Program and Policy Strategies to Promote Healthcare Quality for Children

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Program and Policy Strategies to Promote
Healthcare Quality for Children

• Lisa A. Simpson, MB, BCh, MPH, FAAP
• National Director, Child Health Policy, NICHQ
• Endowed Chair, Child Health Policy
• University of South Florida

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Todays Popular Policy Platforms

• Pay for Performance
• Health Information Technology
• Consumer driven health care
• For each
• What do we know about use and/or its
  effectiveness overall?
• What do we know of its use and/or effectiveness
  for children?

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Pay for Performance (P4P)

• Incentive programs that provide monetary bonuses
  to eligible participants linked to specific
  quality and/or efficiency standards established
  by the program
• Initiated by government agencies, employers
  health plans to stimulate quality improvement
  (one of the earliest from Aetna in 1987)
• Financial rewards based on achievement related to
  
• evidence-based clinical quality of care measures
• patient satisfaction
• efficiency/productivity
• infrastructure of the practice (including use of
  information technologies)
• AMA, Physician Pay for Performance Initiatives,
  2004.

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P4P Programs

• Average incentive payment around 1-5 of a
  physicians total revenue from a given health
  plan (AMA, 2004)
• in Anthem BC/BS (NH) in 2001, average bonus
  payment 1,183 and the highest bonus payment
  15,320
• in IHA program, average group bonus about
  200,000 and will cover 24,000 primary care
  physicians (200 physician groups 7 million
  beneficiaries)
• 2004 survey findings
• Majority of programs were targeted to PCPs,
  confined to HMO, fully insured products with
  annual bonus incentives based on HEDIS
  performance measures
• Dramatic growth
• November, 2004 84 programs w/ 39 million
  beneficiaries
• March 2005 104 programs
• By 2006, predicted to increase to 160 programs
• Baker Carter, 2005
• AMA, Physician Pay for Performance Initiatives,
  2004

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Key Trends in P4P Programs

• Product Spread
• Expansion to PPOs Consumer Directed Healthcare
  products
• Expansion to specialists with use of
  specialty-specific measures
• Changes in Measures
• Use of measures for positive savings (generic
  substitution efficiency)
• Supplementing population-based HEDIS measures
• Use of scorecards and actionable results
  reporting to change behavior
• Use of performance results for public reporting
• Significant growth in health information
  technology adoption measures
• Changes in types of payments
• Use of adjustable fee schedules instead of annual
  bonus payments
• Return on investment analyses (i.e., what would
  have been the financial and clinical outcome in
  the absence of a P4P program?)
• Center for Medicare and Medicaid Services as a
  P4P market driver
• Baker Carter, Provider Pay-for-Performance
  Incentive
• Programs 2004 National Study Results, 2005.

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Landon et al, 2004
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PP4P - Pediatric Pay for Performance

• Leapfrog compendium identifies 12 programs (out
  of 70)
• 4 states (IA, RI, UT, WI) - target health plans
• Rest target physicians
• 3 BC/BS (IL, MA, MO)
• States use of quality information
• Varies by product HMO and PPO
• Rewarding Results

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Leapfrog Compendium

• Focus on
• well visit (child and adolescent)
• immunizations
• appropriate antibiotic utilization
• asthma (self management plans or medication
  management)
• IT. (not clear if applies to peds)
• volume, timeliness, and quality of electronic
  encounter data

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New Leapfrog Hospital Rewards Program

• All short term acute care hospitals
• Five clinical areas including newborn care
  accounting for 33 commercial admissions 20
  commercial inpatient spending
• Newborn care measures include
• Neonatal mortality
• NICU
• Process of Care -- 80 adherence antenatal
  steroids for certain high-risk deliveries
• 3rd/4th degree lacerations
• Computerized physician order entry (CPOE) system
• Leapfrog Quality Index (NQF Safe Practices)

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Factors in Determining Compensation Florida
Child Health Provider, 2005
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Effectiveness of Pediatric PFP Programs RCTs
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Todays Popular Policy Platforms

• Pay for Performance
• Health Information Technology
• Consumer driven health care
• For each
• What do we know about use or its effectiveness
  overall?
• What do we know of its use or effectiveness for
  children?

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Health Information Technology (IT) Adoption by
Physicians

• Physicians either routinely or occasionally use
• 79 electronic billing
• 59 electronic access to patients' test results
  either routinely or occasionally
• 27 EMRs and electronic ordering of tests,
  procedures, or drugs
• 21 have automated patient reminders regarding
  routine preventive care
• 7 e-mail with other doctors
• 6 electronic clinical decision support systems
• 3 email with patients
• Top 3 reported barriers
• costs of system start-up and maintenance
• lack of local, regional, and national standards
• lack of time to consider acquiring, implementing,
  and using a new system
• Audet et al, Medscape 2004 and Health Affairs,
  2005

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Unique Issues for Children

• Not so unique at the technical level
• Differences emerge in
• Market availability
• Policy focus
• Adoption of HIT applications

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Child Health Provider Adoption of HIT Total
by Gender, Florida, 2005

• Methods
• Mailed survey (two waves) between March and May
  2005
• All licensed primary care physicians (MD/DOs) and
  a 25 sample of ambulatory subspecialists
• N1219 child health provider respondents
• Primary care pediatrics, family medicine and
  pediatric subspecialists serving gt0 children

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Child Health Provider Adoption of HIT Total
by Gender, Florida, 2005
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Percent Adoption of HIT by Medical Training
Florida Child Health Providers, 2005
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Adoption of HIT by Provider Age Florida Child
Health Providers, 2005
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Adoption of HIT by Provider RaceFlorida Child
Health Providers, 2005
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Adoption of HIT by Practice SizeFlorida Child
Health Providers, 2005
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Adoption of HIT By Practice TypeFlorida Child
Health Providers, 2005
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Adoption of HIT By Medicaid VolumeFlorida Child
Health Providers, 2005
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Todays Popular Policy Platforms

• Pay for Performance
• Health Information Technology
• Consumer Driven Health Care
• For each
• What do we know about use or its effectiveness
  overall?
• What do we know of its use or effectiveness for
  children?

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Consumer Use of Quality Information

• Consumer driven health care shifts more financial
  responsibility to consumers on the assumption
  that this will drive better decisions
• Several initiatives to publicly report
  performance
• Medicare driven
• State driven
• Having an abundance of information does not
  always translate into its use to inform choices
• All health care decisions plan, provider,
  treatment requires the use of information that
• Includes technical terms and complex ideas
• Compares multiple options on several variables
• Requires the consumer to differentially weight
  the various factors according to individual
  values, preferences and needs
• Information presentation has a significant effect
  on impact and use
• Hibbard Peters,
• Annual Reviews of Public Health (2003)

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Where Consumers FindQuality Information

• KFF/AHRQ/Harvard School of Public Health. Chart
  7. National Survey on
• Consumers Experiences with Patient Safety
  Quality Information, November 2004
• (Conducted July7 Sept 5, 2004)

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Consumer Exposure to Quality Information

• KFF/AHRQ/Harvard School of Public Health. Chart
  7. National Survey on
• Consumers Experiences with Patient Safety
  Quality Information, November 2004
• (Conducted July7 Sept 5, 2004)

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Consumer Use of Quality Information

• KFF/AHRQ/Harvard School of Public Health. Chart
  10. National Survey on
• Consumers Experiences with Patient Safety
  Quality Information, November 2004
• (Conducted July7 Sept 5, 2005)

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Importance of Quality Ratings

• KFF/AHRQ/Harvard School of Public Health. Chart
  7. National Survey on
• Consumers Experiences with Patient Safety
  Quality Information, November 2004
• (Conducted July7 Sept 5, 2004)

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Parental Use of Quality Information

• Little research specifically looking at this
• CAHPS related research points to similarities
• Existing evidence points to even greater
  difficulties for children due to
• Poverty
• Low educational attainment
• LEP

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Conclusions

• Current policy strategies have been less well
  thought out/tested in child health populations
• CHSR community has opportunity to develop more
  evidence on these questions