Confidentiality Notice:

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How to Play Pay for Performance Paul Wheeler,
MD Hill Physicians July 30, 2008
Confidentiality Notice This information is
intended only for the person or entity to which
it is distributed and may contain confidential
and/or privileged information. Any review,
retransmission, dissemination or other use of or
taking of any action in reliance upon this
information by persons or entities other than the
intended recipient is prohibited.
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Methods of Payment
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Fee for service
Thehealthcareblog.com March 2006
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Capitation
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Pay for Performance
Pay for Performance is a broad term used to
describe programs in which health plans pay
healthcare providers for improvement in the
quality and value of care they deliver.
Billed Services (90)
Health Plan
Pay for Performance (10)
Provider
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Performance Measures
The quantitative assessment of health care
processes and outcomes
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Why Performance Measures?
Performance measurement has multiple purposes

• To provide a quantitative basis for healthcare
  providers to continuously improve patient
  outcomes
• To provide information needed to reward providers
  for a high standard of care
• To provide comparative information to assist
  consumers and purchasers of healthcare services
• To help manage limited healthcare resources

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Pay for Performance
Performance measures usually fall into the
following categories
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Clinical Performance Measures

• Measures may be created locally or can come from
  nationally recognized sources (i.e. National
  Committee for Quality Assurance)
• HEDIS-Health Plan Data and Information Set
  (directed by the NCQA)
• 90 of health plans use a subset of the HEDIS
  Measures for their Pay for Performance programs

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Clinical Performance Measures/HEDIS

• HEDIS measures address a broad range of clinical
  areas
• Asthma
• Blood Pressure
• Breast and Cervical Cancer Screening
• Childhood Immunizations
• Diabetes
• Cardiovascular Disease
• Depression
• Smoking
• Colorectal Cancer Screening

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Clinical Performance Measures/HEDIS
Example Breast Cancer Screening
Source National Committee for Quality Assurance,
2006 P4P Manual Addendum, Testing Measures.
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Diabetes Care/HEDIS

• 2000
• 78
• 42
• 77
• 44
• N/A
• 48
• 41

• 2004
• 86
• 31
• 91
• 65
• 40
• 51
• 52

• HbA1c tested
• HbA1c gt 9.5
• LDL-C tested
• LDL lt 130
• LDL lt 100
• Eye exam
• Microalbumin tested

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Utilization Performance Measures

• Primary Care Utilization Profiles
• The amount of resources () a provider uses in
  order to care for his/her patient population.
• Includes all costs associated with a providers
  patient population (including specialist care)
• Measuring Utilization
• Physicians are normally measured against their
  peers
• Measurements are per member per month (PMPM)
• Number of members are adjusted for age, sex, and
  risk for comparison purposes

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Utilization Performance Measures
Components of a Utilization Profile

• Professional Cost
• Office Visits
• Billed Services
• Ordered Services
• Referral Costs (PCPs)

• Facility Cost
• Hospital Days
• Skilled Nursing Facilities
• Outpatient Facilities

• Pharmacy Cost
• Cost per Rx
• Number of Rx per patient
• Percent of patients with an Rx

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Other Performance Measures

• Patient satisfaction
• Surveys sent out to random patients asking a wide
  range of questions
• i.e. Would you recommend the physician to your
  family or friends?
• Administrative
• i.e. A practices level of information technology
• i.e. Compliance with current initiatives
• Patient safety
• i.e. The percentage of patient questioned about
  allergic reactions

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Pay for Performance

• Characteristics of a good plan
• Involvement by multiple sectors of the healthcare
  industry as well as the business community
  (purchasers of employee health plans)
• Uniform performance measures across multiple
  health plans
• Significant incentive payments to physician
  groups
• Public scrutiny (report card)

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Pay for Performance in California

• The Integrated Healthcare Association (IHA)
• IHA is a nonprofit statewide healthcare
  leadership group composed of health plans,
  physician groups, hospitals, and healthcare
  systems. Also includes representatives from
  purchasers, pharmaceuticals, technology,
  consumers, and academics.
• The IHA Pay for Performance program is the
  largest in the country.
• 225 physician organizations
• 35,000 physicians
• 6.2 million patients
• All major health plans participate

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Pay for Performance in California

• IHA Performance Measurement Set for 2006 (3
  domains)
• Clinical (50 of total)
• 50 preventative
• 50 chronic disease management
• Patient Experience/Consumer Assessment Survey
  (CAS) (30 of total)
• Versions for primary care physicians and
  specialists
• Questions fall into 5 categories
• Doctor/Patient communication
• Overall ratings of care
• Specialty Care
• Coordination of care
• Timely care and service
• Information Technology (20 of total)
• Show proficiency in one of two areas
• Integration of clinical electronic data sets for
  population based management
• Tools to support clinical decision making at
  point of care

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Pay for Performance in California
Source Transparency Report on 2006 Health Plan
Payouts, Integrated Health Association.
http//www.iha.org/transpf/Transparency20Report2
0200620Final.pdf
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Suggestions to Maximize Performance

• Clinical Performance Tips
• Utilize a team care approach by utilizing the
  skills of others (i.e. Dieticians, Health
  Educators, PAs. etc)

• Implement disease registries or other reminder
  systems for patients with chronic illnesses with
  a Care Coordinator to keep track of patients
  ongoing needs.
• Empower your patients through education, setting
  goals, and the teaching of self-care where
  possible.
• Try to identify patients who are falling through
  the cracks versus patients who are being treated
  regularly.

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Suggestions to Maximize Facility Performance

• Making the right choice
• Does the patient require an acute level of care?
• If the patient needs a diagnostic test, can it be
  performed in another setting?
• How would changing small details of the clinical
  picture alter the need for hospitalization?
• Options for lower level care
• Skilled nursing facility
• Hospice
• Rehabilitation center
• Convalescent Hospital
• Home nursing
• Outpatient diagnostic facilities

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Suggestions to Maximize Performance

• Utilization Tips
• Schedule follow-up appointments in intervals
  based on medical necessity. Set expectations up
  front regarding length of time necessary between
  visits.
• Offer timely and responsive phone support for
  minor illnesses that dont require an office
  visit. Try to avoid scheduling an appointment
  unless it is medically necessary.
• Consolidate visits as appropriate. Utilizing an
  already scheduled well visit for a follow-up
  visit reduces the need for an additional
  appointment.
• Utilize expertise within your practice to reduce
  external referrals.

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Suggestions to Maximize Performance

• Increasing Performance through Technology
• Electronic Medical Records (EMR) can support
• Office workflow
• Prescription writing
• Lab ordering and review
• Visit documentation
• Billing and coding
• Population based patient management
• Clinical decision making at the point of care

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Summary

• Payers in the healthcare system have struggled to
  find ways to reward providers who manage limited
  resources to achieve the best clinical result.
• Pay for Performance Programs provide an incentive
  for providers to deliver quality care efficiently
• Performance is achieved by implementing
  strategies to
• Keep resource utilization to optimal levels
• Use a proactive approach in managing patient
  populations (i.e. patient information, screening,
  and disease management)