Evaluating the Performance of Hospitals

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Evaluating the Performance of Hospitals HMO
Medical GroupsPay for Performance and Public
Reporting Can Motivate Improvements in
CareCarol Wilhoit, M.D., M.S.Medical Director,
Quality Improvement
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The HMOs of Blue Cross and Blue Shield of Illinois

• HMO Illinois and BlueAdvantage HMO, the BCBSIL
  HMOs, provide coverage for approximately 850,000
  members.
• The HMOs contract with about eighty medical
  groups and IPAs. The HMOs do not contract with
  individual physicians.
• The MG/IPAs are capitated and pay their own
  claims for professional services.
• The contract between BCBSIL and the MG/IPAs
  includes a QI Fund. MG/IPAs can earn additional
  compensation for meeting pre-determined
  performance thresholds.

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HMO Approach to Managing Health
Our Focus engage the member, improve outcomes,
control costs

• Quality Improvement
• Pay-for-performance programs have been successful
  in motivating physicians to improve delivery of
  preventive services and management of chronic
  conditions

• Preventive Care/ Wellness
• Blue Care Connection provides tools to help
  members manage their health and make good health
  care decisions
• Members receive targeted communications to engage
  them in preventive care and wellness activities

• Disease Management
• Members are identified to receive information and
  outreach to assist in improved self-management
• Physician maintains role as manager of the
  member's care
• Providers are incented to optimize the management
  of chronic illness by implementing systems to
  track and improve care

• UtilizationManagement
• Members doctor determines medical need and
  health care treatment decisions
• MG/IPAs review/ approve their own referrals,
  planned surgical procedures and inpatient care

• Decision Tools / Public Reporting
• Provider profiling and information sharing allows
  hospitals and physicians to compare their
  performance to their peers
• Information on hospital and physician quality and
  safety is made publicly available to members for
  more informed decision-making

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A Collaborative Approach to Managing Health
Process has resulted in improved care!!
with physicians
MGs/ IPAs review claims medical records, and
provide BCBSIL with abstracted data
BCBSIL HMOs generates list of members with
specific conditions or needs for MGs/IPAs
MGs/IPAs develop interventionsand interface
with members
BCBSIL verifies and analyzes data
Reports MG/IPA results
Rewards MG/IPA performance
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Blue StarSM Medical Group/IPA Report

• Goal
• Help educate and motivate medical groups/IPAs to
  improve their patient care performance in the
  reported areas
• Approach
• Medical group performance is measured annually by
  BCBSIL. Groups earn a Blue Star each time they
  meet the target care goal

BCBSIL was the first (2003) HMOin Illinois to
publish condition-specific provider data to
members
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Blue Ribbon Report
Members of the HMOs of BCBSIL are surveyed
annually to evaluate their experiences and
satisfaction with contracting medical groups/IPAs
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Disease Management ProgramAsthma
Program Objective Motivate physiciansto give
asthmatic members written asthma action plans to
help them better manage their condition
59 percentage point increase
Percentage of Asthma Members Receiving a Written
Asthma Action Plan

• Results 2000 2005
• Over 3,300 HMO asthma ER visits prevented
• More than 1,000 HMO asthma admissions prevented
• More than 2,400 hospital days saved
• Cost savings of nearly
• 18 million

Results based on comparison to BlueChoice and
HMO billed charges Cost savings based on
billed charges for inpatient care only
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Disease Management ProgramDiabetes
17 percentage point increase

• Program Objective
• Promotes improvements in diabetic care by
  encouraging physicians to track and trend
  diabetes care on a flowsheet, which can help
  members manage their condition

7 percentage point improvement
27 percentage point increase
18 percentage point increase
22 percentage point increase
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Disease Management ProgramCoronary Artery
Disease (CAD)
Program Objective Help members optimally
manage risk factors that contribute to the
potential for heart attack
Percentage of Members with CAD with management of
at least four CAD risk factors, including LDL
cholesterol
Percentage of members with CADwho have LDL mg/dl
Depression screening rate for memberswith CAD
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Quality Improvement ProgramInfluenza Vaccination
Program Objectives Increase influenza
vaccinations among high-risk members
Vaccination Rate 2000-2003
28percentage point increase
Impact is seen through prevented hospital
admissions for influenza and pneumonia
Note 2004-2005 results not reported due to
shortage in flu vaccine
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Other Quality Improvement Programs Show Positive
Results
Childhood Immunization Program 2001-2005
Cervical Cancer Screening Program 1999-2005
31 percentage point increase
9percentage point increase
Additional QI Fund projects include Mental
Health Follow-Up, Colorectal Cancer Screening,
Breast Cancer Screening and Controlling High
Blood Pressure.
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BCBSIL Hospital Profile

• Goal
• Stimulate improvements in quality and safety
  within hospitals and provide members with
  information to assist them in selecting hospitals
• Approach
• Measure diverse indicators of health care quality
  and patient safety and report them to hospitals
  in the BCBSIL Hospital Profile
• Use results to support contracting process and
  build foundation for pay-for-performance
  reimbursement
• Provide information on hospital performance to
  members using the Blue Star Hospital Report

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2007 BCBSIL Hospital Profile
Mean 48.8
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Urban Hospital Profile Cost and Quality Report
Outcome Cost Value
Higher Cost Higher Quality
Lower Cost Higher Quality
Hospital Profile Score ()
Lower Cost Lower Quality
Higher Cost Lower Quality
Cost
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Blue StarSM Hospital Report
BCBSIL publicly reports the following indicators
of hospital performance
In 2006, the Blue Star Hospital report included
93 urban Illinois hospitals
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Leapfrog Reporting
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Impact on AHRQ IQIs and PSIs

• Since 2003, BCBSIL has annually reported
  hospital-specific inpatient complication rates
  using AHRQ indicators. Since 2004, the data
  source includes both Medicare and BCBSIL
  admissions.
• Medicare data are released once a year, by which
  time some admissions are nearly two years old.
  The AHRQ indicators are periodically enhanced,
  making results non-comparable for some years.
  These factors have led to a delay in being able
  to assess the impact of BCBSIL initiatives.

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• BCBSIL reports and scores the following Patient
  Safety Indicators annually
• Selected Infections Due to Medical Care
• Postoperative Pulmonary Embolism or Deep Vein
  Thrombosis
• Postoperative Respiratory Failure
• Postoperative Septicemia
• Obstetric Trauma Vaginal Delivery Without
  Instrument
• Decubitus Ulcer
• Failure to Rescue
• Accidental Puncture or Laceration
• For the Inpatient Quality Indicators, BCBSIL
  reports Mortality Rates for Conditions (acute
  myocardial infarction, congestive heart failure,
  acute stroke, gastrointestinal hemorrhage, hip
  fracture and pneumonia) as one combined rate.
• For urban hospitals, BCBSIL compares hospital
  AHRQ indicator results within hospital peer
  groups.

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Change in AHRQ Complication RatesFFY 2004 to FFY
2005
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Conclusions

• HMO
• For medical groups and IPAs, performance based
  compensation and public reporting in the Blue
  Star MG/IPA Report have been effective in
  motivating physicians to improve the provision of
  recommended services.

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• Hospitals
• Leapfrog public reporting has increased
  substantially over the past five years BCBSIL
  has played a significant role in motivating
  hospitals to report.
• Complication rates for Illinois hospitals,
  calculated using a modification of AHRQ Inpatient
  Quality Indicators and Patient Safety Indicators,
  show substantial improvement between FFY 2004 and
  FFY 2005. This improvement contrasts with the
  national trend towards worsening of results which
  was reported by HealthGrades. While the BCBSIL
  and HealthGrades analyses differ in data source,
  methodology and indicator selection, it appears
  likely that BCBSIL has positively impacted
  performance through
• using the BCBSIL Hospital Profile to give
  hospitals annual feedback on their
  hospital-specific AHRQ indicator results for the
  past five years
• public reporting in the Blue Star Hospital
  Report, and
• performance-based compensation incorporated into
  many BCBSIL Illinois hospital contracts.

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Resources

• The BCBSIL Blue Star MG/IPA report is available
  at
• http//www.bcbsil.com/PDF/bluestar_mg_report.pdf
• The BCBSIL Blue Star Hospital report is available
  at
• http//www.bcbsil.com/PDF/blue_star_report.pdf
• Information about the Leapfrog Safety Practices
  is available at
• http//www.leapfroggroup.org/for_hospitals/leapfr
  og_hospital_quality_and_safety_survey_copy/leapfro
  g_safety_practices
• Information about the AHRQ Patient Safety
  Indicaotrs and Inpatient Quality Indicators is
  available at
• http//www.qualityindicators.ahrq.gov/