through data analysis, our bariatric CQI found that IVC filters, tiny devices that are used prophylactically in patients to prevent pulmonary embolism during bariatric surgery, was not always preventing blood clots and, at times, the data showed that it was actually contributing to increased complications.

These findings were presented to the collaborative in 2008 and, after only one year, IVC use declined dramatically by over 90 percent. Next slide, please.

As noted in the previous slide, this model supports continuous quality improvement for the development of best practices by engaging the physician communities throughout Michigan and focusing on clinical conditions that are relatively common and associated with high cost per episode.

Participating sites, abstractory data to the registries - to the coordinating center's registries to then generate risk adjusted comparative performance reports to guide quality improvement of an intervention. Physicians analyze data across many sites which allow for the variations to be highlighted. The fact that physicians throughout Michigan come together and leave their competition at the door to learn from each other also accelerates the rate of quality improvement.

It's also important to note that these interventions aren't just targeting Blue Cross patients. The CQIs impact all patients throughout the state of Michigan because we want to transform entire processes of care, and the CQIs contribute to further Blue Cross' social mission of cultivating a healthier future for all Michigan residents.

Next slide, please. We have a number of new exciting developments on the horizon. One of our CQI leaders at the University of Michigan secured a 3-year grant from the NIH to conduct a ROI analysis of five of our surgical CQIs. Preliminary results are promising and full study results are expected in mid 2013.

We are also launching two new hospital CQIs this year. The Michigan Spine Surgery Improvement Collaborative which is aimed at improving the quality of care of spine surgery through improving patient reported outcomes following surgery, reducing surgical complications, reducing average cost of surgeries and episodes of care, and reducing the rate of repeat spine surgeries.

We will also be launching the Michigan Value Collaborative this year, and this collaborative is a bit different in that it's not a registry-based CQI. It will actually be focused on examining the relative efficiency of common bundles of care and comparing these across hospitals correlating them with quality results from our existing CQIs, with the purpose of learning which approaches to cure yield the most value and disseminating these result across hospitals and engaging clinical leadership and hospital executives in this learning and change effort.

Gerry Fairbrother:
So, thank you, both David and Lauren, for that great presentation. Before I introduce the next speaker, I'd like to remind the audience to send in questions for the speakers at any time. Simply click on "Ask a question," at the bottom, type your question and hit "Submit." So, our next speaker is Stephen Rosenthal, MBA, MS, the President and Chief Operating Officer for the Care Management Company, LLC, a wholly owned, for profit, subsidiary of the Montefiore Medical Center, and he's Corporate Vice President for Network Care Management for Montefiore's Integrated Delivery System. Mr. Rosenthal's experience includes developing and managing Montefiore's faculty practice of over 1,000 physicians. He currently chairs in the network-wide implementation of Montefiore's Ambulatory Clinical Information System.

Stephen Rosenthal:
Thank you, Gerry. And, I'd like to thank you and Westat and AHRQ for inviting us and, what you had said earlier is true, is that, we have been managing populations at risk now for over 17 years before the term ACO was originated. I thought I'd start out by telling you all a little bit about Montefiore, aside from the fact that Montefiore is in the Bronx, which is one of the five boroughs of New York City. It's also the University Hospital for the Albert Einstein College of Medicine and, as a result, has over 1,200 residents and fellows.

In addition, Montefiore is a fully integrated health care delivery system with four hospitals, three acute care, and one children's hospital with a fairly extensive ambulatory care network reaching out to throughout the Bronx in southern Westchester with some 21 locations. In addition, of course, there are many hospital services, both mobile and satellite, along with probably one of the largest school health programs in the country, now touching over 24 schools in the Bronx.

We have a very large home health agency, as well, and one of the distinctions, I think, about Montefiore, aside from all of the academic components that it shares, certainly many of the notable centers of excellence, such as, cancer care, cardiac care, transplants and neurosciences, it's been engaged in population health and very active in the community since its origin in the early 1900's, focusing on some very challenging issues in a fairly underserved population.

The Care Management Organization as well as our IT emerging health organization supports over 17,000 employees, and a medical staff of over 2,500. The four acute care facilities have over 90,000 admissions annually, and that ambulatory network that I described to you sees over 3-1/2 million visits a year.

Our home health agency, one of the largest hospital-based home health agencies in the country, sees over a half a million home visits a year. As I mentioned, the Bronx has a population of about 1.4 million individuals, a third of which are considered poor, making the Bronx, actually, one of the poorest communities in the United States. Somewhat ironic in that it's sandwiched between two of the most affluent communities, Westchester County and Manhattan.

Over 90 percent of the Bronx is Hispanic and/or black and has a very significant prevalence of disease, particularly, diabetes and its sequelae around obesity, end-stage renal disease, asthma and a series of other chronic conditions. Almost 19 percent of the Bronx population are believed to be diabetic or have significant hemoglobin A1c scores.

On a per capita basis, the Bronx medical expense is 20 percent higher than the country itself, and about 8 percent of the Bronx population accounts for over 50 percent of the medical expenses. As a organizing structure to manage a population at risk, Montefiore created an organizational structure that we call the Montefiore IPA. As you can see, it was founded long before the accountable care concept was developed, and it's really a partnership between our physicians and the hospital systems where the structure is such and the governance centrally provides both the hospital and the physicians each with a single vote, so that in all instances, there must be consensus. And, it's this entity that essentially is managing or accepting the risks and managing that risk going forward.

The Montefiore Care Management Organization or company was founded at the same time to manage the relationship with the network and the health plans and the population at risk and to essentially become the entity that develops the innovative opportunities around care management, some of which we'll explore in the next few moments.

The model that we look at when we talk about risks is an indirect method where the premium, perhaps originating either from the government or from an employer, is paid to an insurance company, and the IPA has indirect risk through negotiations with the insurance company. And, it uses that premium dollar to support the services for the individuals that are attributed or enrolled with those health plans for which the IPA structures a payment, typically a percentage of premium. And it's the care management operations that manages that relationship between the insurance company and the network.

Part of the reason we got started was that we realized that the population that Montefiore serves, the population of 1.4 million, not only were they low income, but over 50 percent of that population are currently on Medicaid. With many of the chronic illnesses, both substance abuse and mental illness, driving many of the dollar costs, particularly, in the Medicaid programs.

The early advent of managed care in the Bronx was largely driven by Montefiore's interest in managing the premium since the payment rates, at that time, would have been problematic for the institution and thinking that the opportunity around managing premiums, would give us the benefit of holding on to the savings that we can achieve through efficiencies and quality improvement, so that we can sustain the infrastructure that we'll be talking about.

Also, the number of insurance companies in the marketplace were significant and believed that, working with Montefiore, would be an opportunity at market share growth. The dominance of Montefiore in the Bronx clearly was a driving force, and we were able to also grow our primary care network fairly significantly during the 90s and early 2000s throughout the Bronx and southern Westchester, as I described earlier. We currently have over 22 locations now with about 400 primary care physicians, all of which are employed, along with an additional 3 or 400 primary care physicians who are not employed but are voluntaries working in the communities. And, certainly, developing and supporting those relationships became very important to Montefiore as well.

Some of the decision points were around how we develop the structure which we talked a little bit about, but also, what kind of risks arrangements were we looking for with the payers and, does it make sense for Montefiore itself to become a payer. And, at that time, we thought that it did not, largely because of the competition in the marketplace. And, the development of care management and network functions were of particular interest because it served a broader issue.

Early on, working with those thoughtful leaders around the country and organizations like the National IPA Coalition, we began to learn how this model was working in other parts of the country, clearly, California and other parts of the Midwest were much further along than the Northeast. We needed to understand the populations that these payers were servicing, and we needed to develop a consistent model which, for us, was full risk capitation. And, we needed to build the infrastructure to support that for many of these plans to feel comfortable in delegating those activities to a network of providers, so we needed a strong work force, we needed investments in information systems, and we needed to accommodate for the many of the shortfalls in the payers' information systems.

This is a snapshot of where we are today in terms of the populations that we're servicing in a value-based model. In our full risk contracts, we have roughly 140,000 individuals that generate in excess of $850 million in premiums. Shared risk at Montefiore is one of the 32 pioneer ACOs across the country. We're now just beginning our second year in that exciting demonstration project. In addition, we have several other insurance companies where we have a shared risk model similar to the shared risk savings model, the ACO model, that I just mentioned.

Also, in New York state, there's a health home initiative which provides a care coordination fee for managing high cost Medicaid beneficiaries. So, and you can see, Montefiore is servicing over 225,000 individuals generating almost half of Montefiore's patient revenue of about $1.4 billion dollars.
So, how do you manage a large population of individuals like that? Well, you need to go through a process of population stratification, as we call it, looking at the different opportunities where you can identify patients and put them in buckets or categories that allow you to explore them even further.

Obviously, patients can be referred by other physicians and, in some instances with some familiarity, they may actually self-identify themselves, but we're very fortunate in that both through a combination of claims data and clinical information through our electronic medical records throughout our delivery system, as well as, of course, sentinel events like an admission or discharge, we're able to sort through that data and essentially create three major buckets or categories of individuals.

The well - the worried well, probably the many of us on this line today where we could probably go to Google health or develop our own personal health record online, and we're pretty comfortable with managing through information query, and we can do that ourselves.

Then, you have the functionally chronically ill. These are individuals who are essentially managing their chronic illness fairly well. They're managing their hemoglobin, their diet is appropriate, and they're taking their medication on a regular basis. They may need some touch-base periodically with a care manager, but they're generally doing self-management and implementing their own tools after we've customized, perhaps, some assessments for them.

The frail ill or the high utilizers, those are the ones that interventions are targeted for. They often require intensive complex case management. They may be in need of palliative care and, often, are in transition and require transition care management.

Because we have such large numbers of chronically ill patients, over the years, we've been able to develop a program that we call, "Care Guidance," and, essentially, it's a systematic approach to the information I just described to you where an accountable care team often led by a nurse with a social worker and a patient educator and, as we'll mention briefly, behavioral care manager becoming a very critical component of the team, often supported by pharmacists and physician. This team work in conjunction with the patients at the medical home, is developing an individualized care plan for this patient.

And, you can see the program offerings on the right hand side. We spoke briefly about the intensive case management. This is where there's regular communication, perhaps, a physician home visit, and an intense relationship between the team and the patient and their physician.

But then there are those who have chronic illness, and we have programs around congestive heart failure, diabetes, COPD and a serious of other chronic illnesses that are managed for individuals who are just coping with those issues.

End-of-life care has become a very important function, not only for the patient but for the family and has often become a tool to make transitions much safer and easier for the patient. As I mentioned, behavioral care, as part of our assessment, we always do a depression analysis for those patients in our programs, and we found that embedding behavior care services within our primary care network has become a very important tool.

Because we're dealing with large numbers of elderly, the skilled nursing facilities, particularly in the Bronx, somewhat atypical, with 53 nursing homes and over 11,000 beds. Telemonitoring with large numbers of individuals. Telemonitoring tools give you the opportunity to provide remote management to those patients and, where we can, we provide services in the patient home, often supported by a pharmacist who helps do medication reconciliation.

Because of the volume of activities that occur in an emergency room, we've also placed care managers that use our systems to actually help identify patients in need as they present in the emergency room so that we can be proactive and, perhaps, putting them in a better alternate care setting.

So, you know, all of these initiatives have an impact. From an efficiency standpoint, post discharge calling has become a very popular tool in many organizations as the issues around readmission have become of such national concern. Here's an example of a program that we began early on and have matured fairly significantly from this point. But you can see at this early stage, employing some of the tools that have made available by the research that many of us are familiar with, we're able to reduce the readmission rate by over a third in this population that were at risk for readmission.

Since that time, we've been in the development of predicted modeling tools that allow us to use our resources more stealthily in those subsets of populations where we believe, based on the predicted modeling tool, that they're very susceptible to readmission within 30 days.

As I mentioned earlier, diabetes is a significant issue in the Bronx, and we've been very fortunate in the program has been a longstanding and well developed over time and, as you can see, the cohort of individuals who are significantly at risk has continued to increase, not visible from this graph is the continuous reduction in admissions per thousand which ultimately resulted in this lowering of the overall cost of care. As you can follow the trend line for the actual costs, projected health care costs rather, you can see substantial savings. And it's savings that we bring and put back into our delivery system to support these kinds of activities that allow us to sustain these programs that we've put in place over these past 16 years.

So, some of the things that we've learned is that, at the individual level, it's very important to focus on, not only the medical issues, but the psychosocial issues. More often than not, it's not so much their health, but rather their life situations that causes them to revisit emergency rooms and potentially be readmitted. Meeting the patient face-to-face is always a value, and what we've developed over time, is a recognition that where we can be part of the delivery system and embedded in the primary care practice, we can be very effective, and that when that patient leaves that physician office which he or she may have only been in for 15 minutes, the time spent outside the office where harm can occur is much greater and making that connection in both those settings gives us a very important tool.

Obviously, incorporating individual behavior change is always important.

At the provider level, access and availability of the physician network is critical and expanding the team approach, the patient centered medical home infrastructure, we believe, has real added value. And, as I mentioned earlier, behavioral health expertise certainly embedded not only in the care management role, but in the primary care practice can have a very significant impact on lowering expense and improving the patient's experience.

At the system level, it's very important to communicate across all the provider community, that reducing preventable utilization is an important undertaking and, that partnering with patients and developing comprehensive care plans is an important aspect, particularly, relating to their caregivers as well.

And, of course, the IT infrastructure to support cross organizational communication and data exchange is a very important component.

So, in promoting an accountable care system, what we've learned is that the organizational governance, as I described earlier, the IPA and the structure and the physician alignment along with data, are critical for the foundation and for sustaining the opportunity going forward. And that understanding and defining the population that you're at risk or you're managing, perhaps, under a shared savings model, is critical for developing appropriate programs and applying resources to care management and that the Pareto rule prevails in that, less than 20 percent of the population will ultimately determine your costs, but 100 percent of the population will determine the quality of care, and that's an important understanding. And that, delivery system transformation is critical in order to sustain these cost reductions and improve performance over time.

Setting the stage, going forward, it's very important to use this empirical evidence to support the spread of our best practices and, of course, engaging in forums like this to engage new champions and leveraging technology to advance our success is so important as, without technology, it's very difficult to move information to the right person at the right time, so that you can enable your staff to practice at the top of their license.

So, what's next? Well, as we learn more and more about populations, we become familiar with recognizing opportunities and targeting interventions for select groups like, in our population, end-stage renal disease is a very important opportunity going forward. Official interventions in the skilled nursing facility as more and more patients wind their way through that experience.

And then linking the community-based providers to our overall system has become extremely important as they have not necessarily always had the opportunity to participate in both the IT opportunities of larger organizations and the quality reporting techniques that we can bring to them. Obviously, expanding strategies for working with our beneficiaries to the patients is an important factor, so that we can actually improve their experience so that focusing on patient's satisfaction gives us the right kind of outcome along with all of the other 30 or 33 accountable care organization quality measures that are expected of us.

And, as those patients age into program or find themselves there because of changes in health status, continue to expand our program as we go forward. Thank you.

Gerry Fairbrother:
And, thank you, Stephen. So we've had some questions come in, and I encourage others to submit questions for our speakers at any time. We look forward to an engaging Q and A period during the last 15 to 20 minutes of this Web event. So, we turn to our next speaker, Xavier Sevilla, MD, MBA, FAAP, is Vice President for Clinical Quality for Catholic Health Initiatives in Denver, Colorado. Until last August, Xavier was a practicing pediatrician on the west coast of Florida at a fully-functioning patient-centered medical home. In 2010, Dr. Sevilla participated in the federal subcommittee that chose the initial core set of child health quality measures CHIPRA legislation. He was appointed, in 2009, to the chair of the steering committee of quality improvement and management for the American Academy of Pediatrics. In that same year, he was also appointed to the National Advisory Council of the Agency for Health Care Research and Quality. Xavier?

Xavier Sevilla:
Thank you so much, Gerry. So, I think if we want to know where we're going in terms of health care policy, we really need to step back and look at the last 15 years, the milestones, the policy milestones that have really set the stage for where we are right now. So, back in 1998, we had the chronic care model by Dr. Ed Wagner, and this really set the stage on how we should treat chronic care.
Of course, in 2000, we had the IOM report, To Err Is Human, which really called for a safer health system and, to me, the most important one was, in 2001, the IOM report, Crossing the Quality Chasm, and it really gave us those six quality dimensions and the ten rules for redesign of health care. They're really as relevant today as they were back in 2001.

In 2007, we had the joint principles of the medical home that really started the whole revolution and transformation of our health care delivery system. And, in 2007, we had the Institute of Healthcare Improvement Triple Aim really looking at the three aims of better care, improving the health of population and decreased costs.

Now, at the federal level, what we've seen is obviously the Accountable Care Act which brought some big landmark policy milestones. The first one in April 2011, the National Quality Strategy, and this was very heavily influenced by IHI's triple aim. Again, looking at those three aims of better care, healthy communities and making care more affordable by decreasing per capita costs.

In 2012, we have a big milestone in terms of payment and, of course, the ACO Medicare shared savings program which has really helped us to move from paying for volume to paying for value.
So, currently, what are some of the innovations going on right now? I have picked four, and I have picked some examples of health systems and companies from all aspects of the health care system that are actually doing this right now as we are.

So, let's go with the first one and that's using data to build a culture of quality. As all of you know, quality is improving which is the good news, but it's improving very slowly, about 2.5 percent a year. And, really, the key to accelerate this improvement is really building a culture of quality and building learning organizations, and Pediatrics Medical Group has done that. This is a group that specializes neonatal intensive care unit care for patients. They take care of about 20 to 25 percent of all neonates in intensive care units in the US.

What they did is, they built a clinical data warehouse that automatically extracted data from their electronic health record, and it changed the data and made it very accessible and easy to use at the point of care. What happened later was - what was really amazing, as clinicians starting accessing this data and looking at their performance, they started comparing themselves with other peers, with other units throughout the country, and it really started a question of why do we have this significant clinical variation. And it really built a culture of quality by having collaboration between physicians and between clinicians in the system to really try to find out those best practices and really building that ongoing quality improvement culture.

So, let's talk about delivery system transformation and Health Partners in Minnesota is a great example of this. They have really achieved some amazing outcomes, 39 percent lower ER visits, 24 percent fewer admissions, 40 percent lower readmissions, as well as, incredible improvements in terms of their optimal diabetes care, 129 percent and an increase in their optimal heart care of 48 percent. And the way that they've been able to do this is really to transform their delivery system completely. So, their delivery system is a care model process which is a very team-based and patient-centered delivery system that is really based on primary care and has been able to, again, change that culture in the organization to a culture of quality.

So, let's talk about payment right now and, as all of you know, we have a zero sum game right now between payers and providers. When one benefits - one benefits at the expense of the other. There's really the wrong kind of competition. Competition should be really on creating value, and this is how most other industries work, the retail industry, financial services, computers, airlines, it's all about creating value for the customer and, in our case, we need to move there.

So, one of the other innovations is really shifting from pay-for-performance to pay-for-value. So, let's talk about pay-for-performance and the status of that right now. Well, we had a huge experiment and that was the quality and outcomes framework in the national health service in the United Kingdom. This was started in 2004, and really they rewarded clinicians for improvement in certain processes that they did in their office. Now, when this process was evaluated, only a very, very small, very modest improvement in quality was actually found, and this was with a very high investment up front by the National Health Service.

So, really, as we go forward, we need to shift to more payment for value, and there's lots of examples right now. One that I would like to highlight is the Alternative Quality Contract by Blue Cross Blue Shield of Massachusetts because it's been there for a few years, and the way that clinicians and health systems would get paid is with a global payment, and this would incentivize to really eliminate the overuse going on. The systems would also be paid for, and their payment was adjusted for inflation, and then there was a third quality bonus.

Now, the interesting thing about this is the quality bonus was really set among different targets. So, there was not just one target where you would get rewarded or not, but there were different degrees of targets where systems that were starting on this journey could really still have some benefit from this contract.

So, let's talk about bending the cost curve and, certainly, this is probably the most challenging aspect of healthcare policy right now. And, we have Bellin Health in Wisconsin that has really done this very well. So, Bellin Health started decreasing health care costs with their own employees, and they were able to do this by about 15 percent. They then took this out to other employee populations from different employers in their area of work and were able to replicate the same things that they were able to do with their employees.

And, there are four things that they do to be able to focus and decrease the health care costs. One of them was really creating a culture of health, both in their organization and the organizations that they work with. Number two is really getting to know their population, diving in to the data, really getting to know that utilization, health risk assessment of all their patients. The third one is really engaging the patient and making them take ownership of their health. And the fourth one is a great integrated system of care with very easy navigation for patients.

So, really, as a conclusion, we know that reform and innovation is not only possible, but is really flourishing in a number of organizations in the country. This is all about leadership. These are leaders that have not waited to see what happens in health care policy or how is the payment going to change, but have really innovated their organizations today to position them in to the future.

So, how do we see the future panning out right now? Well, there's four items that I have chosen. So, the first one is about partnerships and collaboration. And certainly, as we go forward in to the future, collaboration and partnership between physicians, hospitals, payers, other clinicians and, most importantly, patients, is going to be a must and a priority going forward.

The new role for patients. Patients have really been more passive recipients of care, and I think, in the future, they're going to be much more active participants in the health care system. Sick care versus wellness. Our healthcare system is really built around treating disease, about treating illnesses, about treating conditions, and I think we need to move forward more in to prevention and wellness as opposed to illness.

And, finally, health versus health care. We know that only about 10 to 15 percent of health is actually affected by health care, but this is where we spend most of our dollars. So, I think in to the future, health systems are going to have to get in to that other 85 to 90 percent, and we're not going to be able to do this alone. We're going need to partner with our communities to be able to get to those other determinants of health, such as, education, nutrition, socioeconomic status, et cetera.

So, now let's turn to our presenters and let's talk about some of these future issues, so we know that both organizations that were presented today achieve great results with collaboration. In the Michigan project, there was a great collaboration between clinicians and Blue Cross Blue Shield, and then the Montefiore project there's collaboration between different clinicians, between hospitals, between ambulatory settings, home health. So, how did you facilitate cooperation in your initiative and, also, looking at the future, where do you see opportunities for more collaboration between payers and providers? So, let's go ahead and start with you, David and Lauren from Michigan.

David A. Share:
So, thank you. I appreciate you teeing it up that way. First of all, I'd like to clarify that the fundamental frame of reference for the collaboration in our CQI program is really between and among the clinician community across institutions throughout the state. The payers is a vital catalyst and enabler, and so we start with the collaboration that we initiate with the provider community, but then there is this change of locus of control from the payer which is where it traditionally is, and it's kind of the controller or manager to the providers themselves. So, we really cede control.

We are compared to more as a catalyst and a convenor and so, underlying that is an intention to empower the provider community to do the most possible to transform systems and to shoulder responsibility for the ultimate outcomes of the care they provide. This really elevates their level of professionalism and professional satisfaction in what they do and, in contrast, the pay-for-performance which, in my view, tends to inspire doing the least necessary to get the doggie biscuit, these folks are doing the most possible to move mountains, to transform systems and yield pretty dramatic change.

We also are importantly not doing public reporting. This is a safe harbor environment, so they are free to disclose weaknesses as well as shared strength. We are measuring to improve, not to judge, and as long as the programs continue to yield additional improvement in quality and cost outcomes, we continue to fund them, and that's been the case since 1997 steadily. So, which interestingly belies the notion that you have to publicly report variation in percent in order to get people to improve it.

And then finally, once you create this collaborative context, which is very intentional so it's not just, you know, we share the performance reports and hope they make use of them, but there's a structured collaborative consortium-based approach to coming together, sharing best practices, doing reciprocal site visits, have work groups on particular highly technical challenges that they face in common. But, importantly what they discover pretty quickly and I'll end with this observation, is that there's much more variation across institutions than within institutions and that becomes really fertile grist for the mill for self-assessment and improvement in contrast to what they had been able to do on their lonesome since they're looking at their pool of data, especially when complication rates are somewhat modest, it's very hard to see patterns that help show a way forward to improving practice.

Xavier Sevilla:
Great, thank you. Thank you so much, David. And, how about you, Stephen, your perspective from Montefiore?

Stephen Rosenthal:
Sure, thank you. Actually, in many ways, a very similar orientation is that we've always looked for shared opportunities and often have been characterized as kind of the population management's research and development zone. There's an opportunity for common interests among many physicians who are looking for opportunities to be proactive in populations where Fee-for-Service service revenue doesn't make sense, but when you're managing a population with a total cost of care and the quality opportunities begin to provide some additional opportunities that, perhaps, the payment has been pushing down from actually occurring.

An interesting example, for example, is orthopedists working with primary care physicians around reducing the number of unnecessary referrals for low back pain in their practices and supporting the primary care physicians with access and information to help better manage the population. Or, the radiology department where so many insurance companies have been focused on reducing utilization in radiological procedures, we work cooperatively with them around looking at opportunities based on the population-based strategy of where to place our efforts and minimize those things that create hurdles but rather provide ease of access and improve patient experience and, by doing that, we're able to save millions of dollars and not necessarily have an impact of the delivery of service.

So, I think when you share this commitment of population management with the physician community, they're very willing to come to the table and very excited about the opportunity, at least that's been our experience.

Xavier Sevilla:
Thank you, Stephen. So, my next question is really looking at spread. So, you know, really since the IOM report Crossing the Quality Chasm was published, there's been great focal points of excellence like some of the initiatives that we heard in this Webinar. However, a large proportion of the healthcare system has been left behind. Please comment on your ideas and thoughts about how to spread these best practices more rapidly to all the corners of our healthcare system. And, let's go ahead and start with you this time, Stephen.

Stephen Rosenthal:
Well, thank you. You know, it is certainly a challenge very often to disseminate and communicate information, but I think certainly forums like this are excellent opportunities at sharing best practices and then, of course, the follow-ups from this, but to a certain extent, it's somewhat incumbent on organizations like us to take some of the things that we have developed and share them in a more robust and common fashion, like our care guidance model and other things that we've developed over years and begin to provide that more broadly so that individuals can start at a higher point along the curve of the continuum. So, sharing information in the right settings becomes very important.

Then, of course, I think many of organizations are forming around the country, many companies are looking innovative opportunities using technology, new technology opportunities and innovations to bring some of these stealth learning experiences in a more inexpensive way and, hopefully, technology won't be so lagging in health care as it has in the past, and we can take advantage of these new opportunities, new companies.

Xavier Sevilla:
Thank you. David and Lauren?

David A. Share:
So, I agree with Stephen. Those are important factors. I'll take a different angle on answering the question. So, in my view, spread requires ownership. It's necessary but not sufficient to get the word out there and provide the tools, but folks have to really embrace new responsibilities and a new vision for how to provide care in order to make full use of those tools So, one thing that we've done in order to catalyze that ownership is since 2009, we stopped offering any base fee increase for physician services and so that's been several years now, so, as a result, an increasing proportion of professional reimbursements tied to delivering value I refer to paying for value, we use our fee-based system as a fee-for-value approach. And, for the primary care practices, upwards of 40 percent the reimbursement is now dependent upon population value.

And so, that's a strong catalyst for spread as is, I think, this organized system of care programming or ACO program in which providers collectively share accountability for population performance. What's unique about this OFC program is that we explicitly ask providers to own the responsibility to craft new systems of care and have gotten tools, the sort of tools that Stephen was talking about. So, first transform the system and then also be accountable for it&rsquo;s performance. So, that I think that increasingly, as ACO and OFC like reimbursement arrangements are established, providers will feel compelled to own these new approaches to structuring care to clinically integrating across settings to implementing programs like the CQI programs that we've described today.

And then, finally, I've seen large payers the CMS, but other large commercial payers as important catalysts that can bring folks to the table as we&rsquo;ve described, to take on these new challenges and absent market where there is a large predominant payer. There are often regional health coalitions focused on improving health and health care in the community that are able to bring employers and multiple smaller payers together along with key health system leaders to get them to own this change. So, I think, that that sort of way harnessing a community and creating, in a sense just through transform reimbursement and collective responsibilities for performance will help and spread.

Xavier Sevilla:
Thank you, David. So, we're going to shift to the question and answer with the audience part, so back to you, Gerry.

Gerry Fairbrother:
Thank you, Xavier. We're getting some very good questions in, and I'm going to start with one about the ACA. Several people have asked about provisions of the ACA and this question specifically asks, "How are provisions from the ACA influencing your strategies? And the two provisions especially highlighted were hospital readmission reduction program and value-based purchasing program, so how are these two affecting your strategies and then, in general, how is the implementation of ACA affecting things," and let's begin with Stephen.

Stephen Rosenthal:
Well, you know, they're actually a significant influence. As I mentioned in one of my slides, the issue of readmissions and particularly the penalties associated with it, both at the federal level and in New York state, similar penalties around readmissions within 30 days, has driven many organizations to pay attention to those instances where the efficiency of discharging a patient without the appropriate information and follow-up, is an adverse event in this model. So, I think it's affecting everyone who are concerned about that, particularly, if their readmission rates are high. And I think many of the value-based models are the pattern that we're all seeing for the future. So, if you're an ACO, you're obligated to move 50 percent of your business by 2013, the end of 2013, into a value-based reimbursement model, either shared savings, global risks, or some related bundled payment activity. So I think all of us are being fairly significantly impacted by it.

Gerry Fairbrother:
Thank you, Stephen. And, let's move on to Blue Cross Blue Shield. Yeah, go ahead.

David A. Share:
Sorry. So, I'll take, again, a slightly different angle because of our context being different. I'm not going to speak to these questions vis-a-vis our CQI program because this really gets us into the organized system of care and patient-centered medical home world, but to get into hospital readmissions, although, I understand it's the flavor of the month and it will be for awhile. I actually am not enamored personally because, as was seen recently in a report, I can't remember its source, but in the last week or so, the hospitals that are not getting the incentive payment from CMS for this measure tend to be hospitals in lower income communities and academic centers which carry more risks in terms of the patient's severity of illness and, also, importantly, the socioeconomic status.

But, what we're doing in our organized system of care in patient-centered medical home program is focusing more broadly on hospital admission rates and, importantly, on ambulatory care sensitive condition admission rates, and in the nearly 1,000 PCMH designated practices in our program, they've been able to reduce the ambulatory care sensitive condition admission rates by 25 percent and that includes quite a few readmissions for chronic illness where people tend to go through the revolving door. Similarly, we focus on better access to ambulatory care not in the ED, and, also, to more proactive chronic illness management, all of which leads to demonstrably lower ED use rates and, because the rate of admission from the ED is so high, that's yielding lower admission and, importantly, for conditions like pneumonia and heart failure and so forth, lower readmission rates.

So, we're making a dent in it in those ways, but they're focused more on proactive population management than on trying to reduce readmissions per se. On the value-based purchasing side, we're focusing less on the micro level like which meds should have a lower co-pay because they have greater value and what we're moving towards in the context of a patient-centered medical home neighborhood and organized systems of care programs is, creating products in which the member's interests are aligned with those everybody else to achieve better value. It's important we lower out-of-pocket costs for going to the medical home and only to specialists and facilities on referral from the medical home even though it's open access. If they do that, they shoulder less of a financial burden, and that gets them more in to proactive care management and structured approaches to providing care that's consistent with the current evidence base, and so moving them towards value-based services without trying to micro manage that into a benefit design.

Gerry Fairbrother:
OK, thank you. So, we have several questions about the role of patients beginning with understanding that there's an expanded role for patients now from passive recipients to active participants in care, and one of our questioners is asking about specific strategies for engaging patients. So, that goes to both of you, and let's start now with Blue Cross Blue Shield.

David A. Share:
So, again, in the context of our patient-centered medical home and organized system care programs, we have a very ambitious program called, Provider Delivered Care Management, which relies on the medical homes and we're planning this also for oncology practices and other specialists that deal with end-stage illness commonly where patients wind up at the specialist for the vast majority of their care.

So, taking the locus of control of the partnership, the proactive partnership between the patient and the provider, sort of out of the hands or the influence of the health plan where disease management has historically resided and empowering the practices close to the doctor-patient relationship in a multi-disciplinary way, work with the patient to give voice, help the patient give voice to their needs and preferences, treat them as an active participant, empower them in self-management skills and very explicitly reimburse for a care management team that does that, does exactly that.

So, that there are specific codes for various types of care management, care coordination and, importantly, self-management support. And, also, one of the things we have as an expectation, it's probably the only thing that I said was really a must, because in this giving up or ceding control, there's an awful lot of latitude that's been given to the practice community, but the one thing I said had to happen, and they objected at first, was a patient-provider agreement as a foundational element in a medical home program. They thought, "Oh, that'll all work itself out, that's just busy work," but it turns out that requiring that dialogue in whatever form they want with whatever staff members they want, gets people quite animated about being an equal partner in the care process, so that's been an important element as well.

Gerry Fairbrother:
Great. Thank you, David. So, let's move to Stephen and see what ideas you have about patient engagement.

Stephen Rosenthal:
Well, as you know, Gerry, our patient population has many psychosocial issues aside from their health issues, and part of the hands-on challenge that we have is not only engaging the patient but often engaging the patient along with either their caregiver or family and focusing on the elements of our extensive assessment where we think the patient is ready to engage. So, the motivational aspects of when they're ready to engage and with what they're engage with has become a very critical piece to this. And, we need to translate that to the patient-centered medical home team as well.

But, very often, it really revolves around the psychosocial issue, so we spend a great deal of time connecting them to community-based organizations, social service agencies and work with them on things like stable housing and all of the nutritional benefits associated healthy eating and bringing them the kinds of services that could best support and help manage their complex lives as well as their health issues.

Gerry Fairbrother:
Thank you, Stephen. So, we've gotten a number of questions on this topic, so let me see if Xavier could speak to the role of patient engagement and what your organization is doing around - what specific strategies your organization has.

Xavier Sevilla:
Sure, absolutely, thank you, Gerry, and I feel very passionate about this particular topic, and I think really we have to move patients to be part of the care team and, you know, one of the simplest things that folks can do right now, I mean, you could do it next Tuesday is really to form a patient advisory council at your hospital, at your practice, at your nursing home, whichever delivery system you work in. It's pretty simple to do. We have it here at Catholic Health Initiatives at the hospital level, and we also have a patient advisory council that advises kind of the whole company, more at the strategic level, but I think this can be done by really everybody. Patients are itching at their feet to become active participants and, in my experience, it's been amazing the feedback that you get from patients, just things that us as health care providers, we do not think about, but patients can bring it up and really contribute to the discussion of how to improve health.

Gerry Fairbrother:
Thank you very much. This has been a great session, and we're about out of time, so let me turn to Judi to close us out.

Judi Consalvo:
Thank you, Gerry. And, this was great. A big thanks to our presenters, our moderator, our discussant and, also, to our audience. Please remember to complete the Web event evaluation because it helps us to improve our offerings, to bring a great event such as this to you all. Your comments definitely help us to plan future events that meet your needs and, as always, we invite you to visit the Health Care Innovations Exchange Web site and to follow us on Twitter for all of the latest developments. You can also contact us at any time at info@innovations.ahrq.gov and thank you, again, all of you for joining us.

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