MEDICAID PHYSICIAN AND NURSING HOME PAY FOR PERFORMANCE P4P INITIATIVES

1
MEDICAID PHYSICIAN AND NURSING HOME PAY FOR
PERFORMANCE (P4P) INITIATIVES

• Presentation to
• Quality, Transparency Prevention Workgroup
• Governors Health Care Reform Commission

November 14, 2006 Richmond, Virginia
Patrick W. Finnerty Department of Medical
Assistance Services
2
Other States Medicaid Physician P4P Plans

• Pennsylvania Part of ACCESS-PLUS program
  (enhanced primary care case management program)
• Pays PCPs for disease management services such as
  enrollment assistance, coordination of care, key
  clinical interventions (asthma, diabetes, COPD,
  CAD and CHF)
• Implemented Nov, 2005
• As of October, 2006.337 participating PCPs (16)
• Unison, a Medicaid MCO in Pennsylvania, has
  announced plans to pay bonuses to providers who
  adhere to nationally recognized quality standards
  and meet patient satisfaction and efficiency
  benchmarks
• Scheduled for April, 2007
• Physicians could earn bonuses ranging from 5,000
  to 50,000 per year

3
Other States Medicaid Physician P4P Plans
(contd)

• North Carolina Incentive payments for
  physicians who are top performers or who improve
  by 20 in terms of asthma treatment, diabetes
  testing and OTC prescribing practice
• Maine Incentive payments for PCPs who rank
  above the 20th percentile in number of recipients
  served, ER utilization and prevention/quality
  services
• Minnesota Incentive payments for physician
  group practices who meet targets for disease
  management (diabetes initially) using HEDIS-like
  measures

4
Types of Physician Performance Rewarded

• Activities - Pennsylvania makes payments based on
  specific DM services furnished
• Standards - Compliance with best practices or
  targeted clinical interventions (pre-natal care,
  tests, visits, immunizations, screenings, etc.)
• Outcomes - Least common, but some states (NC and
  Maine) track reduction in ER claims

5
Medicaid Physician P4P Considerations

• Support specific initiatives such as disease
  management, EPSDT, etc.
• Determining and calculating the measures
• Administrative information vs. clinical
  information
• Medicaid programs may also want to reward managed
  care plans for positive physician behavior
• Sufficiency of existing physician reimbursement
• Virginias current reimbursement levels are low

6
Criteria used in Nursing Home P4P Programs

• Minimum Data Set (MDS)-based resident outcome
  measures good recent research on reliability
  and validity of quality measures
• Deficiencies from state survey inspections
  concerns about variability among surveyors and
  focus on the negative but federal governments
  minimum standard is used in all Nursing Home P4P
  programs
• Nursing home staffing not a true outcome
  measure but studies show correlation with quality
  and DMAS already has this information for
  analysis

7
Criteria used in Nursing Home P4P Programs
(contd)

• Resident satisfaction Used in some states but
  DMAS does not have a current data source for such
  information
• Rate of potentially avoidable hospitalizations
  included in Medicare NH P4P due to importance of
  achieving savings in demonstration and relevance
  to Medicare population but complicated to
  calculate

8
Medicaid Nursing Home P4P Programs

• Texas Program operated only in 2001-2002
  victim of budget cuts in 2003. Used MDS data and
  survey deficiencies
• Iowa Uses 10 quality and efficiency criteria,
  but not MDS data
• Kansas Modeled after Iowa
• Minnesota Initial effort to build incentives
  and disincentives into payment system were never
  implemented in favor of an incentive program
  implemented 10/1/06 relying primarily on staffing
  and MDS measures
• Vermont Uses survey deficiencies, resident
  satisfaction and staffing

9
Medicare Nursing Home P4P Demonstration Program

• Contracted with Abt Associates
• 50 Nursing Homes in each of 4-5 States
• Incentive Payments for top 20 of Nursing Homes
  in Overall Performance or Improvement
• Total Payments dependent on pool of savings
• May seek state Medicaid participation
• Uses MDS data, survey deficiencies, staffing and
  rate of avoidable hospitalizations

10
DMAS Nursing Home P4P Budget Decision Package

• If approved, program to be designed with
  stakeholder input
• Decision package proposes a 5 million incentive
  program for nursing homes whose performance at a
  minimum exceeds the statewide average
• Would use MDS data to measure quality outcomes
• Would consider other performance criteria

11
Nursing Home P4P Considerations

• What incentives should be used?
• What criteria/measures should be used?
• Should overall performance and/or improvement be
  measured?
• How to adjust for resident case mix?
• How to make it easily understood by nursing
  facilities and stakeholders?
• How to maximize existing data sources and
  minimize additional administrative burden?