Second Generation P4P

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Second Generation P4P Community-Wide Diabetes
and Asthma Care
Thomas Foels, MD MMM drfoels_at_independenthealth.co
m
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Agenda

1. General comments P4P
2. Second generation Independent Health model
3. Results of asthma and diabetes program

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Courtesy 2004 MedVantage Survey
Growth of Pay-for-Performance
Year 2004 84 programs (39 M lives)
Year 2006 160 programs
Pioneers
Early Majority
Late Majority
Laggards
Aetna Health Partners BCBS-Hi BCBS-Md IHA-WNY
Highmark IHA (CA-6 plans) Bridges to Excellence
Other healthplans CMS (federal)
TPA Medicaid (state)
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First Generation
Second Generation
PCP SCP PCP HMO PPO, HSA,
non-gatekeeper Component Composite (Uni-dimens
ional) (Multi-dimensional) Secondary
Source Primary source (Claims) (Medical
record)
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First Generation
Second Generation
Focus on Simple Utilization Satisfaction Sat
isfaction, Clinical Process (early
HEDIS) Clinical Outcome (late
HEDIS) Hybrid with Efficiency Index
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First Generation
Second Generation
Social Darwinism Social Democrats

• learning objectives
• improvement literacy
• member-specific profiling

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Improvement Equation
Physician Profiles Incentives Improvement
Literacy
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Practice Excellence Program
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400,000 members 30 market share 2,100
physicians
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Chronic Conditions Family Practice /
Internal Medicine Diabetes Cardiovascular
risk Pediatric Asthma
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Improvement Equation
Physician Profiles Incentives Improvement
Literacy
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Unique features Profiles
Self-directed chart review
Physician-specific
Sampling, not registry
Target active patients
Composite scoring methodology
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Asthma
Process Measures Clinical
Decision Four components history Correct
Severity Severity Assessment Right med for
severity Office PFT Review of PFT
history Influenza
vaccine Action Plan
Maximum patient score 10
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Diabetes

• Process Measures Outcome Measures
• A1C test 1 and 2 A1C lt 7.0
• LDL test LDL lt 100
• BP test BP sys lt 130
• DRE dia lt 80
• Lower extremity exam
• Nephropathy
• GFR

Maximum patient score 10
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CV Risk
Process Measures Outcome
Measures Family history Smoke history LDL
at goal Exercise history HDL at goal
BMI BP at goal Established goals Waist
circ (NC)
Maximum patient score 10
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Independent Health
Def populations Random sampling
Chart Review
93-97 participation
Physician Office
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Independent Health
Def populations Random sampling
Data Analysis Report Generation
Chart Review
Physician Office
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Independent Health
Def populations Random sampling
Data Analysis Report Generation
Chart Review
Results
Physician Office
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Improvement Equation
Physician Profiles Incentives Improvement
Literacy
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Unique features Incentives
Participation (not Performance) based
CME (20 hrs)
Board re-certification
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Overall 2.40 pmpm Diabetes / asthma 0.70
pmpm CV risk 0.80 pmpm 500 members
4,200 per component
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Improvement Equation
Physician Profiles Incentives Improvement
Literacy
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Unique features Improvement Literacy
Actionable reporting
Interactive web site for data submission
Physician account executive (PAE) outreach
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5 Minute Tip Sheet
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Incomplete history ? Did you
assign a severity rating ? Does your
assigned severity match the patients clinical
history (calculated severity) ? Do all
available medications match the patients disease
severity ? Did the patient receive needed
services ? Patients with lowest adherence
scores have the greatest need for services
and management.
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What is Improvement Literacy ?
Identify system flaws bad systems, not
bad doctors Motivation / engagement of
physicians and staff Create a culture of
mutual learning and discovery Foster idea
diffusion / consensus building
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Data Analysis and Trends Asthma
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Patient's Adherence Scores to Asthma Guidelines
Baseline
Following Intervention
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Variation by Medical Office Site
Highest Scoring Office
Lowest Scoring Office
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Asthma Outcomes
2003 2004
ER Utilization 3.71 2.92 plt0.01 Hosp
rate 0.83 0.81 HEDIS preferred
pharmacy age 5-9 74 81
plt0.05 age 10-17 68 76 plt0.01
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Data Analysis and Trends Diabetes
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5 meet all criteria
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Variation by Medical Office Site
Highest Scoring Office
Lowest Scoring Office
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Diabetes Outcomes
Seven diabetes HEDIS measures Statistically
significant improvement in 2/3rd (all LOB)
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Diabetics with co-morbid conditions (20) Had
higher adherence scores (esp outcome measures)
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Data Analysis and Trends CV Risk
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CV Risk (baseline cycle 1)
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Key Learnings

• Community-wide physician engagement
• Improvement without performance-based
• awards
• Process measures rapid
• Outcome measures slower
• Composite measures slowest

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Key Learnings

• Sampling is an effective
• touching every patient
• Improvement literacy communicated economically

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Questions ?
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Contact Information Thomas Foels, MD
MMM Associate Medical Director Independent
Health Association 511 Farber Lakes
Drive Williamsville, NY 14221 (716)
635-3854 drfoels_at_independenthealth.com