Pay for Performance Savior, Scam, Smokescreen, Sham, or Solution

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Pay for PerformanceSavior, Scam, Smoke-screen,
Sham, or Solution?

• Robert Lamberts, MD
• Evans Medical Group
• Evans, GA

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• I have seen the future and it doesn't work.  -
  Robert Fulford
• By the time a man realizes that maybe his father
  was right, he usually has a son who thinks he's
  wrong.  - Charles Wadsworth
• The real problem is not whether machines think
  but whether men do.  - BF Skinner

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Warning!!

• This talk will be less practical than most and is
  intended for the educational purposes of our
  audience. Any practically applicable information
  is entirely coincidental and should not be
  credited to this speaker.

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P4P Todays Agenda

• Who The players in the game
• Why is it really needed?
• What what does/will P4P look like?
• Does it really work?
• Problems and Challenges
• What GE is Doing
• Debate???

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Who?

• Payors
• Insurance Companies
• Government
• Businesses
• Patients
• Physicians
• Other groups

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The Players Alphabet Soup

• CMS Centers for Medicare and Medicaid Services
• IOM Institutes of Medicine
• AQA American Care Quality Alliance (A
  consortium of ACP, AFP, AHIP, and AHRQ)
• JHACO Joint Commission on the Accreditation of
  Health Care Organizations
• AHQA American Health Quality Association
• QIO Quality Improvement Organizations
• DOQ-IT Doctors Office Quality Information
  Technology
• NCQA National Committee for Quality Assurance
• AHRQ Agency for Healthcare Research and Quality
• BTE Bridges to Excellence
• RWJF Robert Wood Johnson Foundation
• Leapfrog Sorry, no abbreviation
• AND MANY MORE!!!

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Key Collaborations

• Joint initiative between the Robert Wood Johnson
  Foundation, California HealthCare Foundation and
  the Commonwealth Fund
• Provides grants to health care payers to develop,
  evaluate and diffuse innovative financial and
  non-financial incentives for providers to promote
  high quality care
• Joint evaluation by RWJF and AHRQ

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Key Collaborations
3rd year of pilots testing effectiveness of
incentive and reward programs that motivate
providers to speed implementation of Leapfrogs
recommended quality and safety practices

• GE, Verizon, Hannaford Bros., NY
• Boeing nationwide
• Healthcare 21, TN
• Blue Shield of California
• Buyers Health Care Action Group, MN
• Maine Health Management Coalition

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Why P4P?

• Large gaps in quality and safety
• Rapid rise of health care costs
• Perverse incentives in payment systems
• Huge budget problems in private and public sector
• Payers want to use market forces to move the
  needle on quality, cost or both

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Cost of Poor Glycemic Control
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Unsustainable Cost Escalation

• Estimate is statistically different from the
  previous year shown at plt0.05.
• Estimate is statistically different from the
  previous year shown at plt0.1.
• Note Data on premium increases reflect the cost
  of health insurance premiums for a family of
  four.
• Source KFF/HRET Survey of Employer-Sponsored
  Health Benefits 1999-2004 KPMG Survey of
  Employer-Sponsored Health Benefits1993, 1996
  The Health Insurance Association of America
  (HIAA) 1988, 1989, 1990 Bureau of Labor
  Statistics, Consumer Price Index (U.S. City
  Average of Annual Inflation (April to April),
  1988-2004 Bureau of Labor Statistics, Seasonally
  Adjusted Data from the Current Employment
  Statistics Survey (April to April), 1988-2004.

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Kaiser/HRET Survey 2005

• Healthcare premiums up 73 since 2000, workers
  earnings up only 15
• Premiums are now 10,800 for a family
• 8,167 paid by Employer (76)
• 2,713 paid by Employee (24)
• Premiums are now 4,024 for a single
• 3,143 paid by Employer (81)
• 610 by employee (19)
• 20 of Employers offering HDHP
• 2.3 (1.6 million) enrolled HDHPHRA
• 1.2 (810K) enrolled HDHPHSA

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Health Care Costs and Consequences

• For the Uninsured Rising from 45 million today
  to 56 million in 2013
• For the Working Poor In 1970 health benefits
  cost 10 of the minimum wage, today it is 100
• For the Median Household Health benefits are
  20 of median compensation will rise to 60 by
  2020 if trends continue
• For Small Businesses Only 60 of firms offer
  insurance in 2005 down from 69 in 2000
• For Big Business Delphi goes bankrupt, Big Auto
  renegotiates because corporate healthcare costs
  surpasses the net profit of all business

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(No Transcript)
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Improve Care and Outcomes
Nearly one-half of physician care not based on
best practices
of Recommended Care Received
64.7 Hypertension 63.9 Congestive Heart
Failure 53.9 Colorectal Cancer 53.5 Asthma 45.4
Diabetes 39.0 Pneumonia 22.8 Hip Fracture
Source Elizabeth McGlynn et al, RAND, 2003
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Improve Care and Outcomes
More care, higher spending do not result in
better outcomes

• Using Medicare claims data, researchers found
• Where people live, who treats them and in what
  hospital-- not their illness-- determines how
  much care is given and how much money is spent
• Hospitals providing more care for one condition
  have similar patterns for other conditions
• Level of care intensity likely to apply to
  commercially insured patients

Source John Wennberg, et al and Elliott Fisher,
et al, Health Affairs web exclusives, October 7,
2004.
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Save Lives
Patients receive recommended care only half of
the time. These consequences are avoidable.
Avoidable Toll
Shortfall in Care
Condition
2,600 blind 29,000 kidney failure
Average blood sugar not measured for 24
Diabetes
68,000 deaths
lt65 received indicated care
Hypertension
37,000 deaths
39 to 55 didnt receive needed medications
Heart Attack
10,000 deaths
36 of elderly didnt receive vaccine
Pneumonia
9,600 deaths
62 not screened
Colorectal Cancer
Source Woolf, SH, JAMA, Vol. 282, 1999
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Concentration of Medicare Spending
Notes Data from a 5 percent random sample of
fee-for-service (FFS) beneficiaries between 1995
and 1999. Spending reported in 1999 dollars.
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Profiles of Beneficiaries by Spending Group
Notes Data from a 5 percent random sample of
fee-for-service (FFS) beneficiaries between 1995
and 1999. Spending reported in 1999 dollars.
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What is Being Done?

• Public (CMS)
• Private (Insurance Companies)
• Private (Business Consortiums i.e. Leapfrog,
  BTE)

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CMS Initiatives Already Going On

• Hospital-based
• Physicians or Integrated Delivery Systems
• Disease Management/Chronic Care Improvement

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Hospital-Based

• Hospital Quality Initiative
• focuses on an initial set of 10 quality measures
  by linking reporting of those measures to the
  payments the hospitals receive for each discharge
  
• Nearly all (98.3) of the hospitals eligible to
  participate in this program are complying with
  the requirements of the provision
• http//www.cms.hhs.gov/apps/media/press/release.as
  p?Counter1343

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Premier Hospital Quality Incentive Demonstration

• CMS is collecting data on 34 quality measures
  relating to five clinical conditions
• Hospital specific performance will be publicly
  reported on CMSs web site.
• Hospitals scoring in the top 10 for a given set
  of quality measures will receive a 2 bonus
  payment on top of the standard DRG payment for
  the relevant discharges.
• Those scoring in the next highest 10 will
  receive a 1 bonus.
• In the third year of the demonstration, those
  hospitals that do not meet a predetermined
  threshold score on quality measures will be
  subject to reductions in payment.
• http//www.cms.hhs.gov/apps/media/press/release.as
  p?Counter1343

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Physician Group Practice Demonstration

• Mandated by Congress (BIPA 2000)
• The first pay-for-performance initiative for
  physicians under the Medicare program
• Rewards physicians for improving the quality and
  efficiency of health care services delivered to
  Medicare fee-for-service beneficiaries
• Ten large (200 physicians) group practices
  across the country are participating in this
  demonstration

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Medicare Care Management Performance
Demonstration

• Modeled on the Bridges to Excellence program
• Three-year demonstration with physicians to
  promote the adoption and use of health IT to
  improve the quality of patient care for
  chronically ill Medicare patients
• Focused on small and medium-sized physician
  practices
• Will be implemented in four states Arkansas,
  California, Massachusetts, and Utah, with the
  support of the QIOs in those states.

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Disease Management/Chronic Care Improvement

• Chronic Care Improvement Program
• ESRD Disease Management Demonstration
• Disease Management Demonstration for Severely
  Chronically Ill Medicare Beneficiaries
• Disease Management Demonstration for Chronically
  Ill Dual Eligible Beneficiaries
• Care Management For High Cost Beneficiaries 

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Chronic Care Improvement Program

• Participating organizations are paid a monthly
  per beneficiary fee for managing a population of
  chronically ill beneficiaries with advanced
  congestive heart failure and/or complex diabetes
• These organizations, which include disease
  management vendors and larger organizations such
  as insurance companies, must guarantee CMS a
  savings of at least 5 plus the cost of the
  monthly fees compared to a similar population of
  beneficiaries.
• Payment of fees is also contingent upon
  performance on quality measures and satisfaction
  of both beneficiaries and providers

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DOQ-IT

• Comes out of The Medicare Prescription Drug and
  Modernization Act of 2003 (H.R. 1-263), which
  encourages the use of health information
  technology to manage the clinical care of
  beneficiaries.
• Largely involves the Quality Improvement
  Organizations (QIOs) in each state
• Called 8th Scope of Work

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DOQ-IT

• Promotes the adoption of electronic health record
  (EHR) systems and information technology (IT) in
  small-to-medium sized physician offices
• Goal of improving care for Medicare beneficiaries
  in the areas of
• Diabetes
• Heart failure
• Coronary artery disease
• Hypertension
• Osteoarthritis
• Preventive care

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DOQ-IT (Continued)

• Educating offices about EHR system solutions and
  alternatives
• Providing implementation and quality improvement
  assistance
• Assist physician offices in migrating easily from
  paper-based health records to EHR systems that
  suit the needs of their office
• DOQ-IT does not endorse any particular vendor
  product or service

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DOQ-IT Measures

• Coronary Artery Disease (CAD)
• Antiplatelet Therapy
• Lipid Profile Drug
• Therapy for Lowering LDL Cholesterol
• LDL Cholesterol Level
• Beta-Blocker Therapy-Prior MI
• ACE Inhibitor Therapy
• Blood Pressure  

• Diabetes Mellitus (DM)
• HbA1c management
• Lipid Measurement
• HbA1c management control
• LDL Cholesterol Level
• Blood Pressure Management
• Urine protein testing
• Eye exam Foot exam

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DOQ-IT Measures

• Heart Failure (HF)
• Left Ventricular Function (LVF) Assessment
• Patient Education
• Left Ventricular Function (LVF) Testing
• Beta-Blocker Therapy
• Weight Measurement
• ACE Inhibitor Therapy
• Blood Pressure Screening
• Warfarin Therapy for Patients with Atrial
  Fibrillation

• Hypertension (HTN)
• Blood Pressure Screening
• Blood Pressure Control
• Plan of Care
• Preventive Care (PC)
• Blood Pressure Measurement
• Pneumonia Vaccination
• Tobacco Use
• Colorectal Cancer Screening
• Lipid Measurement
• Tobacco Cessation
• Influenza Vaccination
• LDL Cholesterol Level
• Breast Cancer Screening

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DOQ-IT

• Physicians participating in the DOQ-IT project
  will be required to submit data about all of
  their relevant adult patient visits by
  appropriate condition over the Internet to the
  QIO Clinical Warehouse

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So, does it work?
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Evidence Supporting P4P

• Few comprehensive studies exist on P4P
• Only 3 demonstrate that P4P leads to improved
  quality all single measure efforts
• Early Experience with Pay-for-Performance From
  Concept to Practice
• Rosenthal, Frank, Zhonghe, Epstein Published in
  JAMA Oct. 12th, 2005
• Volume 294, No. 14

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Rosenthal et al JAMA Study

• PacifiCare Health Systems in California
• Public Reporting since 1998
• Began P4P in 2003
• PacifiCare in Washington and Oregon
• Public Reporting since 1998
• No P4P
• PacifiCare established performance targets on 10
  measures

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Rosenthal et al JAMA Study

• PacifiCare providers eligible for quarterly bonus
  of 0.23 PMPM for each performance target met
• Potential Dollars Physician Group with 10K plan
  members that reached one target would receive
  approx. 6900/quarter, or 27,600/year
• Approx. 5 of plan payment

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Rosenthal et al JAMA Study

• Complete pre and post data available on 3
  targeted quality measures
• Cervical Cancer screening
• Mammography
• HbA1c Testing
• No significant differences in quality for
  Mammography or HbA1c
• 3.6 improvement in CA over WA/OR in cervical
  cancer screening

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Rosenthal et al Findings

• Low performers improved the most
• high performers improved the least maintained
  status quo
• Researchers surprised that low performers
  improved as much as they did
• Chances of receiving bonus low
• Saw P4P program as sign of the future?
• Lesson Pay for improvement AND for meeting
  targets

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Rosenthal et al Findings

• Why didnt this P4P program yield higher quality
  gains across all three measures?
• Need to pay for performance and improvement
• Financial rewards too low? (5)
• Only one payer, accounting for 15 of the average
  groups revenue
• Study spanned 5 quarters Did providers have
  enough time to invest in required infrastructure?
• Money alone is not enough.
• Need technical assistance, reporting, incent
  consumers to choose quality, and P4P

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Rewarding Results Pay-for-Performance Initiative
- Ten Lessons Learned

• Financial incentives do motivate change.
• Non-financial incentives also can make a
  difference.
• Engaging physicians is a critical activity.
• There is no clear picture yet of return on
  investment.
• Public reporting is a strong catalyst for
  providers to improve care.
• Providers need feedback on their performance.
• Providers need to be better educated about P4P.
• Data integrity is important.
• Experience with managed care matters.
• P4P is not a magic bullet.

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Findings Applied Bridges To Excellence (BTE)

• Active in 5 markets
• 16,000 participating physicians
• 1600 (10) are recognized
• 1275 (8) have been rewarded ()
• 4.76 million in rewards paid to date

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BTEs programs have led to better clinical and
financial outcomes
Diabetes Care Link
Physician Office Link
Average episode costs of care for recognized and
non-recognized physicians
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Bottom Line

• Yes, P4P is coming and wont stop coming any time
  soon
• Leadership is mainly from the government and from
  business
• Physician leadership is scarce
• IT adoption is a common theme both as a means
  and an end

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NCQA Software Certification

• FIRST EMR in the Industry
• Diabetes Physician Recognition Program
• Commitment to Quality
• Pay for Performance

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NCQA Diabetes Recognition
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Clinician Level Detail
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Clinician Specific Reports
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NCQA Heart/Stroke Recognition
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Roadmap P4P Measures Re-identification
DOQ-IT Estimated Availability
CMS Physician Focus Quality Initiative, March
04 Source Lumetra
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Other Means of Collecting Data

• Inquiries/Reports
• Crystal Reports Within CPO-EMR
• Crystal Reports Independent of CPO-EMR

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So. Is this a good or a bad thing?

• Best-Case Scenario
• Pay for good work
• Good doctors get better pay
• Patient care improves for all
• Waste is removed from the system
• Easy accounting with IT reduces middle-man

• Worst-Case Scenario
• Must participate to maintain income
• Doctors drop out of Medicare as drop
• Another level of bureaucracy
• Others make more money off of our quality
• Docs select patients

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What will make the difference?

• Who is driving the change?
• Need much more physician involvement
• Patients need to be educated as to the problem at
  hand
• IT adoption by itself will drive change
• Whoever cuts waste has first dibs on the piece of
  pie

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P4P Success Factors
PROVIDERS NEED TO

• Understand the incentives and what must be done
  to qualify for them
• Perceive the value of the incentives to be worth
  their time and efforts
• Believe the incentives will be good for their
  patients
• Have sufficient control over the clinical
  activities required to achieve the targets
• Be assured incentives are administered fairly

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• When you're through changing, you're through.  -
  Bruce Barton
• How much easier it is to be critical than to be
  correct.  - Benjamin Disraeli

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Debate, Anyone?