Task%20Force%20on%20Performance%20Assessment,%20Recognition,%20Reinforcement%20and%20Reward%20(PAR3)

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Task Force on Performance Assessment,
Recognition, Reinforcement and Reward (PAR3)

• Pennsylvania Chapter Meeting
• October 12-14, 2007
• Janet Wright MD FACC

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PAR 3

• What
• Why
• Which
• How
• When
• Help

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to foster optimal cardiovascular care and
disease prevention through professional
education, promotion of research, leadership in
the development of standards and Guidelines and
the formulation of health care policy.Measuremen
t and Improvement
ACC Mission Statement

• Define Care Standards Clinical Guidelines
• Define Data Standards Data Standards
• Develop Measures
  Performance Measures
• Appropriateness
  AC
• Measure Quality NCDR
• Improve Quality Take ACTION, D2B

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Par3 Goal Excellence in Performance

• Assessment beyond measurement
• Recognition identification acknowledgment
• Reinforcement lower the hurdles, make case
• Reward heal the healer, restore trust, rational
  reimbursement
• Reporting what to whom for what purpose

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Performance Measurement Today
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Par3 Forces at Work
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Par3 Forces at Work
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Par3 Forces at Work
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Par3 Forces at Work
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Par3 Forces at Work

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Performance Assessment Attitudes

• Passive
• Placid
• Paranoid
• P-----, uh, Livid
• Proactive
• Prepared

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Par3 Composition

• Advocacy Quality Strategic Directions Education
• NCDR Informatics Medical Directors Institute
• Guidelines Perf Measures Data Stds
• Board of Governors CCAs Board of Trustees
• Approp Criteria Practice Administration
• Reps from SCAI, HRS, HFSA, ASNC
• Linkages Physicians Consortium for Performance
  Improvement, AQA, NQF, NCQA, NBGH

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What Do We Do?

• Formulate and recommend strategy
• Monitor activities that may impact patient care
  and members practice
• Influence the performance assessment process
• Inform and learn from members

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Stat Stat Stat Stat

1. Principles for P4P Programs
2. Principles for Public Reporting on CV Physician
   Performance
3. Influence 2007 PQRI cardiology measure
   implementation
4. Educate members and provide toolkit for PQRI
   implementation

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Urgent but Challenging

• Influence payer proposals for cardiologist
  recognition programs
• Monitor the Patient-Centered Medical Home
  movement
• Position Public Reporting
• Position Comparative Effectiveness
• What IS a quality cardiologist?

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July 2007 Retreat

• Cardiologist Recognition Program valid,
  feasible, actionable
• Strategy for implementing PCPI performance
  measures
• Understand and influence efficiency measure
  development
• Track the implementation of the Patient-centered
  Medical Home

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Work Groups

• CV Specialist Recognition Program
• PCPI Measures Implementation
• Efficiency Measurement
• Patient-Centered Medical Home
• Comparative Effectiveness in Health Care

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2008 Work Plan

• Medical Directors Institute, Oct 23-24
• Par3 work groups form, November
• 2nd Wednesday Webinars each quarter
• Quarterly Payer Roundtables
• CVRP
• Efficiency

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PAR3 Members
Kathleen Blake Robert Bonow
Ralph Brindis
John Brush Joseph
Cacchione James Fasules Greg Dehmer
Joseph Drozda Kim
Eagle Paul Heidenreich Robert Hendel Jerry
Kennett Harlan Krumholz
Fred Masoudi Joseph Messer
Chuck McKay Michael Mirro Michael OToole
Jim Palazzo Eric Peterson Rita
Redberg Andrea Russo
Mark Sanz John Schaeffer Sidney Smith
John Spertus John Strobeck
Henry Ting Michael
Valentine Bonnie Weiner Janet Wright
Staff Eileen Hagan, Kathleen Flood, Joel Harder
(HRS), Patricia Upchurch (ASNC), Wayne Powell
(SCAI)
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Public Reporting

• Will enhanced transparency and
  accountability improve healthcare?

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Public Reporting Bandwagon

• Employers accelerate QI, steerage
• Hospitals , competitive advantage
• Health Plans accelerate QI, tierage
• Consumers right to know, choose

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Experience to Date

• Cardiac surgery
• HCFA
• NNECSG
• STS
• Pa CABG, NY CSRS, MA
• CMS Hospital Compare
• Consumer Web Sites

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Guidance

• Mass Medical Society
• AQA Alliance
• RAND
• NCQA

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Basic Principles

• Promote quality improvement
• Develop in partnership with physicians
• Provide the evidence base for program
• PMs should be clinically relevant
• Risk- and case mix- adjusted
• Monitor for unintended consequences

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Basic Facts

• Assessment of individual MDs is in its infancy
• Claims data do not adequately represent care and
  cannot serve as the primary assessor of
  performance
• EHRs can provide valuable clinical data
• Poorly designed or executed PR programs can
  damage reputations, relationships, access to care

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ACC Comparative Effectiveness

• Church State as CE researchcoverage
• Complex area requiring specific skill sets
• High risk for unintended consequences
• Source of practical information for clinicians

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PCMH result of 2yr policy review

• Data on rising costs of care, gaps/variations
• Need to offer alternatives to the SGR
• P4P limitations consequences
• Workforce trends showing a marked decline in
  physicians going into general primary care
• Increase in patients with chronic diseases
• Evidence that care coordinated by a personal
  physician is associated with better outcomes
• Purchasers demands for accountability and
  transparency

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Principles of the Patient-Centered Medical Home

• Personal physician
• Physician directed medical practice
• Whole person orientation
• Care is coordinated and/or integrated
• Quality and safety
• Enhanced access to care
• Payment to support the PCMH

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PCMH Practices

• Organize the delivery of care for all patients
• Use evidence-based medicine and clinical decision
  support tools
• Coordinate care in partnership with patients and
  families
• Provide enhanced and convenient access
• Identify and measure key quality indicators
• Use HIT to promote quality, safety security
• Provide feedback on performance accept
  accountability for process improvement and
  outcomes

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PCMH Practice Facilitates Care

• to sub-specialists through better information
  sharing, coordinated transitions, and feedback
• for tests, procedures and hospitalization
• by reducing redundant testing
• through the appropriate application of EVM where
  such guidelines exist
• via direct collaboration with DM entities or by
  providing such care support directly
• .with HIT that supports population management,
  clinical decision support, and health information
  exchange

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PCMH-Not Defined by Specialty

• Any physician in a recognized practice who has
  the training and experience to provide first
  contact, continuous and comprehensive care could
  be the patients personal physician
• In some cases, the most qualified personal
  physician to take care of the whole patient
  will be a subspecialist or specialist

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• AARP
• AAFP
• AAP
• ACP
• AHQA
• AOA
• Aurum Dx
• Bridges to Excellence
• The Center for Excellence in Primary Care
• The Center for Health Value Innovation
• CVS Caremark
• Disease Management Association of America
• eHealth Initiative
• The ERISA Industry Committee
• Exelon Corp
• Foundation for Informed Medical Decision Making

• General Motors
• HR Policy Association
• IBM
• McKesson Corporation
• NACHC
• Natl Business Group on Health
• Natl Business Coalition on Health
• Natl Coalition on Health Care
• NCQA
• National Retail Foundation
• Pacific Group on Health
• Partners in Care
• The Roger C. Lipitz Center for Integrated Health
  Care, Johns Hopkins
• Walgreens Health Initiatives
• Wyeth
• Xerox

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Partnership with NCQA

• AAFP, AAP, ACP, AOA worked with NCQA to revise
  the 2006 Physician Practice Connections module to
  align with PCMH
• Evolving process
• PPC-PCMH to be ready January 2008
• Current statistics on NCQA Physician recognition
  programs
• 3,335 PPC Recognized Physicians
• 2,873 Diabetes Module
• 1,092 Heart/Stroke

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Proposal Hybrid Payment Structure

• Bundled, severity-adjusted, prospective care
  coordination fee to cover the following
• the physician and non-physician clinical staff
  work required to manage care outside a
  face-to-face visit
• the health information technology and system
  redesign incurred by the practice
• Combined with per visit FFS payment
• Performance based bonus payments based on
  evidence based measures of care
• Shared savings

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Other Demonstration Projects

• North Carolina Medicaid demonstration reports
  considerable savings
• A Mercer analysis showed that an upfront 10.2
  million investment for North Carolina Community
  Care operations in SFY04 saved 244 million in
  overall healthcare costs for the state. Similar
  results were found in 2005 and 2006
• Other potential demonstration projects
• Louisiana
• New York
• Rhode Island
• Wyoming
• Arizona
• Washington

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Key Questions to Explore

• How much does the PCMH cost?
• How will the PCMH model affect referrals to
  subspecialty practices?
• Under what circumstances would/should
  subspecialty practices qualify as a PCMH?
• How do patients transition from one PCMH to
  another?
• How and what should information flow to/from the
  PCMH?
• How will the PCMH be funded?
• What will the impact be on the primary care work
  force?
• What if a subspecialty practice provides some of
  the services characteristic of a PCMH but not all
  or not for all patients?

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Opportunities

• Explore dynamics of primary care/subspecialty
  care interactions in an environment with medical
  homes
• Collaboration with health systems, disease
  management companies
• Development of virtual teams
• Support for small medical offices to facilitate
  transformation of practices QIOs, others
• Implementation/testing of information technology
  health information exchange
• Research

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Conclusions

• PCMH concept has garnered considerable attention
  and support
• Evidence supports the hypothesis that this model
  can improve health care in the U.S.
• Tests of the PCMH model are being developed
• Uncertain whether model will prove attractive
  enough to drive more medical students into
  primary care
• Reimbursement methodology needs to be defined and
  tested
• Critical operational issues need to be explored
  and described

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PAR3 Take-Aways

• Measurement is here to stay
• Your ability to practice will be impacted
• Your professional society is working with others
  to influence, analyze, push back
• This process is iterative and will only work
• -to protect patients and to improve quality- if
  you are aware, engaged, prepared

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Medical Directors Institute 2007

• Partnerships for Transformation
• Systematic Assessment, Recognition, and
  Reporting
• Identify gaps in performance assessment,
  recognition, and reporting
• Develop collaborative recommendations for
  improvements that can be implemented in 09
• October 24-25, 2007 in Phoenix