Case Studies in Quality Based Purchasing

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Case Studies in Quality Based Purchasing

• Meredith Rosenthal, Ph.D.
• Acknowledgement Financial support for this work
  was provided by the Agency for Healthcare
  Research and Quality.

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Overview

• 4 case studies of QBP implementation
• Pay-for-performance and public reporting of
  quality information
• Cases selected to inform new entrants
• Lessons learned in implementation
• Key questions/issues for discussion

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Maine Health Management Coalition (MHMC)

• Business and health coalition with
  multi-stakeholder involvement (150,000 lives)
• Quality measurement and reporting initiative for
  primary care and hospitals preceded
  pay-for-performance
• Primary care pay-for-performance extended to all
  practices in the state
• Hospital pay-for-performance pilot

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MHMC Primary Care Pay-for-Performance

• Funding willing (not all) employers and health
  plans contributed to a fixed bonus pool
  (400,000)
• Measures
• Office system survey developed to assess capacity
  for patient management
• Administrative measures for appropriate
  screening, medication, prevention
• Practice-reported data for chronic care
  management and intermediate health outcomes
  (e.g., blood pressure control)
• Bonuses determined based on overall scores and
  number of patients

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Key Lessons Learned

• Collaboration critical to successful launch
  Coalition provided the ground for productive give
  and take between payers and providers 14-member
  physician steering committee had substantial role
  in measure selection
• Leverage outside expertise MHMC used a national
  expert to help develop useable report card local
  academic resources also tapped experts brought
  resources, legitimacy

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Hudson Health Plan

• Prepaid health services plan in NY State serving
  55,000 Medicaid and SCHIP enrollees
• Began pay-for-performance in 1999 with state
  payment rate increase using existing quality data
  from internal quality review payments depend on
  ranking everyone gets something
• Added specific programs using better data for
  preventive care, SSI needs assessment, diabetes
  care payments are for every patient whose care
  meets guidelines (e.g. 300 for well-managed
  patient with diabetes)

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Key Lessons Learned

• Phase in the program use existing data, start
  small, garner interest/support tackle harder
  (more meaningful) goals later
• Communicate frequently with providers educate
  about program, provide assistance with tools for
  improvement (i.e., dont assume building a
  technically nice program is enough)

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Ohio Long-Term Care Consumer Guide

• Department of Aging
• On-line tool for consumers and families to make
  quality-based choices
• Structure, measures of quality collecte by CMS,
  resident and family experiences
• Funding initially through civil penalty pool
  then fees assessed facilities annually
• State subsequently legislated nursing home
  pay-for-performance based on same measure sets

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Key Lessons Learned

• Talk (listen) to consumers first!
• Seize the moment market factors led to
  facilities being eager to undertake effort
• Collaborate with providers facilities helped
  make way for legislation, working together
  increased trust, willingness to accept standards

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Colorado Business Group on Health

• Statewide business coalition
• Hospital report card
• Collaboration with Colorado Hospital Association
• AHRQ IQI measures populate report card Colorado
  Hospital Association statewide discharge data
  were used

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Key Lessons Learned

• Identify a few champions to gain the backing of
  the hospital association, support from within was
  built
• Rely on well-established measures for provider
  acceptance, validated measure sets are best AHRQ
  provides software to compute risk-adjusted
  quality measures
• Engage local employers it is not obvious to all
  employers that they have a role to play in
  quality improvement

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Questions/Issues to Consider

• Where is there most to gain from collaboration
  within a market (across payers, stakeholders)?
• Should public reporting come first? Or last?
• How do you build a case for transparency with
  providers?
• Where is the low-hanging fruit in this market
  existing data? problems with known solutions
  (local models?)? Major quality deficits? Quality
  deficits that could result in total cost savings
  if fixed?
• What message works to convince employers, other
  purchasers that investment in quality based
  purchasing is worthwhile?
• Are there good (cheap? systematic?) ways of
  learning what information consumers want (and how
  they want it)?
• Is there a sustainable business model for
  collecting and publicly reporting quality and
  cost data?
• Is the need for collaboration and alignment of
  performance measurement and payment compatible
  with health plan competitive strategies?
• How can free-riding be minimized (some payers
  contribute to QBP efforts but others just reap
  the benefits)?