Workshop on the Future of Rural Health

1
Payment for Quality Performance Rural Realities
Workshop on the Future of Rural Health Robert S.
Galvin, MD March 1, 2004
2
Three Key Realties

• Pay-For-Performance Is More Challenging, But No
  Less Important, in Rural Settings
• Challenges are Opportunities for Solutions, Not
  Excuses
• Needed Actions Require True Leadership

3
Crossing the Quality Chasm
The Goals of Any Payment Method Should Be to
Reward High Quality Care and to Permit the
Development of More Effective Ways of Delivering
Care to Improve the Value Obtained for the
Resources Expended. The Goals Are Relevant
Regardless of Whether Care Is Delivered in a
Predominantly Competitive or Regulated
Environment, and Whether the Ultimate Purchaser
Is an Employer or the Patient-consumer. Payment
Policies Should Not Create Barriers to Improving
the Quality of Care
IOM Crossing the Quality Chasm
4
REWARD INCENTIVIZE QUALITY
Professional Model
Improvement Higher Quality Lower Costs
Motivation
.
Adoption
Consumer Model
5
A Market Approach to Costs
Employers believe that consumer pressure is a
powerful, underutilized lever for improving
quality and efficiency. They believe that higher
quality and lower cost will result if consumers
spend more of their own money for services they
believe are high quality, and if providers
respond by improving their performance. For this
strategy to succeed, consumers will have to be
activated to seek more efficient, higher quality
care and physicians will have to be rewarded for
delivering it. Sounding Board NEJM, September
19, 2002

• Transparency
• Incentives and Rewards
• Focus on Quality and Efficiency

6
Challenges In Pay-For-Performance
General

• Business Case for Quality
• For Whom?
• Zero Sum Game
• Definitions
• Quality Underuse, Misuse, Overuse
• Reward Volume, Recognition, Price
• Measures
• Accuracy, Attribution, Specificity
• Collections
• Burden
• Who Pays?
• Litigation
• Dont Underestimate Pernicious Effects
• Partnerships and Culture

7
Challenges In Pay-For-Performance
Unique to Rural

• Solo / Small Group Practices Make Performance
  Measures Even More Challenging
• Solo / Small Group Practices Make Time and
  Capital Very Scarce
• Competitive Model Doesnt Work Price Is Only
  Viable Reward
• The Leapfrog Story

8
Whats Going On In The Pay-for-Performance World?

• 85 Initiatives Listed
• Private Sector California IHA, Bridges to
  Excellence, Leapfrog, RWJ Rewarding Results
• Public Sector CMS Demos Group Practice,
  Disease Management, CMP

9
Rewarding Outpatient Quality

• Improve outcomes for patients with diabetes

• Redesign processes of care to close the Quality
  Chasm

• Improve outcomes for patients with CVDs

What BTE Did Differently

• Physicians As Co-Designers Customers Not
  Stakeholders
• What Is An Acceptable Measure?
• What Is Reward?
• Structured Six Sigma Process DFSS
• Actuarial analyses to Define Business Case

10
An Effort To Cross the Chasm Bridges To
Excellence
Diabetes Care Link
Using Evidence-Based Literature and Actuarial
Analysis

• Diabetes
• Quality Care Saves 350/Diabetic/Year
• Purchaser Keeps 175
• Physicians Get 100/Patient Incentives 75

All Payers For Practice with 100 Diabetics -
10,000/Year For Diabetes Clinic with 1,000
Diabetics - 100,000/Year
11
Physician and Practice Self-Reported Measures
Managed Through NCQA
Structure (PPC)

• Patient safety e-prescribing
• Guideline-driven care EHRs
• Focus on high-cost patients Care coordination
• Improved compliance Patient education support

Process Outcomes (DPRP HSRP)

• HbA1Cs tested and controlled
• LDLs tested and controlled
• BP tested and controlled
• Eye, Foot and Urine exams

• LDLs tested and controlled
• BP tested and controlled
• Use of aspirin
• Smoking cessation advice

12
Engaging ConsumersBeyond Create, Connect,
Support
13
Engaging Consumers With Incentives

• Incentives for Good Behavior
• BTE Encourages Chronically Ill to Focus on
  Treatment Compliance
• Rewards of up to 50 Annually for Lower LDL or
  HgBA1C
• Incentives to Seek Out Quality Focused Providers
• A Recent Internal Survey Indicated That 20 of
  Patients Would Shift Hospitals (Provided They
  Were of Same Quality) for 100 Difference in Cost
• Another 25 Would Shift With an Incentive of
  About 500
• Reduced Co-pay for NCQA-Recognized Docs
• Waive Co-pays for NQF/leapfrog-Recognized
  Hospitals

14
Provider Evaluation
Quickly gives the consumer a high-level roll-up
of the physicians overall performance
Gives the consumer the ability to distinguish
objective and subjective measures
15
Recommendations

• Investment in Ambulatory IT
• Common Measures Are Critical NQF
• Physicians As Partners
• Design Measures With Rural Realities in Mind

16
Appendix
17
Summary of Expected Impact From CIS Measures
Clinical Information Systems/ Evidence-Based
Medicine
Targeted Quality Improvements
Business Case

• Basic Registries and Follow-up
• Type of registry used for chronic conditions
• Percentage of patients in registry
• Use of registry to identify patient populations
• Use of paper or electronic system to track and
  follow up on referrals and test results

• Registries and Follow-up
• Better coordination of care with other
  practitioners
• Better adherence to treatment protocols
• Some reduced ADEs
• Some reduction in overuse of lab and radiology
  tests

• Bodenheimer T, Wagner EH, Grumbach K, Improving
  Primary Care for Patients with Chronic Illness
  The Chronic Care Model JAMA 2002 Oct 9
  288(14)1775-9 Oct 16 288(15)1909-14.
• Jones DL, Kroenke K, Landry FJ, Tomich DJ, Ferrel
  RJ. Cost savings using a stepped-care prescribing
  protocol for nonsteroidal anti-inflammatory
  drugs. JAMA 1996 275(12)926-30.

• Electronic Systems for Rx and Tests
• Significant reduction in ADEs
• Higher compliance with standards of care
• Reduction in overuse of tests
• Reduction in overuse of inappropriate medications
• Greater coordination of care with other
  practitioners

• Honigman B, Lee J, Rothschild J, Light P, Pulling
  RM, Yu T et al. Using computerized data to
  identify adverse drug events in outpatients. J Am
  Med Inform Assoc 2001 8(3)254-66.
• Harpole LH, Khorasani R, Fiskio J, Kuperman GJ,
  Bates DW. Automated evidence-based critiquing of
  orders for abdominal radiographs impact on
  utilization and appropriateness. J Am Med Inform
  Assoc 1997 4(6)511-21.

• Electronic Registries, Rx and Test Ordering
• Types of patient information in registry
• Capabilities of an electronic system for
  prescriptions and tests
• Use of electronic system for ordering
  prescriptions and checking for safety
  efficiency
• Use of electronic system to order and retrieve
  tests
• Use of electronic system to track missing test
  results, distinguish abnormal results and prompt
  follow up on test results

• Lobach DF, Hammond WE, Computerized decision
  support based on a clinical practice guideline
  improved compliance with care standards Am J Med
  1997 Jan 102(1) 89-98.
• Dexter PR, Perkins S, Overhage JM, et al, A
  computerized reminders system to increase the use
  of preventive care for hospitalized patients, N
  Engl J Med 2001 Sept 27 345(13) 965-70.
• Overhage JM, Tierney WM, Zhou XH, et al, A
  randomized trial of corollary orders to prevent
  errors of ommission, J Am Med Inform Assoc 1997
  Sept-Oct 4(5) 364-75.

• Use of Electronic Medical Record
• Reduction in ADEs
• Significant compliance with standards of care
• Significant reduction in overuse of tests
• Significant reduction in overuse of inappropriate
  medications
• Significant increase in coordination of care with
  other practitioners

• Electronic Medical Records
• Types of patient information in an EMR
• Percentage of patients who have information in
  the EMR
• EMRs capability to report across practice on
  multiple fields
• EMRs capability to use decision support to
  prompt physician interventions
• EMRs capability to capture services ordered,
  delivered or paid
• Use of EMR to track referrals and test results

18
Summary of Expected Impact From Care Management
Measures
Targeted Defects
Business Case
Care Management

• Harris LE, Luft FC, Rudy DW, et al, Effects of
  multidisciplinary case management in patients
  with chronic renal insufficiency Am J Med 1998
  Dec105(6)464-71. .
• Riegel B, Carlson B, Kopp Z, et al, Effect of a
  standardized nurse case-management telephone
  intervention on resource use in patients with
  chronic heart failure Arch Intern Med 2002 Mar
  25162(6)705-12..

• Chronic Conditions
• Reduction in ACSC admissions
• Increase in compliance with protocols
• Better control of chronic conditions

• Care of Chronic Conditions
• Identification of the practices top three
  chronic conditions
• Structured process for disease management for
  patients with the top three conditions
• Use of resources to assist with medication
  compliance, appointments and barriers to care

• Preventable Admissions
• Reduced ER and Hospital admissions

• Arnold Chen, Randall Brown, Nancy Archibald,
  Sherry Aliotta, and Peter D. Fox, "Best Practices
  in Coordinated Care., Document No. PR00-10,
  Mathematica Policy Research, Inc., March 2000.
• Issakidis C, Sanderson K, Teesson M, et al,
  Intensive case management in Australia a
  randomized controlled trial Acta Psychiatr Scand
  1999 May99(5)360-7.

• Preventable Admissions
• Using data to identify patients who are at risk
  for emergency admissions
• Identification of the reasons and prevalence of
  emergency admissions
• Structured system to prevent emergency admissions

• Lobach DF, Hammond WE, Computerized decision
  support based on a clinical practice guideline
  improved compliance with care standards Am J Med
  1997 Jan 102(1) 89-98.
• Dexter PR, Perkins S, Overhage JM, et al, A
  computerized reminders system to increase the use
  of preventive care for hospitalized patients, N
  Engl J Med 2001 Sept 27 345(13) 965-70.
• Overhage JM, Tierney WM, Zhou XH, et al, A
  randomized trial of corollary orders to prevent
  errors of ommission, J Am Med Inform Assoc 1997
  Sept-Oct 4(5) 364-75.

• High-Risk Patient Care
• Reduced ER and Hospital admissions
• Increased compliance with treatment protocols
• Increased adherence to guidelines

• Care of High-Risk Medical Conditions
• Resources for managing patients with high-risk
  conditions
• Number and percent of patients who receive
  high-risk care management
• Contents of the high-risk care management program
• Qualifications of the high-risk care manager
• Types of information in database of patients with
  high-risk conditions
• Frequency of communication between physician and
  care manager
• Frequency of communication between care manager
  and patient

19
Summary of Expected Impact From Patient
Ed/Support Measures
Patient Education and Support
Targeted Defects
Business Case

• Freemantle N, Harvey EL, Wolf F, et al, Printed
  educational materials effects on professional
  practice and health care outcomes (Cochrane
  Review) The Cochrane Library, Issue 4, 2001.
• Gonzales, R, Steiner JF, Lum A, et al,
  Decreasing Antibiotic Use in Ambulatory
  Practice Impact of a Multidimensional
  Intervention on the Treatment of Uncomplicated
  Acute Bronchitis in Adults JAMA 1999 Apr
  28281(16)1512-9 .

• Educational Resources
• Increase in compliance with protocols
• Better control of chronic conditions

• Educational Resources
• Assessment of patient language preferences and
  risk factors
• Identification of preferred languages in patient
  population
• Provision of educational resources in preferred
  languages for risk factors and chronic conditions
  

• Risk Factors and Chronic Conditions
• Reduced ER and Hospital admissions

• Stone EG, Morton SC, Hulscher ME, et al,
  Interventions that increase use of adult
  immunization and cancer screening services A
  Meta-Analysis, unpublished draft.
• OBrien T, Oxman AD, Davis DA, et al,
  Educational outreach visits effects on
  professional practice and health care outcomes
  (Cochrane Review) The Cochrane Library, Issue 4,
  2001, Oxford Update Software.

• Referrals for Risk Factors Chronic Conditions
• Percent of patients who have specific risk
  factors
• Provision of referrals for education support to
  patients with risk factors and chronic conditions

• Lenert LA, Cher DJ, Use of meta-analytic results
  to facilitate shared decision making, J Am Med
  Inform Assoc 1999 Sept-Oct6(5)412-9 .
• OConner A, Using patient decision aids to
  promote evidence-based decision making
  Editorial, ACP Journal Club 2001
  July-Aug135(1)A11-2 .
• OConner AM, Stacey D, Rovner D, et al, Decision
  aids for people facing health treatment or
  screening decisions Review Cochrane Database of
  Systematic Reviews, Issue 3, 2001.

• Quality Evaluation and Improvement
• Reduced ER and Hospital admissions
• Increased compliance with treatment protocols
• Increased adherence to guidelines

• Quality Measurement and Improvement
• Identification of opportunities for improving
  outcomes or processes
• Setting goals for performance for identified
  opportunities of improvement
• Measurement of performance and identification of
  goals not met
• Implementation of improvement activities

20
Summary of Physician Office Link Modules and
Standards
Clinical Information Systems/ Evidence-Based
Medicine
Patient Education and Support
Care Management

• Basic Registries and Follow-up
• Type of registry used for chronic conditions
• Percentage of patients in registry
• Use of registry to identify patient populations
• Use of paper or electronic system to track and
  follow up on referrals and test results

• Educational Resources
• Assessment of patient language preferences and
  risk factors
• Identification of preferred languages in patient
  population
• Provision of educational resources in preferred
  languages for risk factors and chronic conditions
  

• Care of Chronic Conditions
• Identification of the practices top three
  chronic conditions
• Structured process for disease management for
  patients with the top three conditions
• Use of resources to assist with medication
  compliance, appointments and barriers to care

Pts 10 10 40 40
Pts 30 35 35
Pts 10 45 45
100
100
100

• Electronic Registries, Rx and Test Ordering
• Types of patient information in registry
• Capabilities of an electronic system for
  prescriptions and tests
• Use of electronic system for ordering
  prescriptions and checking for safety
  efficiency
• Use of electronic system to order and retrieve
  tests
• Use of electronic system to track missing test
  results, distinguish abnormal results and prompt
  follow up on test results

• Referrals for Risk Factors Chronic Conditions
• Percent of patients who have specific risk
  factors
• Provision of referrals for education support to
  patients with risk factors and chronic conditions

• Preventable Admissions
• Using data to identify patients who are at risk
  for emergency admissions
• Identification of the reasons and prevalence of
  emergency admissions
• Structured system to prevent emergency admissions

Pts 10 20 40 10 20
Pts 50 50
Pts 20 20 60
100
100
100

• Electronic Medical Records
• Types of patient information in an EMR
• Percentage of patients who have information in
  the EMR
• EMRs capability to report across practice on
  multiple fields
• EMRs capability to use decision support to
  prompt physician interventions
• EMRs capability to capture services ordered,
  delivered or paid
• Use of EMR to track referrals and test results

• Quality Measurement and Improvement
• Identification of opportunities for improving
  outcomes or processes
• Setting goals for performance for identified
  opportunities of improvement
• Measurement of performance and identification of
  goals not met
• Implementation of improvement activities

• Care of High-Risk Medical Conditions
• Resources for managing patients with high-risk
  conditions
• Number and percent of patients who receive
  high-risk care management
• Contents of the high-risk care management program
• Qualifications of the high-risk care manager
• Types of information in database of patients with
  high-risk conditions
• Frequency of communication between physician and
  care manager
• Frequency of communication between care manager
  and patient

Pts 10 20 30 30 5 5
Pts 20 20 20 40
Pts 5 5 30 10 15 5 30
100
100
100