A VALUE AGENDA FOR HEALTH CARE PHYSICIAN PERFORMANCE MEASUREMENT

1
A VALUE AGENDA FOR HEALTH CARE PHYSICIAN
PERFORMANCE MEASUREMENT

• Tricia Marine BarrettSeptember 1, 2009

2
ABOUT TODAYS PRESENTATION

• About NCQA
• We Know Quality
• NCQA Physician Measurement Initiatives
• Valid Physician Measurement
• A few thoughts on ARRA Using HIT to Drive
  Quality Improvement

3
NCQA Mission and Vision
Mission To improve the quality of health
care. Vision To transform health care
throughquality measurement, transparency, and
accountability.
4
ACHIEVING THE MISSION Impact of Accreditation
Recognition Programs

• Over 800 plans report HEDIS data to NCQA
  (Commercial, Medicaid, Medicare) including 240
  PPOs
• 70.5 of Americans enrolled in health plans are
  in an NCQA Accredited plan
• This accounts for 109 million lives!
• More than 14,000 physicians are recognized by
  NCQA Recognition Programs
• More than 1,000 Medicare Special Needs Plans
  (SNPs) have been reviewed by NCQA under contract
  to CMS

5
WHAT WEVE LEARNED FROMMEASURING QUALITY
6
IN THE BEGINNING...

• Quality widely assumed to be high
• Measurement regarded as a novelty
• Health plans went first
• Employer demand, threat of regulation were key
• Provider resistance was strong
• Performance gaps revealed, quality improvement
  efforts launched
• Patient safety story unfolded
• Notion of cost/quality tradeoff exploded

7
MEASUREMENT DRIVES IMPROVEMENT
Denotes measure specification change
8
BETA-BLOCKER TREATMENT AFTER A HEART ATTACK 1996
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Each of these dotsis a health plan.
Note the variability from plan to plan.
National average 62.6
9
BETA-BLOCKER TREATMENT AFTER A HEART ATTACK 1996
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
97.7
10
BUT UNEXPLAINED VARIATIONS IN CARE
PERVADE,LEADING TO QUALITY GAPS
90th Percentile among accountable plans
Average quality gap in 2008 12.1 points
System-wide performance
11
THESE GAPS COST LIVES...
12
...BILLIONS IN AVOIDABLE HOSPITAL COSTS...
13
...AND COST EMPLOYERS MILLIONS OF AVOIDABLE SICK
DAYS AND BILLIONS IN LOST PRODUCTIVITY
More data available at NCQAs Quality Dividend
Calculator ? www.ncqacalculator.com
14
NCQA PHYSICIAN MEASUREMENT INITIATIVES
15
WHY MEASURE AT THE PHYSICIAN LEVEL?

• Physicians can heavily influence quality and
  costs
• Consumers want information about doctors
• Plans, purchasers want to incorporate information
  into pay-for-performance programs

16
NCQA Recognition Programs

• gt14,000 recognitions awarded to physicians for
  providing superior care
• Clinical programs
• Diabetes Recognition Program (DRP)
• Heart/Stroke Recognition Program (HSRP)
• Back Pain Recognition Program (BPRP)
• Medical practice process and structural measures
• Physician Practice Connections
• Physician Practice Connections-Patient-Centered
  Medical Home (PPC-PCMH)

As of 7/31/09
7534 physicians
2072 physicians
3440 physicians 254 practices
121physicians 24 practices
1001 physicians 178 practices
17
HOW NCQA RECOGNITION PROGRAMS WORK

• Evidence-based measures
• Voluntary
• Practice identifies patients using
  specifications self-assesses and collects data
  using Web-based tool with specifications
• Practice submits documentation to NCQA when ready
• NCQA reviews scores submissions
• NCQA conducts additional audit of sample of
  practices
• NCQA reports Recognized physicians on website and
  licenses list to others

18
DRP MEASURES PERFORMANCE GOALS

• MEASURES PERFORMANCE GOAL
  POINTS
• HbA1C
• HbA1c control lt 7.0 40
  5
• HbA1c control lt 8.0 60 8
• HbA1c gt9.0 (poor control) lt15 12
• Blood Pressure
• Blood pressure control lt140/90 mm Hg lt35
  15
• Blood pressure control lt130/80 mm Hg 25
  10
• Lipids
• LDL control lt130 mg/dl lt37 10
• LDL control lt100 mg/dl 36 10
• Eye Exam
• Eye exam (dilated) 60 10
• Foot Exam
• Foot exam 80 5
• Nephropathy
• Nephropathy screening 80 5
• Smoking Status

75/100pointsneeded
19
VALID PHYSICIAN MEASUREMENT
Putting the pieces together
20
WHY PHYSICIAN QUALITY

• Purchasers, Consumers seek information
• Evidence of variation and that high quality?high
  cost
• Mature efforts in CA, MA, MN, where physicians
  are organized into groups
• Purchasers pushing plans to steer to high value
  physicians
• Physicians experience shortcomings of early
  measurement efforts

Leads to legal action and settlements in
Washington and New York
21
Consumer-Purchaser Disclosure Project Uniting
the End-Users of the Market to Advance
Transparency

• Coalition of consumer, labor, and employer
  organizations advocating for full dashboard of
  comparative performance information
• Comparative information will drive quality and
  efficiency improvements by allowing
• Consumers to use valid performance information to
  choose providers and treatments
• Purchasers and plans to build performance
  expectations into their contracts, benefit
  designs and payments
• Providers to act on their desire to improve,
  supported with better information.
• Funded by The Robert Wood Johnson Foundation
  along with support from participating
  organizations

22
Performance Measurement Through Consumers
Purchasers Eyes

• Scope and pace of measure development and
  implementation too narrow and slow
• Pressing sense of urgency
• Real consumer/patient choices being made with
  little real information
• High costs resulting in more uninsured and often
  value-blind benefit designs and purchasing
  strategies
• Robust performance dashboard essential
• Consumer engagement requires relevant and
  adequate information
• Plan designs, payment systems and networks must
  recognize quality and efficiency
• Performance information must be valid and readily
  available dont let perfection be the enemy of
  the public good

23
PHYSICIAN AND HOSPITAL QUALITYA BRIEF TIMELINE

• April 2006 NCQA launches voluntary Physician and
  Hospital Quality program
• August 2007 NY AG Cuomo tells plans to cease
  physician ranking efforts consumer groups
  intervene
• December 2007 AG office reaches agreement with
  seven plans
• March 2008 NCQA appointed ratings examiner for
  three plans
• April 2008 Consumer-Purchaser Disclosure Project
  issues Patient Charter
• June 2008 NCQA Board approves revised PHQ
  Standards aligned with CPDP and NYAG
• August 2008 CPDP endorses NCQA PHQ standards

24
PHQ Evaluates How Organizations Use

• Standardized measures of quality, valid measures
  of cost, appropriate methods and fair,
  transparent processes when acting on measures of
  the quality and efficiency of care provided by
  physicians
• All-payer data on hospitals to provide members
  with information and resources to inform
  decision-making

25
ISSUE 1 STANDARDIZATION
The same doctor may be ranked different ways by
different health plans. Which health plans
ranking is more accurate? --Massachusetts
Medical Society, March 27, 2008
Plans use varying measure specifications for MDs

• NCQA PHQ STANDARDS
• Promote use of measures endorsed by NQF, AQA,
  accreditors, PCPI, government agencies
• Plans must follow exact specifications

26
ISSUE 2 CLAIMS DATA
Doctors say part of the problem is that the
measures are applied to patients' claim data
information they say only tells half a
story. --The Associated Press, February 7, 2008
Claims data used by plans may be inaccurate or
lack needed detail

• NCQA PHQ STANDARDS
• Specify that plans have process for MDs to
  provide additional information or data and
  request corrections or changes in advance
• Review files for compliance with process

27
ISSUE 3 ATTRIBTUION
What if an internist calls a patient's
cardiologist for advice? The cardiologist didn't
see the patient and doesn't bill for the help,
but probably deserves some of the credit,
right? --Shreveport Times, Editorial, May 3,
2008
Plan methodology for assigning patients to MDs
may not be clear may result in inappropriate
attribution

• NCQA PHQ STANDARDS
• Require transparency of attribution
  methodologies, in advance
• Give MDs opportunity to request corrections

28
ISSUE 4 TRANSPARENCY
Physicians and patients have seen little
transparency in the methods insurers use to
determine how a physician is ranked, or why they
may be in a narrow network. --American Medical
News Editorial September 17, 2007
Key aspects of plan methodologies may not be
communicated

• NCQA PHQ STANDARDS
• Require plan methodologies be communicated in
  advance
• Require that MDs be able to get full detail on
  patient data used to calculate measure results

29
ISSUE 5 NONREPRESENTATIVE DATA
Physicians say that quality assessments are
random and based solely on a tiny sample of
claims data. . . --AM News, Editorial, September
17, 2007
Plans data may not be representative of MD
practice

• NCQA PHQ STANDARDS
• Specify minimum sample size, confidence interval
  or reliability score
• Promote data aggregation

30
ISSUE 6 COST ONLY
Many physicians are concerned that
pay-for-performance measures favoring cost
savings over quality could actually make care
worse. --The Associated Press, April 12, 2007
Plans measure and reward MDs based only on cost
measurement

• NCQA PHQ STANDARDS
• Require that plans take action on cost results
  only in conjunction with quality results

31
ISSUE 7 INDEPENDENT ASSESSMENT
Doctors have chafed at being measured by what
they describe as a hodgepodge of systems that
lack any oversight and consistency --The Wall
Street Journal, April 2, 2008
No independent oversight of plan measurement
activities

• NCQA PHQ STANDARDS
• Provide for independent review by NCQA

32
PROGRESS

• PHQ standards introduce rigor into process
• PHQ standards provide for transparency that
  hasnt always existed
• Review by NCQA available to plans and other
  organizations that measure and report on MD
  quality

33

• Using HIT to Drive Quality Improvement

34
NCQA EXPERIENCE

• Physician Practice Connections-Patient Centered
  Medical Home Recognition
• 425 Practices
• 4,363 MDs
• HEDIS for MDs
• Measure validation
• Audits
• Software certification
• Documentation
• PQRI Registry
• 560 submissions in 2008
• Measures for EHRs
• NCQA/AMA/EHRA (The Collaborative)
• Prototype framework developed (2007-2009)
• NQF taking forward thru SDO (2009)
• Commonwealth Grant with Johns Hopkins and Park
  Nicollet

35
IDENTIFYING PATIENT-CENTERED MEDICAL HOMES USING
NCQA STANDARDS

• Assessing whether practices provide
• Access and communication
• Patient tracking and registry functions
• Care management
• Patient self-management support
• Electronic prescribing
• Test tracking
• Referral tracking
• Performance reporting and improvement
• Advanced electronic communications

36
PPC-PCMH

• Encourages practices to adopt proven systems for
  improving care
• Provides mechanism for incentivizing investment
  in quality infrastructure and processes
• Complements evaluation of clinical effectiveness,
  patient experiences, and efficiency

37
PPC-PCMH EXPERIENCE

• Link between HIT capabilities and practice
  redesign must be clear
• Published research presence or absence of EMR
  per se correlates only weakly with clinical
  measures
• Implementation is disruptive, takes time
• Small practices need assistance
• Financial support necessary
• Documentation necessary reporting effort needs
  to be minimized
• Published research practice self report (without
  documentation or audit) does not produce reliable
  information
• Current EHRs generally do not support
  standardized quality measure reporting

38
ARRAS UNPRECEDENTED OPPORTUNITY

• Practice redesign incorporating HIT
• Practices need roadmap
• Practices need assistance
• Measures reinforce care management processes
• Link to other delivery system reform efforts
• THINC RHIO
• NYC PCIP
• Vendors need clear direction, advance notice
• EHR systems need to accommodate measure changes
• With interoperability, can address coordination
  of care

39
SAMPLE MEASURES

• Searchable patient-level clinical information
• of patients seen in last 3 months with 7
  specified data fields entered
• Use of registry functions
• Practice uses electronic data to generate lists
  of patients needing specified types of services
• Test tracking
• Practice uses electronic system for lab, imaging
• Use of eRx
• Stand-alone
• Linked to patient info
• Linked to alerts
• Linked to generic info
• Linked to patient formulary
• Quality measurement
• Practice electronically reports on nationally
  approved measures
• Practice achieves improvement

Measures can progress from structure, process
to outcome
40
Steps in Quality Measure Reporting Under
Meaningful Use
Measures Developed, Endorsed
Convert Specs to Basic EHR Codes and Logic
Standards for Importing and Exporting Measures
Translate Measures into Standard
Incorporate Measures into EHR
Link EHR to Reporting Systems
41
Electronic Quality Measurement

• Prepare for electronic clinically-rich data
• Need to develop standard measure definition
  methodology/terminology
• Evolve future measures to leverage new data
• NCQA/AMA/EHRA (The Collaborative)
• Prototype framework developed (2007-2009)
• NQF taking forward thru SDO (2009-2010)
• Federal support needed to mandate use

42
VALIDATION
HITECH provides opportunity to standardize,
streamline
43
Important Considerations

• Opportunity leverage HIT use for health reform
• Improved quality, safety
• Reduced unnecessary costs
• Broad vision necessary
• Multistakeholder input needed
• Realistic phase-in strategy needed
• Practices need support
• Financial
• Redesign
• Functional
• Quality improvement
• Federal leverage needed for standardization

44
Contact Information

• Tricia Marine Barrett
• Vice President, Product Development
• NCQA
• 1100 13th Street, NW, Suite 1000
• Washington, DC 20005
• Phone [phone]
• barrett_at_ncqa.org
• ?for more information, visit www.ncqa.org

45
Questions?