New York Quality Alliance Pay forPerformance Physician Alliance

1
New York State Demonstration Grant Pay for
Performance The New York Quality
Alliance Performance Measurement to Drive
Quality of Care
NY Chapter of the American College of Physicians
and the Physician Alliance
2
Presentation Outline

• Health Care Quality The Case for Change
• Pay for Performance as a Driver for Change
• New York State Department of Health Demonstration
  Projects
• New York Quality Alliance (NYQA)
• Physician Alliance (PA)
• Chartered Value Exchanges The Next Wave

3
Learning Objectives

• The physician will understand the extent of
  concerns about the quality, cost availability
  of health care services in the US.
• The physician will become familiar with national
  organizations addressing health care quality and
  learn about standards for development and use of
  performance (quality) measures The physician
  will understand the potential benefits and
  limitations of performance measurement and
  pay-for-performance programs.
• The physician will learn about the New York
  State Department of Health P4P projects and be
  able to define the terms New York Quality
  Alliance (NYQA) and the Physician Alliance (PA).
• The physician will understand Chartered Value
  Exchanges and the four cornerstones of value
  driven health care.    
• The physician will understand the specifics
  regarding the NYQA/PA and their role within
  the NYDOH Grant.
• The physician will be educated regarding the 10
  HEIDIS measures that will be utilized in the
  NYSDOH P4P Grant including their specifications.
  
• The physicians will be provided information
  regarding best practice guidelines for the
  selected measures including, where available,
  tools to facilitate provision of efficient
  effective care, complete documentation and
  accurate billing. 

4

• The Need to Change

5
Why The Status Quo is Not Acceptable

• Costs continue to rise
• Over 47 million citizens are without insurance
• No clear association between spending and quality
• Perception that current payment methodologies are
  misaligned- pay the same for care regardless of
  the quality of care provided. Pay for Performance
  (performance based reimbursement) programs are
  designed to align incentives

6
The Needs Of The Uninsured Are Not Being Met

• Declines in health insurance coverage have been
  recorded in all but four years since 1994.
• 1994 36.5 million nonelderly individuals were
  uninsured
• 2006 46.5 million nonelderly individuals were
  uninsured
• In spite of substantial growth of the Medicaid
  population
• 83 of uninsured are from working families
• Additional cost of the uninsured over 100
  billion annually
• Worse health outcomes for the uninsured
• 25 increase in mortality
• Cancer diagnosed in later stages
• Use of ER for routine care

Sources Agency for Healthcare Quality and
Research American College of Physicians,
Employee Benefit Research Institute
7
2005 16.0
19294
Source CMS
8
Source Congressional Budget Office report, The
Long-Term Outlook for Health Care Spending, Nov.
13, 2007
9
Health care outstrips inflation
Source Kaiser Family Foundation (2005)
10
(No Transcript)
11
(No Transcript)
12
Average 54.9
Source McGlynn, et. al., The quality of health
care delivered to adults in the United States, N
Engl J Med 2003 3482635-45
13
National Health Care Spending 2005

• 2 trillion (6,697 per capita)
• Growth higher than inflation for decades
• 6.9 increase from 2004
• 16.0 of GDP
• Highest in the world
• Other developed countries 8-12
• 7th largest economy in the world
• Medicare 408 billion
• Medicaid 291 billion

Figures in actual dollars. Data from CMS
14
The Future

• Health Care spending in 2016
• 4.1 trillion
• 20 of GDP
• Annual rate of increase 6.5-7.0
• Estimate based on projection of current trends
• Assumes
• optimistic economic projections
• conservative spending projections
• no change in fundamental structure of the system
• Medicare will grow 7.5-9.0 annually
• Unknown cost of new technologies and standards of
  practice
• Implantable defibrillators
• Apo-A1 Milano
• 64-slice CT scanners for cardiac disease

Data from CMS reported in Poisal, JA. et. al.,
Health Spending Projections Through 2015, Health
Affairs web exclusive Feb 21, 2007
15
The New Vision

• The Value Equation
• Are we currently getting value?
• Medicare spending 50 in the last year of life
• Many studies more Medicare spending does not
  prolong life, improve quality of life or result
  in higher quality of care
• US ranks low vs. other countries in commonly
  accepted measures of health care quality and
  efficiency

16
The Future is Here

• Clearly, the focus of the health care debate is
  moving toward demanding efficient and effective
  care and only paying when such care is provided.
  Quality measurement is embraced as fundamental
  to quality improvement and increasingly Pay for
  Performance is being investigated and implemented
  in multiple forms.

17
The Field of Quality Measurement Reporting is
Getting Crowded

• National Committee for Quality Assurance (NCQA)
• -- Founded 1990 to ensure quality of care to
  health plan members, develops Health
  Effectiveness Data Information Set (HEDIS)
  measures
• -- www.ncqa.org
• New York Quality Assurance Reporting Requirements
  (QARR)
• NYS Department of Health (NYSDOH) collects QARR
  measures from all NY managed care plans health
  plans, based on HEDIS since 1996
• www.nyhealth.gov/health_care/managed_care/reports/
  
• National Quality Forum (NQF)
• -- Created in 1999 to develop a national
  strategy for health care quality measurement and
  reporting.
• -- A not-for-profit, public-private,
  membership organization with broad participation
  from all sectors of the health care system
  including consumers
• -- www.qualityforum.org/about/

18
Quality Measurement Reporting

• Institute of Medicine Reports
• To Err is Human, 2000 www.iom.edu/?id12735
• Crossing the Quality Chasm, 2001
  www.iom.edu/?id12736
• AMA Physician Consortium for Performance
  Improvement
• -- Established 2000 to develop performance
  measures for physicians from evidence-based
  clinical guidelines for select clinical
  conditions
• -- Broad representation from the house
  of medicine with AHRQ and the Center for
  Medicaid and Medicare Services (CMS)
• -- www.ama-assn.org/ama/pub/category/294
  6.html
• Hospital Quality Alliance (HQA)
• Established 2002 to make information about
  hospital performance accessible to the public and
  to encouraging efforts to improve quality
• www.hospitalqualityalliance.org
  www.HospitalCompare.hhs.gov

19
Quality Measurement Reporting

• AQA Alliance
• In 2004 medical specialty societies, insurance
  plans and the Agency for Healthcare Research and
  Quality (AHRQ), joined to determine how to most
  effectively and efficiently improve performance
  measurement, data aggregation, and reporting in
  the ambulatory care setting
• Originally known as the Ambulatory Care Quality
  Alliance
• www.aqaalliance.org/
• Quality Alliance Steering Committee (QASC)
• Established in 2006 to develop an overall
  framework for the effective use of standard
  health care quality and cost measures nationwide
• www.brookings.edu/projects/qasc.aspx

20
Quality Measurement Reporting

• Value Driven Health Care Initiative
• Established 2006 by executive order
• Four cornerstones interoperable health
  information technology measure and publish
  quality information measure and publish price
  information promote quality and efficiency of
  care.
• Certified Value Exchanges (CVE) local and
  regional multi-stakeholder collaborative
  organizations working to improve quality and
  value in health care by measuring the performance
  of local health care providers and reporting
  these findings publicly.
• NYQA designated one of 14 nationally recognized
  CVEs
• www.hhs.gov/valuedriven/index.html
• 64-slice CT scanners for cardiac disease

21

• Pay For Performance

22
Pay For Performance

• Pay-for-performance programs are growing, but
  there is little evidence on their effectiveness
  or of their potential unintended consequences and
  effects on the patient-physician relationship.
• Pay-for-performance has the potential to help
  improve the quality of care if it can be aligned
  with the goals of medical professionalism.
• Annals Int Med 2007146792-794

23
Pay For -Performance

• It is no longer enough to take good care of the
  patient in front of you. To improve results, we
  must find ways to help patients who do not come
  to the office regularly. Keeping track of all
  this data requires a whole new set of skills and
  resources this is new work, it costs time and
  money and it has to be compensated.
• Dr Janet (Jessie) Sullivan, Chief Medical Officer
  of Hudson Health Plan)

24
PROFESSIONAL ISSUES Pay-for-performance programs
stir debate Ethics Forum. Nov. 6, 2006.
25
Examples of P4P Initiatives

• CMS
• Hospital Core Measures
• PQRI
• Ambulatory Core Measures
• NY State
• NYQA Grant and other similar pilots
• Commercial and Medicaid Health Plans in NY
• Purchaser/Employer
• Bridges to Excellence

26
Pay For Performance Issues To Consider

• Measures
• Data collection
• Data validation/reconciliation
• Reports
• Impact on care and cost, desired and otherwise

27
Measures

• Ideal Measures
• Valid
• Evidence based
• Reliable
• Identify real differences in provider quality
• Must be risk adjusted
• Actionable
• Measure what is intended
• No unintended consequences
• Measures should be Feasible

28
Measure Collection

• Types of Measures
• Process
• Outcomes
• Structural
• Data sources
• Administrative/claims and billing data
• Medical Record Abstraction
• Electronic clinical data EHR, registries, RHIOS
• Hybrid combinations
• Data reconciliation
• Opportunities to review and correct errors prior
  to publication
• Discrepancies between data sources
• Missing Data
• Transcription and coding errors

29
Reports

• Attribution issues
• Whose patient is it?
• Reports for group vs. individual
• Small numbers
• Samples too small for valid conclusions
• Report timeliness
• Time for claims to be filed and processed
• Time for abstraction, aggregation, processing
  data
• Report actionable
• Identified vs de-identified data
• Current but incomplete vs. complete but
  out-of-date

30
Potential Benefits

• System
• Reduce costs and improve quality
• underuse, overuse, misuse
• Physician
• Economic
• Quality of Care
• Preparing for the Future

31
Ethical Concerns

• Inequitable impact
• Inefficient use of resources and tendency to
  focus on efficiency (cost) not other facets of
  quality
• Unreliable (therefore unfair) measures
• Concern that Pay for performance is
  deprofessionalizing
• Matthew Wynia, MD, MPH
• Institute for Ethics at the American Medical
  Association

32
Inequitable impact

• Physician
• Large practices with HIT will win
• Those already doing well will win
• Patient
• Non-adherent patients will be shunned
• Minorities/elderly/immigrants will be shunned

33
P4P Aimed At Hitting Target Performance Level
Might Be Counterproductive
Organizations in this area have little hope of
gaining the bonus
Organizations in this area have an incentive to
improve
Organizations in this area will get the bonus
with no additional work
Quality
P4P Target
34
Will the Vulnerable be Neglected?

• Some evidence from public reporting
• Pt transfers to Cleveland Clinic from NY
  increased 31 after public reporting on CABG,
  sicker patients more likely to be sent. (Omoigui
  1996)
• 59 of internists in PA say harder to find
  surgeon for high risk patients after public
  reporting (Schneider 1996)
• Such programs could also result in the
  de-selection of patients, playing to the
  measures rather than focusing on the patient as
  a whole..
• Annals Int Med 2007146792-794

35
What do physicians say?

• Dr. Brook correctly states that the use of
  physician-specific outcome data would radically
  change how we practice medicine. Based on his
  system, I would assess each patient's risk. If it
  differed dramatically from the "sickness" scale
  that he proposes, I would consider asking the
  patient to seek care elsewhere.
• Stephen Clement, MD, Annals of Intern Med 1994
• If my pay depended on A1c values, I have 10-15
  patients whom I would have to fire. The poor,
  unmotivated, obese and noncompliant would all
  have to find new physicians.
• Physician in a 2006 survey on P4P
• 39 of physicians in this study were willing to
  discharge hypothetical patients who were
  nonadherent or questioned the physicians
  decision-making.
• Farber et al. JGIM 2007

36
Inefficient Use of Resources

• Documentation (rather than quality) improves
• Inappropriate emphasis on whats measured
• Little more for lots more work not enough to
  offset costs of measurement
• Incentives based on a handful of measures of
  quality may encourage physicians to focus their
  efforts on improving quality in the areas
  targeted by the programs, neglecting other
  important aspects of care (Epstein et al. 2004)

37
Unfair Measures Reliability

• Importance of data aggregation
• The largest participating plan in the IHA
  program has about 1.4 million members, less than
  23 of the entire 6.2 million population. Even a
  plan of this size using its own data often lacks
  sufficient sample size to allow for statistical
  reliability. (Integrated Healthcare
  Association, 2006)

38
Unfair Measures Data Reliability

• Assigning responsibility (attribution)
• Medicare beneficiaries see a median of 2 PCPs and
  5 specialists working in 4 different practices
  per year
• 35 of patients visits are with their assigned
  physicians
• 33 change PCP each year
• A PCPs assigned patients are only 39 of the
  Medicare patients they see
• (Pham et al. 2007)

39
Unfair Measures Data Reliability

• Not enough patients per practice for reliable
  results year to year
• Among 232 PCPs, 4 of the variance of their
  diabetic patients outcomes was attributable to
  physician practice patterns
• Reliability of measures never better than 0.40
• Would need gt100 diabetic patients to get
  reliability of 0.80
• Outliers could dramatically improve performance
  by dropping 1-3 patients
• Hofer 1999

40
Impact on the Profession of Medicine

• Doctors shouldnt be motivated by greed
• P4P programs insinuate that the existing moral
  and social incentives for providing excellent
  care are not sufficient that financial
  incentives will succeed where the clinicians
  professional character failed. (Satin,
  2006)i.e., If they work it would be
  embarrassing.
• Increasing external incentives reduces internal
  motivation so the worst problem with P4P would
  be if you ended up with a system where doctors
  only did anything because they were paid for it
  and had lost their professional ethos. Martin
  Rowland, NHS (Health Affairs interview, Sept 2006)

41
A Possible Path to TakeNew York State
Department of Health Demonstration Grant
42
New York State Demonstration P4P Grant

• The legislative intent of the demonstration
  project is to promote the development of pay-for
  performance programs, involving multiple payers
  that achieve increased quality and cost
  effectiveness.
• The legislation extended authority to the
  Commissioner of Health to
• A. Convene a workgroup to delineate the
  ambulatory and inpatient measures of performance
  to be used in the demonstration programs
• B. Oversee a grant program which will provide
  funding to purchaser and provider coalitions to
  establish regional pay-for-performance programs

43
The Process

• The NYS DOH Commissioners Workgroup convened in
  July 2005 . The workgroup consisted of
  representatives from managed care plans,
  hospitals, statewide and regional provider
  associations, payers, labor unions, and
  consumers.
• Charged with seeking consensus on the inpatient
  and ambulatory measures to be included in the
  pay-for-performance demonstrations, the workgroup
  met on four occasions between July and December
  2005.
• In May 2006 DOH issued a RFP making 9.5 million
  available to support demonstration projects for a
  period of two years.
• The workgroup agreed to begin with administrative
  data, but acknowledged that this was just a first
  step and over the long run administrative data
  needed to be replaced with outcome data.

44
Elements of The Demonstration Grant

• To study and test incentive programs, including
  performance-based payments to physicians,
  hospitals and clinics that provide high-quality
  care to their patients.
• The state funding will pay project costs and help
  fund rewards to providers.
• Participating health plans will select the
  incentive structure they use, but typical
  incentives include bonuses or increases in
  reimbursement rates provided to physicians,
  hospitals and clinics based on their performance
  meeting various measures of quality.

45

• The projects are part of the State Health
  Departments efforts to encourage providers and
  insurers to work collaboratively to improve the
  quality of care that is delivered in New York
  State.
• State Health Commissioner Richard F. Daines, M.D.
  said Evidence-based care that improves
  patients ability to live healthier, productive
  lives is crucial to reforming our health care
  system and reducing health care costs. This is an
  area where the public and private sectors can
  work together to foster change.

46
The Four State Demonstration Projects

• Independent Health Association Inc. (Buffalo)
• Taconic Health Information Network and Community
  Regional (THINC RHIO) in Hudson Valley Region)
• Montefiore Medical Center (Bronx)
• New York Health Plan Association (NYHPA)
• This project is a statewide
  collaboration involving 12 health plans Aetna,
  Affinity, CDPHP, Elderplan, GHI HMO, HealthNet,
  HealthNow, HIP, Hudson Health Plan, Independent
  Health Association, MVP, and Oxford. HPA will
  partner with physician, business and consumer
  groups, Capital District hospitals and RHIOs .

47

• New York Health Plan Association (NYHPA)
  Demonstration Grant

48
NYHPA Demonstration Grant Overview

• Goal
• Collaborators
• Structure
• Clinical Measures
• Data Collection/Management/Validation
• Timelines
• Physician Reports
• Incentives

49
NYHPA Demonstration Grant Goals

• Project is to promote patient safety and quality
  of care through the development of
  pay-for-performance programs in New York State.
  
• A two year demonstration Project.
• Brings all the stakeholders together Patients,
  Physicians and Health Plans, and consumer
  advocates.
• Develop policies and procedures for long lasting
  P4P programs in New York.
• Develop a mechanism to have ongoing Dialogue with
  the Health Plans

50
Grant Elements

• The New York State Health Plan Association
  through the grant has created the New York
  Quality Alliance (NYQA), which is a
  multi-stakeholder collaborative partnership that
  will guide the adoption and use of evidence based
  measures to measure, report and drive
  improvements.
• The reports generated under the guidance of NYQA
  will be used in pay for performance programs
  initiated by the Health Plans so that physicians
  will be financially rewarded that have good
  patient outcomes.

51
Grant Elements

• Standardized set of measures for all
  participating Health Plans, so a physician
  collects one data set.
• Establish one set of goals to reach a financial
  incentive (Because of anti-trust concerns, the
  amount of the financial incentives for each
  indicator will be established by the individual
  health plan.)
• Data Collection will be administrative billing
  data.
• Subcontract with NYACP to educate physicians
  regarding the Demonstration Grant and to support
  development of and staff the Physician Alliance

52
Clinical Measures

• The project will use tested and familiar
  HEDIS/QARR measures to simplify data collection
  only administrative (claims) data will be used.
• Preventive Care Domain (womens services)
• Breast Care Screening
• Chlamydia Screening
• Cervical Cancer
• Heart Disease Domain
• Persistence of Beta-blocker therapy post MI
• Diabetes Domain
• HbA1C Testing
• Lipid Measurement
• Urine Protein Screening
• Eye Exam in Diabetics
• Appropriate Antibiotic Use (pediatric)
• Appropriate Treatment for Children with Upper
  Respiratory Infection (URI)
• Appropriate Testing for Children with Pharyngitis

53
Time Line For NYDOH Grant

• 2007 will be the baseline year a baseline report
  will be distributed toward the end of 2008.
  (Dont wait until then to start!)
• 2008 will be the measurement year. Thats now,
  the clock is ticking.
• The data collection will consist of health plan
  administrative data that will be supplemented
  with an adjusted medical record factor, such as
  the hybrid claims adjustment factor utilized by
  the Massachusetts's Health Quality Partner (
  MHQP).

54
Grant Incentives

• Grant funding is available due to matching funds
  being provided by payers participating in the
  demonstration project and the DOH.
• The Health Plans have committed 8,740,968 in
  potential incentives.
• The NYS Department of Health have awarded
  1,379,278 in matching incentives.

55
Grant Incentives

• All Plans will collect data on all 10 measures
• All plans will utilize the same report for
  determining performance payment
• The determination for achieving payment will vary
  from plan to plan

56
Bonus Payments

• Health plan specific payments are within the
  control of the plans due to
• ANTITRUST concerns

57

• New York Quality Alliance
• multi-stakeholder collaborative partnership
  created within the Grant that will guide the
  adoption and use of evidence based measures to
• Measure
• Report
• Drive improvements.

58
NYQA Collaborators

• PROVIDER GROUPS
• NY Chapter of the American College of Physicians
• NYS Academy of Family Physicians
• Medical Society of the State of NY
• NY Medical Group Mgmt. Association
• Hudson Headwaters Health Network
• Institute for Urban Family Health
• Community Health Care Association of NYS
• CONSUMER GROUPS
• American Heart Association
• Niagara Health Quality Coalition
• NY Diabetes Coalition
• Center for Medical Consumers

• BUSINESS
• Business Council of NYS
• New York Business Group on Health
• HEALTH PLANS
• Aetna
• Affinity Health Plan
• CDPHP
• Elderplan
• GHI HMO
• Health Net
• HealthNow NY
• HIP of New York
• Hudson Health Plan
• Independent Health
• MVP Health Care
• Oxford Health Plans

59
NYQA Work Group Structure and Function

• A work in progress
• Workgroups
• Governance
• Data Management
• Project Evaluation
• Operations
• Legal
• Physician Alliance

60
NYQA Structure and Function

• Governance Workgroup
• Develop general operating rules for the NYQA
• Synthesize the materials and produce general
  operating principles until a formal structure is
  in place
• Develop a mission statement and framework to
  allow the project to meet the grant deliverables
  and ensure an open and transparent process
• Development of a permanent structure (i.e.
  bylaws, tax status) that will enable to NYQA to
  continue beyond the DOH grant funded component

61
NYQA Structure and Function

• Data Management Workgroup
• Review the responses to the Request for
  Information from potential data mangers and
  assist in the selection of a NYQA project vendor
  
• Responsible for issues related to the data inputs
  and outputs as well as issues related to
  performance benchmarking, inpatient measurement
  and reporting for the AMI project component and
  development of a matching funds allocation
  methodology

62
NYQA Structure and Function

• Project Evaluation Workgroup
• Develop the questions to be addressed to the
  project evaluator.
• Develop the desired framework for the project
  evaluation and will work to define the
  deliverables from the evaluator that will form
  the contract.
• Monitor the evaluation progress and assist with
  the ongoing evaluation data collection and
  analysis.

63
NYQA Structure and Function

• Operations Workgroup
• Responsible for vetting project component issues,
  not addressed by the other workgroups that will
  need to be addressed by the voting members of the
  NYQA
• Legal Workgroup
• Develop standard Business Associate Agreements
  and Data Use Agreements.

64
NYQA Physician Alliance

• Structure and Membership
• Formed in 2007, the Physician Alliance,
  spearheaded by the New York Chapter of the
  American College of Physicians consists of a
  diverse geographically dispersed group of primary
  care physician organizations across New York
  State.
• The Alliance membership is composed of nine
  physician representatives from the American
  College of Obstetrics and Gynecology, the
  American Academy of Pediatrics, New York Chapter
  American College of Physicians (Internal
  Medicine), the New York Chapter of the American
  Academy of Family Physicians and the Medical
  Society of the State of New York.

65
NYQA Physician Alliance

• Goals of Physician Alliance
• Short term, the PA is committed to working
  jointly with the NYQA to develop fair and
  reasonable practices of data collection and
  scoring standards for the P4P demonstration
  project, funded by New York State over the next
  two years.
• The long range goal of the PA will be to work
  with the NYQA and other entities to develop fair,
  reasonable and SUSTAINABLE policies and
  procedures for quality improvement truly impact
  patient care and safety in a cost effective
  fashion.

66
NYQA Physician Alliance

• Responsibilities of Physician Alliance
• Define and promote the use of nationally
  recognized best practices for the 10 selected
  clinical measures adopted from the National
  Committee for Quality Assurance Health Plan
  Employer Data and Information Set (NCQA/ HEDIS)
  that the health plans have all agreed upon to
  measure and report

67
NYQA Physician Alliance

• Responsibilities (CONTINUED)
• Develop the core curriculum for NYQA and with
  NYACP provide education for Primary care
  physicians.
• The core curriculum will include the description
  of the P4P Grant, NYQA and the PA, best practice
  materials and administrative specifications. The
  training will involve web-based materials,
  performance improvement tools and checklists that
  will allow practices the ability to evaluate
  themselves. The educational materials will be
  available on the web, CD and in traditional
  lectures modalities.

68
NYQA Physician Alliance

• Responsibilities (CONTINUED
• Represent clinicians interest in the development
  of the data collection methodology, measurement
  benchmarking, measurement reports and project
  evaluation
• Provide input to the NYQA on proposed data
  collection methodology and aggregation standards
• Provide input to the NYQA on the adjustment
  factor to be employed for selected HEDIS
  measures
• Identify process improvement activities, develop
  checklists to facilitate implementation of best
  practices and develop corrective action plans to
  assist clinicians with measurement improvement

69
NYQA Physician Alliance

• Responsibilities (CONTINUED
• Work with the NYQA to develop fair, reasonable
  and sustainable policies and procedures for
  quality improvement designed to impact patient
  care and safety in a cost efficient fashion.
• Education to Improve coding/compliance so that
  the correct information can be obtained form
  billing data.
• Development of tools to document compliance
• Conduct 30 total presentations (10 hospital Grand
  Rounds and 20 conferences, meetings or other
  educational events).

70
Clinical Measures

• The project will use tested and familiar
  HEDIS/QARR measures to simplify data collection
  only administrative (claims) data will be used.
• Preventive Care Domain (womens services)
• Breast Care Screening
• Chlamydia Screening
• Cervical Cancer
• Heart Disease Domain
• Persistence of Beta-blocker therapy post MI
• Diabetes Domain
• HbA1C Testing
• Lipid Measurement
• Urine Protein Screening
• Eye Exam in Diabetics
• Appropriate Antibiotic Use (pediatric)
• Appropriate Treatment for Children with Upper
  Respiratory Infection (URI)
• Appropriate Testing for Children with Pharyngitis

71
Preventive Health(Indicators for Women)

• Chlamydia screening Women 1625 years as of
  December 31 of the measurement year who were
  identified as being sexually active and had at
  least one Chlamydia test
• Cervical Cancer Women 2164 years of age who
  received one or more Pap tests to screen for
  cervical cancer as of December 31 of the
  measurement year.
• Breast Care Screening Women 4269 years as of
  December 31 of the measurement year who have had
  a mammogram to screen for breast cancer during
  the measurement year and the year prior to the
  measurement year

72
Indicators for Heart Disease

• Persistence of Beta-blocker Therapy After a Heart
  Attack
• The percentage of members 18 years of age and
  older during the measurement year who were
  hospitalized and discharged alive from July 1 of
  the year prior to the measurement year to June 30
  of the measurement year with a diagnosis of acute
  myocardial infarction and who received persistent
  beta-blocker treatment for six months (180 days)
  after discharge as evidenced by pharmacy claims
  data (prescriptions filled.)

73
Indicators for Diabetes

• (For members aged 18-75 identified with diabetes
  based on an encounter during the measurement
  year with either ICD-9 diagnosis codes 250.xx,
  357.2, 362.0x, 366.41, 648.0x or DRG 294,295)

• HbA1C TestingOne A1C test as of December 31st of
  the reporting year evidenced by CPT code 83036
  or 83037 or CPT Category II Code 3044F, 3045F,
  3046F or 3047F or LOINC code 4548-4, 4549-2 or
  17856-6.
• Lipid MeasurementOne LDL-C test as of December
  31st of the reporting year as evidenced by CPT
  codes 80061,83700, 83701, 83704, 83716 0r 83721
  or, CPT Category II code 3084F, 3049F or 3050F
  or, LOINC 2089-1,12773-8, 13457-7, 18261-8,
  18262-6, 22748-8, 24331-1 or 39469-2.
• Nephropathy Screening One nephropathy
  (microalbumin) test as of December 31st of the
  reporting year as evidenced by listed CPT, CPT
  Cat II, or LOINC codes or, evidence of
  nephropathy indicated by a positive macroalbumin
  test confirmed by automated laboratory result
  data or evidence of ACE inhibitor/ARB treatment
  or treatment for nephropathy indicated by listed
  CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG
  codes.
• Eye Exam in Diabetics A retinal or dilated eye
  exam by an eye care professional as of December
  31st of the reporting year or a negative retinal
  exam by an eye care professional in the prior
  year.

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Indicators for Children

• Appropriate Treatment for Children with Upper
  Respiratory Infection (URI)The percentage of
  children 3 months 18 years of age who had an
  encounter with a diagnosis of acute upper
  respiratory infection (ICD9-CM code 460 or 465)
  and who were not dispensed an antibiotic for the
  episode. Children with a listed competing
  diagnosis or who received antibiotics in the
  prior 30 days are excluded.
• Appropriate Testing for Children with Pharyngitis
  Percentage of children 2-18 years of age who
  had an encounter with only a diagnosis of
  pharyngitis (ICD-9-CM codes 462, 463 or 034.0),
  who were dispensed an antibiotic and who
  received a group A streptococcus test for the
  episode evidenced by listed CPT or LOINC codes.
  Children who received antibiotics in the prior 30
  days are excluded.

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Data Collection, Management and Validation

• A Data Manager (vendor) will aggregate and
  analyze the participating health plan claims and
  lab information and create measurement reports.
  The data from all NYS P4P Demonstration projects
  will be forwarded to IPRO for analysis.
• Public Reporting is not a component of this
  demonstration project
• The Physician Alliance will be involved in all
  aspects of data collection, management and
  appeals process.

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How to Succeed with Performance Measures

• 1 Designate an office Quality Manager,
• --someone to be responsible for performance
  measurement
• 2 Bill all services provided
• 3 Code accurately and completely
• -- review encounter forms to be sure that codes
  used will count.
• -- verify with your billing company that
  correct codes are billed.
• 4 Request current actionable reports from
  plans and review baseline NYQA report
• -- to improve coding and billing practice
• -- to identify practice patterns not consistent
  with measured standards
• -- to identify patients who need to be called
  in for care
• 5 For future success, reinvest bonus money
• -- to strengthen skills and resources related
  to data management
• -- consider implementation of a registry or an
  electronic health record with a registry
  function. .

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Participating Health Plans
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Summary

• The status quo is not sustainable cost, quality,
  access
• Performance (Quality) Measurement is increasingly
  seen nationally and locally as a cornerstone of
  building a better health care delivery system
• Pay-for-performance programs have been embraced
  by CMS and health plans and are increasingly
  common
• The House of Medicine is already extensively
  present on the national scene The Physicians
  Alliance of the NYQA gives New York physicians a
  voice and a vote in how measures are implemented
  locally
• To survive and thrive learn to manage data as
  well as you manage patients.

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Why Should Physicians Be Involved?

• You have physician representation on the project
  and input.
• Physicians will be working with the Health plans
  to adopt FAIR and REASONABLE principles for
  P4P.
• Get in on the Ground Floor and Help shape the
  future!
• Next steps for physicians.
• Physician participation and support is critical.

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Value Exchanges

• NYQA has been designated a Certified Value
  Exchange

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Value Exchanges

• Multi-stakeholder collaborative organizations
  that are working to improve quality and value in
  health care by measuring the performance of local
  health care providers and reporting these
  findings publicly.
• The plan would be to bring the local
  collaboratives into a nation-wide system, and the
  collaboratives would use nationally-recognized
  standards to measure and improve quality of care
  in their local areas.
• The chartered collaboratives would be called
  Value Exchanges

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Value Exchanges

• The Exchanges could also pioneer new quality
  improvement strategies and share results through
  the Learning Network.
• The new system would be administered by HHS'
  Agency for Healthcare Research and Quality
  (AHRQ). AHRQ Director Carolyn M. Clancy, M.D.,
  said providers would lead in the development of
  standards.
• Advance the four cornerstones of Value-Driven
  Health Care.

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Four Cornerstones of Value-Driven Health Care

• Interoperable Health Information Technology
  (Health IT Standards)
• Interoperable health information technology has
  the potential to create greater efficiency in
  health care delivery. 
• develop standards that enable health information
  systems to communicate and exchange data quickly
  and securely to protect patient privacy. 
• all health care systems and products should meet
  these standards as they are acquired or
  upgraded.  

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Four Cornerstones of Value-Driven Health Care

• Measure and Publish Quality Information (Quality
  Standards)
• To make confident decisions about their health
  care providers and treatment options, consumers
  need quality of care information. 
• Similarly, this information is important to
  providers who are interested in improving the
  quality of care they deliver. 
• Quality measurement should be based on measures
  that are developed through consensus-based
  processes involving all stakeholders, such as the
  processes used by the AQA (multi-stakeholder
  group focused on physician quality measurement)
  and the Hospital Quality Alliance.

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Four Cornerstones of Value-Driven Health Care

• Measure and Publish Price Information (Price
  Standards)
• To make confident decisions about their health
  care providers and treatment options, consumers
  also need price information.
• Efforts are underway to develop uniform
  approaches to measuring and reporting price
  information for the benefit of consumers. 
• In addition, strategies are being developed to
  measure the overall cost of services for common
  episodes of care and the treatment of common
  chronic diseases. 

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Four Cornerstones of Value-Driven Health Care

• Promote Quality and Efficiency of Care
  (Incentives)
• All parties - providers, patients, insurance
  plans, and payers - should participate in
  arrangements that reward both those who offer and
  those who purchase high-quality,
  competitively-priced health care. 
• Such arrangements may include implementation of
  pay-for-performance methods of reimbursement for
  providers or the offering of consumer-directed
  health plan products, such as account-based plans
  for enrollees in employer-sponsored health
  benefit plans.

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Value Exchanges

• Participation as a Chartered Value Exchange
  offers several benefits.
• Members can join their peers in a nationwide
  Learning Network sponsored by the Agency for
  Healthcare Research and Quality (AHRQ). Often
  called communities of practice,
• A Learning Network provides peer-to-peer learning
  experiences through facilitated meetings, both
  face to face and on the Web. The network also
  features tools, access to experts, and an ongoing
  private Web-based knowledge management system.

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Value Exchanges

• The Learning Network allows members to
• Share their experiences.
• Identify promising practices.
• Point out gaps where innovation is needed.
• Raise issues for national consensus-building
  organizations
• Provide an on-the-ground perspective to
  participate in setting national priorities for
  improvement.
• Chartered Value Exchanges will have access to
  summary Medicare provider performance results,
  which can be combined with similarly calculated
  private-sector results to produce and publish
  all-payer performance results.