代做PH 124: Health Care and Public Health Management Assignment #3代做Statistics统计

日期：2024-04-20 06:23

PH 124: Health Care and Public Health Management

Assignment #3: Excel and Performance Improvement Analyses (15 points)

The primary objective is to analyze Excel performance data from the Golden Bear Health System to address inadequate follow-up patients with mental health diagnoses after emergency department visits.

Measure Definition: Emergency department (ED) visits for adults and children 6 years of age and older with a diagnosis of mental illness or intentional self-harm and who received a follow-up visit for mental illness within 7 and 30 days.

Source: https://www.ncqa.org/hedis/measures/follow-up-after-emergency-department-visit-for-mental-illness/

Milestones:

1. Review data about Golden Bear Health system’s scope and overall differences in the availability of services and organizational partnerships between IPA and IMG practice sites.

2. Review data about the system’s health information technology and care management capabilities and note differences for the IPA and IMG practice sites.

3. Review the system’s “run chart” data that includes trend line charts for performance data related to the mental health follow-up measure and analyses information about Golden Bear practices using the “practice site” data.

4. Develop a SMART Goal and Delineate Project Measures (3 points)

5. Analyze the reasons and analysis findings on why the mental health follow-up performance measure is not being met for Q4 2023 in the Pareto data worksheet.  (5 points)

6. Analyze the practice readiness data in your “practice site” Excel sheet for your IPA and integrated group practices. Determine the opportunities for improvement and potential solutions to test. How does information about readiness inform. your approach to disseminating solutions to improve performance on mental health follow-up? (7 points).

Background Case Information for Excel and Performance Improvement Analyses:

The Golden Bear Health Care System operates under a leadership and management structure that includes administrative and clinical functions. However, the organization needs to manage many third-party relationships to effectively perform. multiple tasks within their scope. The system has contracts with billing and claims-management firms, care coordinators, information-technology vendors and staffing companies. Market conditions and the type of payments that it accepts will determine the kinds of medical personnel needed to make a health care system function. These factors are important because health care organizations must meet cost benchmarks and quality standards. 

Golden Bear participates in a multi-payer Accountable Care Organization (ACO) contract with upside and downside risk arrangements, meaning that if the health care system meets cost and quality targets, they earn a bonus incentive, but if the system fails to meet the targets, they pay a financial penalty.  ACO contracts differ from managed care arrangements in the 1990s because medical groups make the decisions, not insurers, and because both cost and quality are taken into account rather than cost alone. Physician teams attempt to save money by pooling resources needed for effective patient care that meets cost and quality targets. These teams, in turn, must coordinate their efforts with a separate administrative, legal and management structure responsible for overseeing the organization's day-to-day affairs. Starting in the fall of 2010, health care systems were allowed to begin trying the ACO model in the Medicare program, the nation's elderly and disability insurance program. Section 3022 of the Patient Protection and Affordable Care Act (ACA) lays out the basic framework.  The ACA gave wide latitude in how physicians may participate in ACO contracts. Examples include health care systems that employ medical professionals, group and individual physicians' practices, and physicians' networks.  Your health care system has group physicians and a network of independent physicians.

A multi-payer ACO contract means that the 4 major insurers and the state Medi-Cal program have joined forces to align performance measures and incentives as part of the ACO arrangement.  The ACO contract arrangement follows the general terms of the Medicare Shared Savings Program (MSSP).  The 4 major commercial insurers in Northern California (not including Kaiser Foundation Health Plan) are:

· Anthem Blue Cross

· Blue Shield of California

· Health Net

· Western Health Advantage

The benefit of the aligned incentives across payers is that the internal performance management requirements are reduced (less specialty reporting, less complexity in providing feedback). Golden Bear’s organizational structure includes an integrated group practice (IMG) model and extensive contractual arrangements with practices part of Golden Bear’s home-grown independent practice association (IPA). To date, the health care system has pursued separate organizational arrangements for the integrated group model physicians vs. the IPA physicians because of their distinct markets, patient populations, and organizational characteristics. The affiliated IPA practices began contracting with the health care system approximately eight years ago, but the health care system’s internal organizational design does NOT include any shared departments or services across the IPA and IMG physicians. 

· The current organizational structure is divisional, with integrated medical group administration and IPA administration operating fairly autonomously: 

· Integrated Medical Group (IMG)  Sites Description:

o Physicians of the integrated group physicians are employees of the medical group. The health care system and medical group are jointly accountable for managing facilities and improving the quality of care. 

o This health care system operates 35 integrated group practice sites with a total of 664 adult primary care physicians and 193 specialists. Larger practice sites have a broader range of specialties than smaller sites and medical group patients receive higher quality of care compared to IPA patients across the board.

o This group is also part of a physician-hospital organization with a non-profit hospital system (Superior Hospital System) with 13 hospitals geographically dispersed across Northern California located in San Francisco, Richmond, Oakland, San Leandro, Fremont, Redwood City, Vallejo, Stockton, San Jose, Walnut Creek, Fresno, Sacramento, and Roseville. “Physician Hospital Organization (“PHO”)” is an organization or association involving a hospital and one or more providers, which is formed for the purpose of, or has authority to, negotiate with third parties for contracts for provision of health care services. The PHO relationship predated the ACO contract and the relationship between Superior Hospitals and your healthcare system has been functioning well because of the strong cultural alignment of Superior Hospitals with your integrated medical group, whose physicians provide most of general medical and pediatric care for hospitalized patients in Super Hospitals. 

o The integrated group practices solely refer patients to Superior Hospitals unless their patients need care when in geographically distant areas from their hospitals or need highly specialized care. 

o In 2023, 97% of patients of integrated physician group practices were hospitalized at a Superior Hospital facility.

· Independent Practice Association (IPA) Practice Sites Description:

o Own and operate their own facilities. 

o Most IPA physicians coordinate with the healthcare system and integrated medical group on a handful of priority quality improvement initiatives such as the one your team has been assigned, but do not share resources and coordination tends to be low. This approach has not been particularly effective in improving performance in the past, but health care system leadership has been especially cautious as to not force collaboration.

o One challenge of managing the performance of IPA physicians is that they belong to multiple IPAs (including some owned by competitor health systems in Northern California). Your health care system contracts with 1,070 IPA physicians at 290 independent practice sites, half of which are primary care focused. Most of your IPA physicians face competing demands from other health care systems they are affiliated with competitor health systems and IPAs in your region. This makes your performance improvement plan difficult because your health system has relatively less of their attention and therefore less influence over their performance. This is especially challenging because IPA sites are disproportionately the lowest performing sites under your health system.  

o Your IPA’s primary care and specialist physicians work in community-based settings and many in remote areas; 40% of their hospitalized patients receive care at Superior Hospital System, while 60% are hospitalized in other systems.

o Your health system and IMG have yet to acquire any of the IPA practices (IPA sites are system-affiliated but are not owned by the system) .

o Some IPA practice sites, however, have high volumes of health system-attributed patients.  The health system and medical group leadership have had extensive discussions about the integrated medical group (IMG) acquiring select IPA practices based on their capabilities, geography, and performance.  A reputable consulting firm has been hired to provide recommendations on how to go about aligning the IMG and IPA to leverage system and medical group capabilities to support the IPA practices and improve the healthcare system’s performance.

Table 1 is a summary of your health care system’s services and organizational arrangements for the integrated medical groups vs. IPA practice sites.

Table 1: Health care system partners and how they differ overall by Integrated Medical Group vs. IPA

	Integrated medical group sites  (n = 35)	Contracted IPA practice sites  (n = 290)
Composition of partners
Includes a hospital	100%	51%
Includes a community health center	100%	25%
Includes a nursing facility	80%	20%
Services offered
Routine specialty care	70%	74%
Highly specialized care	58%	67%
Emergency care	100%	57%
Urgent care	80%	50%
Inpatient rehabilitation	75%	40%
Outpatient rehabilitation	90%	48%
Behavioral health care	95%	54%
Skilled nursing	90%	20%
Palliative or hospice care	75%	33%
Home health care	50%	50%
Electronic Health Record (EHR)
All clinicians use the health system’s EHR platform. and can exchange data with Superior Hospitals.	100%	33%

Financial Arrangements

A complicating factor to your organizational design decision is that your health care system has two types of financial arrangements for ACO contracts- one for the integrated medical group and another for the contracted IPA physicians:

1. The integrated medical group receives the ACO contract incentives on top of capitated payment (per member per month payment). Upside and downside ACO risk sharing arrangement for patients of the health care system’s integrated medical group, which can result in a bonus upwards of 10% of total payments and also penalties up to 10% of total payments.  

2. In contrast, the IPA practices, which are predominantly in rural and suburban areas, receive the ACO contract incentives on top of fee-for-service (FFS) payment. Upside only risk sharing arrangements for patients of IPA physicians, which can result in a bonus upwards of 3% of total payments.

Because of the different levels of risk involved in the IMG  vs. IPA contracts, there is currently very little overlap in the management of the two types of ACO contracts (one for IPA side, one for IMG side). For more information on health care systems and ACO contracts, see Week Zero in bcourses.

Your health care system’s IMG and IPA organizations have very distinct organizational cultures:

· The IMG practices have a rules-driven and entrepreneurial culture and tend to serve urban and suburban neighborhoods and physicians with access to services across the continuum of care, including skilled nursing facilities, nursing homes, and hospitals. 

· The IPA practices, which tend to be small and have less developed technical infrastructure for performance improvement, emphasizes flexibility, discretion, and teamwork, and tend to serve rural patients with fewer organizational partners to help the IPA practice sites manage IPA patient care across the continuum, e.g., no nursing home or community health center partnerships.

Instead of organizational integration or medical group acquisition of high-performing IPA physicians, your health care system leadership is currently using joint IMG-IPA subcommittees to oversee quality and access to services across the two sides of the health care system. For example, the health care system steering committee coordinates marketing and communications and oversees performance standards, customer and member care services. Contracts with providers and medical management, however, continue to be managed under the IPA and integrated medical group administration rather than directly managed by the health care system.

Current Health Care System Performance and Strategy:

· Your health care system is currently “breaking even” financially collectively across medical group vs. IPA ACO contracts once administrative costs are considered, but the integrated medical group practices have made much greater strides in managing costs and achieving high performance (quality and patient experience) on many targets, achieving incrementally greater shared savings bonuses in the ACO contract each year during the 3 years prior to the COVID-19 pandemic. During 2020, ACO contracts did not enforce penalties due to COVID-19, but contract rewards and penalties resumed in 2022. 

· IPA physicians are not achieving shared savings because of their predominant FFS incentives. This has been a long-standing issue that was made worse by the COVID-19 pandemic. Due to their “upside only” ACO contracts, however, no penalties or withholds have been realized.

· Your integrated group practice sites have much higher performance on your assigned performance indicator compared to IPA practices (See your Excel sheets).

· Due to increased pressure from employers and the multipayer ACO contract to reduce costs, your executive team must develop a strategy to reduce administrative costs, remain competitive, and close performance gaps. There has been some consolidation of physician services across the IPA and IMG segments, but these changes have not been easy, often resulting in dissatisfaction among IPA physicians who are not used to the intensive performance management efforts required of ACO contract participation.

· COVID-19 resulted in a dramatic drop (~40% drop) in total encounters to your health care system in Q2 2020. Total visit volume has never recovered (even after multiple years) and is still 20% shy of 2019 pre-COVID-19 quarterly volumes. As a result, performance across most key performance indicators is low because recommended care was not consistently provided to patients due to challenges of meeting quality targets since Q2 2020.

· Although your health care system participates in value-based initiatives, telehealth video visits are still not routinely implemented across the system and a subset of IMG practices have fully implemented video visits but almost none of the IPA practices have done so.  In contrast, clinicians and staff are using audio (phone) telehealth because reimbursement for audio and video were equivalent during the COVID-19 emergency, but reimbursement parity ended recently and audio visits only reimburse at 30% the rate of telehealth video and in-person visits.  In addition, remote monitoring technologies, such as wireless blood pressure monitoring and at-home glucose monitoring, are not being used.

· Important internal stakeholders are divided as to whether integration of integrated group and IPA clinical and administrative services will reduce costs and improve performance of the healthcare system. 

· The current divisional structure clearly duplicates some functions across the firm (Human Resources, Public Relations, Sales/Marketing, etc.).

Your Excel Worksheets

You have 4 separate sheets that will be used in the course. Please revisit Module 0’s tutorials to help with the Excel components.  You will notice that your health care system’s performance for your assigned measure declined dramatically in Q2 2020, due to COVID-19 shelter in place, and still has not recovered. Your team is tasked with planning a “turnaround” in performance using a combination of telemedicine and in-person encounters. There are long standing (pre-COVID-19) issues with performance that have yet to be addressed.  

1. “Practice Site” Excel Data:  This sheet has practice capabilities data for each of your integrated medical group and IPA sites.  The first columns (A-AB) cover practice characteristics, health information technology, and care management capabilities.  These columns are the focus of Section 3’s assignment to understand practice site variation. Column C represents each site’s latest performance level on the mental health follow-up performance measure.  You will use this sheet to analyze the practice site “readiness” data columns (after the red demarcation).

2. Pivot Table Example (in “Practice Site” sheet):  This is an example of a pivot table analyzing data from the Practice Site Data sheet.  You should modify this pivot table (using the Pivot Table Editor on the right hand of the Workbook) to examine practice variation within your health care system.

3. “Run Chart” Excel Data:  You will analyze the performance trend data and create performance targets for future quarters.

4. “Pareto” Excel Data: Includes results from a survey of 100 IPA and 100 integrated medical group patients who did not meet the performance measure (Performance Data sheet).  The results include counts of patient-reported barriers to meeting the performance measure.  You will create Pareto Charts to examine how the drivers of performance differ for IPA and integrated medical group practices. 

SMART GOAL AND PERFORMANCE TARGETS

1. Review your Performance Measure Data in your workbook:  Analyze the Current Performance data from Q1 2017 – Q4 2023 in your Practice Site Excel sheet, then determine your performance targets for Q2 2024 – Q4 2024.  Once you identify, prioritize your improvement strategies you will demonstrate how these changes impact your performance over time.

a. Review your Practice Site Data on health information technology, care management, and other characteristics.

2. Propose your performance improvement targets  

3. Draft your SMART Goal for your performance measure. A SMART goal is a single statement that explains exactly what you are striving to achieve with your project:

a. Specific – clearly says what will be improved, without operational definitions or acronyms       

b. Measurable – states current performance and desired performance

c. Attainable – the team working on it believes it can be done

d. Reflects the Customer’s Perspective – represents what the customer wants

e. Time Bound – by what date the goal will be reached 

Develop a SMART goal(s). A SMART goal is a single statement that explains exactly what you are striving to achieve with your project. Enter the SMART goal below.

SMART goal

Delineate Project Measures and Scope.

Project Measures

· Outcome Measure:  · Process Measures: · Balancing Measures:

Project Scope

· In-scope: · As Needed: · Out of Scope:

Analyzing Practice Variation

Analyzing Practice Site Variation

● Analyze your health information technology and care management capabilities using Pivot Tables and/or other Excel tools.  Make sure to note the key differences for the IPA and IMG practice sites.er to Module 0’s Excel Readiness Tutorials to guide you on how to create Pivot Tab

Review your Health Care System Google Sheet Data:   1. Raw Practice Site Data describing your Health Care System’s practices 2. Pivot Table Example: Modify the example pivot table to generate new analyses for the observations below a. Refer to Module 0’s Excel Readiness Tutorials to guide you on how to create Pivot Tables b. Note observations about your capabilities and differences by geography (urban vs. rural vs. suburban), IPA vs. IMG practice affiliation, practice size (patient counts)
Observations: Electronic Health Record Functions and Electronic Decision Support
Observations:  Use of Evidence-Based Guidelines

Generate a Pareto Charts for the IPA and integrated medical group data and copy and paste it below.   

Post Pareto Charts here- 1 for the IPA and 1 for the integrated medical group.   What are the major drivers of performance deficits in the IPA vs. the integrated medical group?

Testing and Dissemination

Determine the opportunities for improvement and potential solutions to test.
How does information about readiness inform. your approach to disseminating solutions to improve performance on mental health follow-up across Golden Bear practices?
How will you assess the voice of the customer? Who are your most important customers? What are their needs? How will you translate their needs into actions/resources?