DOQ-IT And P4P by fanzhongqing

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									Doctors’ Office Quality-
Information Technology
  (DOQ-IT Initiative):
          and
Paying for Performance

 Oklahoma Foundation for Medical Quality
            (405) 840-2891
              Oklahoma Foundation for
              Medical Quality (OFMQ)
   •   Formerly known as the peer review
       organization (PRO)
   •   Now, called the “QIO”, or quality
       improvement organization
   •   Holds the contract with (CMS) the
       Centers for Medicare & Medicaid
       Services to provide quality improve-
       ment and patient advocacy for Medicare
       beneficiaries in Oklahoma
Oklahoma Foundation for Medical Quality
                     Quality Improvement
                     Organization (QIO):
        •   Primary Mission: To monitor and
            measurably improve the quality of
            health care delivered to Medicare
            beneficiaries

        •   Primary Focus: On systems of care,
            rather than the care delivered to one
            patient at a time
Oklahoma Foundation for Medical Quality
                A “New” National Vision for
                Health Care - Safety, Quality
                and Efficiency:
•   Nearly 40 years ago, the vision for
    electronic health record (EHR) systems
    was born
•   In 1991 the IOM’s report increased
    interest in computer-based patient
    records
•   In 2001 the IOM said information
    technology (IT) must support clinical
    processes
•   Today, we are in “The Year of the
    EHR”                              Waegemann,
Oklahoma Foundation for Medical Quality   MRI, 2004
Oklahoma Foundation for Medical Quality   Leonard D. Schaeffer, Wellpoint presentation, HIT Summit, Washington DC, 10/21/04
              What Does the New Health Care
                 Environment Look Like?

                 •   Cost conscious
                 •   Customer driven
                 •   Web connected
                 •   Information rich
                 •   Best practices known by all
                 •   Patients will become informed
                     purchasers
                 •   Safety, quality and
                     accountability expected
Oklahoma Foundation for Medical Quality
                CMS, DHHS, and
                Federal Action:
•   Start special pilot project : DOQ-IT
•   Collaboration with VA on Vista EHR
•   Medicare Modernization Act: IT demos
•   Appointment of David Brailer, MD,
    National Healthcare IT Coordinator
•   National Health Information
    Infrastructure


Oklahoma Foundation for Medical Quality
                National Health Information
                Infrastructure (NHII):

•   An initiative to improve the
    effectiveness, efficiency, safety and
    quality of health and health care in the
    U.S.
•   Lead by David J. Brailer, M.D.
•   Executive Order calling for widespread
    adoption of interoperable EHRs within
    10 years.
Oklahoma Foundation for Medical Quality
                 NHII: Consumer-centric and
                 Information-rich Health Care :

          •   Medical information follows the
              consumer
          •   Information tools enhance medical
              decision making
          •   Clinicians have appropriate access to
              a patient’s treatment history, medical
              records, medication, lab results,
              etc…
Oklahoma Foundation for Medical Quality
                     Mission of the National
                       DOQ-IT Project:

        Improve physician office care
        management of chronic illness and
        preventive services using workflow
        redesign, evidence-based
        guidelines, best practices, and data
        reporting through the use of
        electronic health record (EHR)
        systems
Oklahoma Foundation for Medical Quality
                  DOQ-IT Project Focuses
                  on Improved Outcomes in
                        Five Areas:
       •   Coronary Artery Disease
       •   Diabetes Mellitus
       •   Heart Failure
       •   Hypertension
       •   Preventive Care (including
           mammography, adult immunizations,
           colorectal cancer screening)


Oklahoma Foundation for Medical Quality
                Clinical Quality Measures:
   •   DOQ-IT measures, jointly developed with AMA’s
       Physicians’ Consortium on Performance Improvement,
       and harmonized with NCQA

   •   Derived from evidence based medicine

   •   Emphasize the ability of the system to output data to a
       clinical data warehouse

   •   Built on HL7 and other standards

   •   Are clearly defined in specifications (see
       www.doqit.org).
Oklahoma Foundation for Medical Quality
                 Key DOQ-IT Project Partners:

      •   American Academy of Family
          Physicians (AAFP)
      •   American Medical Association (AMA)
      •   American College of Physicians (ACP)
      •   Pacific Business Group on Health
          (PBGH)


Oklahoma Foundation for Medical Quality
                 EMR Supports Quality:

        •   Provides a platform for office
            redesign
        •   Rx writing and transmission
        •   Medication interactions and allergy
            checking
        •   Built-in guidelines and protocols
        •   Decision support tools
        •   Online resources
Oklahoma Foundation for Medical Quality
                OFMQ’s DOQ-IT
                Project Goals:
•   Encourage either adoption of full EHR, or
    systems of e-prescribing, e-laboratory results
    management, and e-care reminders/registries
•   Recruit physician practices in both urban and
    rural settings in Okla.
•   Provide ongoing assistance
•   Undertake local/regional initiatives
•   Analyze data to identify strategies and
    opportunities for quality improvement


Oklahoma Foundation for Medical Quality
                 OFMQ Role:

         •   Analyze and support practice
             readiness evaluation
         •   Assist practice in identifying IT
             solutions to meet their needs
         •   Support vendor selection
         •   Provide workflow design
             recommendations


Oklahoma Foundation for Medical Quality
                OFMQ Role (cont’d):

    •   Facilitate data submission and standard
        reporting
    •   Work with practices to review
        population based outcomes
    •   Assist in identifying quality
        improvement interventions
    •   Assist with staff training on electronic
        systems’ capabilities
Oklahoma Foundation for Medical Quality
                  Barriers to EHR Adoption,
                  particularly in Small Practices:

    •   Lack of financial capital for IT investment
    •   Lack of alignment of financial incentives for
        data collection and quality performance
    •   Confusion and uncertainty about vendor
        products and IT industry
    •   Implementation is resource intensive
    •   Successful implementation requires physician
        leadership and culture change


Oklahoma Foundation for Medical Quality
                   Physician Resistance:

What you hear...

         • “I can’t possibly afford this”
         • “This will slow me down”
         • “It may work for others, but
         my practice is different”
         •“Why aren’t the payors
         providing $$ incentives?”


Oklahoma Foundation for Medical Quality
                 Classes of Benefits
                 for EHR Adoption:




       Hard Dollar                  Stretch      Soft
        Benefits                    Benefits   Benefits

Oklahoma Foundation for Medical Quality
                Incremental vs. Big Bang:
                     Pro’s and Con’s
    Incremental Approach:                     Big Bang Approach:
•   Reduces “shock” to staff and          •   Shortens painful “parallel
    physicians                                paper/EMR” operation period
•   Spreads out costs of software         •   Achieves ROI more quickly
    and implementation over longer
    period                                •   Less likely to get “stuck”
•   Project less likely to ‘blow up’          partway to the goal
•   Total training, implementation        •   Higher risk of ‘blow up’
    costs may be higher                   •   Significant productivity hit at go-
•   ROI is not achieved as quickly            live and some time afterward
•   Risk getting ‘stuck’ at midpoint      •   Staff or physicians unable to
                                              cope with change may rebel



          • Larger practices                      • Small practices
          • Complex politics                      • Strong leadership
          • Mixed attitudes                       • Total consensus
Oklahoma Foundation for Medical Quality
                        DOQ-IT Project
                     Compensation/Incentives:
    •   Participating practices do not receive
        financial compensation
    •   The Centers for Medicare & Medicaid
        Services (CMS) is looking at incentives for
        physician offices with EHRs:
                 Rapid payment
                 Increase of payment
                 Pay for Performance

Oklahoma Foundation for Medical Quality
                A Critical Deadlock:
                                Can’t offer incentives
                                 unless benefits and
                              interoperability of EHRs
                                     are assured
                                          Payers




              IT Vendors                                 Providers
            Can’t bring down                        Slow to buy EHRs until
           costs until provider                    costs and risks are lower
          adoption accelerates                     and/or incentives higher


Oklahoma Foundation for Medical Quality
                Creating a Positive Spiral:
                                Assurance of benefit
                              from provider adoption
                               encourages incentive
                                     payments
                                          Payers




              IT Vendors                                 Providers
            Growing market                            Reduced risk and
          attracts investment,                     availability of incentives
              lowers costs                          accelerates adoption


Oklahoma Foundation for Medical Quality
                  Conclusions:

    • The “New Model of Care” and electronic
      medical records will be essential to
      participate in the 21st Century health care
      system.
    • Practice economics, quality, safety,
      efficiency and the need for accountability
      will drive the change
    • Those who are unable or unwilling to make
      the change will not be viewed as providing
      up-to-date medical care.
Oklahoma Foundation for Medical Quality
                  References:
        •   “The Decade of Health Information Technology: Delivering
            Consumer-centric & Information-rich Health Care”
            http://aspe.hhs.gov/sp/nhii/
        •   Achieving Electronic Connectivity in Healthcare: A
            Preliminary Roadmap from the Nation's Public and Private-
            Sector Healthcare Leaders
            http://www.connectingforhealth.org/resources/general
        •   resources.html
        •   Doctors' Office Quality - Information Technology (DOQ-IT)
            http://www.doqit.org/doqit/jsp/index.jsp
        •   Office of the National Health Information Technology
            Coordinator (ONCHIT) http://www.hhs.gov/healthit/
        •   www.ofmq.com

Oklahoma Foundation for Medical Quality
                                P4P
                       Paying for Performance

                    P4P
           Paying for Performance


                Oklahoma Foundation for Medical Quality
                           (405) 840-2891


                                                          27
Oklahoma Foundation for Medical Quality
                  IOM

         IOM reports “To Err is Human”
        and “Crossing the Quality Chasm”
          drew attention to medical errors
          and both overuse and under use
           of many tests and treatments




Oklahoma Foundation for Medical Quality
                 Methods to Raise Quality

        • Practice Guidelines
        • Disease Management
        • Clinical Decision Support Systems



Oklahoma Foundation for Medical Quality
                   Quality

    Purchasers are now exploring linking
     payment to performance as another way
     to improve quality.
    Currently, purchasers pay the same for
     units of service (hospital stay, physician
     visit) regardless of quality of care
     provided



Oklahoma Foundation for Medical Quality
P4P          Setting Performance
 expectations
              Measuring Performance
             Rewarding Results
              (financial and other
 incentives)



 Oklahoma Foundation for Medical Quality
                   Setting Performance Expectations


Collaborative Process – Purchasers, Providers, Consumers

Indicator Measures – Unambiguous, understandable,
  valid, reliable, timely, efficient to collect, risk-adjusted,
  wide applicability




  Oklahoma Foundation for Medical Quality
                 Quality Measures

                     - Structural
                         - Process
                           - Outcomes




Oklahoma Foundation for Medical Quality
                       Quality of care can be measured
                             in different ways…
  Types of
   Quality                                 Examples                                      Initiative
  Measures
Structure     • Computerized Physician Order Entry (CPOE) Systems for              Empire Blue Cross
              Prescriptions: Systems that notify physicians of adverse drug        Blue Shield Hospital
              events                                                               Patient Safety
              • ICU Staffing Levels: Hospital ICU’s staffed with “intensivists”    Initiative
Process       • Childhood Immunizations: % of 2 year olds who received a           Integrated
              specified vaccine regimen                                            Healthcare
              • Asthma: % of Patients with persistent asthma who received at       Association Pay-
              least one prescription for inhaled corticosteroids                   for-Performance
                                                                                   Initiative
Outcome       • Hip/Knee Replacement Clinical Outcomes: Indicators of post         Federal
              operative hemorrhage, post operative physiologic and metabolic       CMS/Premier
              derangement, readmissions 30 days after post discharge, discharge    Hospital Quality
              to home/home health                                                  Incentive
              • Patient Satisfaction Outcomes: Indicators of respect for patient   Demonstration
              preferences, coordination of care, information and education,        Project
              physical comfort, emotional support, involvement of family and       Pacificare Quality
              friends, and transition to home                                      Index Profile of
                                                                                   Hospitals
    Oklahoma Foundation for Medical Quality
                      …and rated based on a variety of
                                 targets.

Type of Performance          Examples
Target
Absolute benchmark           Performing foot exams on a t least 70 percent of diabetic
                             patients



Incremental target           Increasing by 20 percent the number of diabetic patients
                             receiving foot exams



Relative target              Scoring in the top 10 percent of all providers in performing foot
                             exams on diabetic patients




    Oklahoma Foundation for Medical Quality
                  Issues in the Selection of
                      Quality Measures
    •  Outcome measures (i.e. mortality) require risk
      adjustment
    • Disease-specific(B.B. post M.I.) doesn’t necessarily
      reflect overall quality
    • Volume as a proxy (leapfrog) but quality variation
    • Statistical issues with small providers/low volume
      programs
    • Separating hospital performance and medical staff
      performance
    • Subjective standards (communication/satisfaction)
      not easily measured

Oklahoma Foundation for Medical Quality
                 Non-Financial Awards

 •   High rating on publicly disclosed report card
     (healthgrades.com)
 •   Elimination of referral or prior authorization
     requirements for providers
 •   Confidential profiling – (GAP- Guidelines Applied
     in Practice) Michigan study on AMI with
     performance compared to benchmark
 •   Selective Contracting – Choice Plus – Buyers
     Health Care Action Group selectively contracts
     with providers based on performance

Oklahoma Foundation for Medical Quality
                 Financial Rewards/Incentives


          • Bonus Payments
          • Awards for Improvement Projects
          • Fee Schedules Based on Performance
          • “At-Risk” Contracting
          • Cost Differentials for Consumers




Oklahoma Foundation for Medical Quality
                   Bonus Payments

            •   Provider meeting predetermined
                standards receive higher
                payments
                Examples: CMS/Premier Hospitals (278
                participating) PacifiCare Quality Incentive
                Program BCBS of Hawaii – QSP program




Oklahoma Foundation for Medical Quality
                    An Example of Bonus Payments:
                      PacifiCare Quality Incentive
                               Program
   Percentage Change in Service Rates from 2Q 2002 to 2Q 2003

                                                                             44.7



                         27.3


                                                            15.9

        7.6                               8.3



  LDL Cholesterol   Hemoglobin H1C    Breast Cancer    Cervical Cancer     Childhood
     Testing           Testing          Screening        Screening       Immunizations

Source: Managed Care Outlook, Offering physicians Incentives Helps Boost Clinical
    Oklahoma Foundation for
Indicators, August 1, 2003 Medical Quality
                                           An Example of Bonus Payments: BCBS
                                               of Hawaii Quality and Service
                                                   Recognition Program

                             Change in Total Points by Hospital (100 Points Possible)
                                                   2001-2002
                        16

                        14                                                                    13.5

                        12
                             10.1                                                                                 10.4
Change in HQSR Points




                        10                                                                                  9.3

                        8                                                               7.6
                                                  6.1
                        6
                                                                        4.5
                                            3.7
                        4

                        2
                                                               0.3
                        0
                                    -0.3
                        -2                                                       -1.1                -1.3
                        -4                              -2.5
                             A      B       C     D     E      F        G        H      I      J     K      L     M
              Oklahoma Foundation for Medical Quality                Hosptials
                   Awards for Improvement Projects

               •   Buyers Health Care Action Group
                   (BHCAG), Minnesota financial
                   awards for systems with
                   improvement projects
               •   Empire BCBS increasing hospital
                   payments for implementing patient
                   safety measures


Oklahoma Foundation for Medical Quality
                    Fee Schedule Based on
                         Performance

                •   Central Florida Health Care Coalition
                    (CFHCC) grouping physicians –
                    Platinum, Gold, Silver based on
                    national standards
                •   Payment above, at, or below Medicare
                    schedule




Oklahoma Foundation for Medical Quality
                “At-Risk” Contracting

                   •   Portion of reimbursement
                       increases contingent upon
                       performance
                   •   Anthem BCBS an example




Oklahoma Foundation for Medical Quality
                  An Example of “At-Risk” Contracting:
                Anthem Midwest Hospital Quality Program

                 2002 Hospital Quality Program Scorecard

      Section                                         Possible Points


      Hospital Quality Improvement Plan & Program          29
      Joint Commission Grid Score                          10
      ED/Asthma/Pneumonia                                  24
      Cardiac Care                                         22
      Joint Replacement Care                               22
      Obstetrical care                                     16
      Cancer Care                                           8
      Acute MI/Congestive Heart Failure                     8
      Patient Safety                                        6
      Total                                                145

Oklahoma Foundation for Medical Quality
                   2002 Hospital Quality Program Scorecard

                          Reimbursement Increase Schedule
                                   2002-2005
Reimbursement
Relative

Rate




                2002            2003            2004             2005

                  Proportion of rate increase based on clinical quality
                  Base increase in hospital contract rate

 Oklahoma Foundation for Medical Quality
                  Cost Differentials for Consumers

    •   Aetna and Blue Shield of California

    •   “Tiered” networks, with lower co-
        payments or deductibles when “higher-
        quality” providers are used.

    •   “Choice” Providers / ”Affiliate” Providers


Oklahoma Foundation for Medical Quality
                 Reporting                     Rewarding

               Voluntary                  Involuntary


             CMS/AHA Quality Initiative
             tied a 0.4% full market basket update
             for Medicare only reporting hospitals



Oklahoma Foundation for Medical Quality
                Reporting Requirements

                                Hospitals
    2004                                       2006

10 Indicators                               23 Indicators




Oklahoma Foundation for Medical Quality
                Reporting “Requirements”

                              Physicians
2004                                       2006
Diabetes, Mammography                      CAD         7
Adult Immunizations                        Diabetes    8
5 Indicators                                 CHF          8
                                               HTN          3
                                               Preventive 9
                                                    35
       Indicators
Oklahoma Foundation for Medical Quality
                 DOQ-IT Measures Overview

      The set of health care quality measures that will be used to track
        progress in achieving the goals of the DOQ-IT project are:

    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


Oklahoma Foundation for Medical Quality
                   DOQ-IT Measures Overview
                                      (Cont’d)
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

Oklahoma Foundation for Medical Quality
                 Reporting


Voluntary                    Incentives   Involuntary
Reporting                    Penalties    Reporting




Oklahoma Foundation for Medical Quality
Reporting                                    Rewarding

                      •   Bonus Payments
                      •   Performance Based Fee
                          Schedule
                      •   Awards
                      •   “At-Risk” Contracting
                      •   Consumer Differentials

Oklahoma Foundation for Medical Quality
                     Sample P4P Programs
•     Aetna
                                               Cigna and Promina (GA)
•     Anthem Blue Cross Blue Shield of
      Midwest (OH, IN, KY)                    Empire Blue Cross and Leapfrog employers
•     Anthem Blue Cross Blue Shield of VA     Employer Coaltion on Health
      (formerly Trigon)                       Harvard Pilgrim Health Care (MA)
•     Blue Cross Blue Shield of IL            Hawaii Medical Service Association (Blue
•     Blue Cross Blue Shield of MA            Cross Blue Shield of HI)
•     Blue Cross Blue Shield of MN            HealthGaurd (PA)
•     Blue Cross Blue Shield of MI            Health Net
•     Blue Cross Blue Shield of MO            HealthPartners (MN)
•     Blue Cross Blue Shield of Rochester     Highmark Blue Cross Blue Shield (PA)
      (Excellus) and Rochester IPA (NY)
                                              Independence Blue Cross (PA)
•     Blue Cross of CA
                                              Independent Health (NY)
•     Blue Shield of CA
                                              Integrated Healthcare Associtaion (IHA)
•     Bridges of Excellence                   Local Initiative Rewarding Results (CA)
•     Buyers Health Care Action Group         Pacificare (CA)
•     Centers for Medicare and Medicaid
                                              Tri-River Healthcare Coalition (OH)
      Services (CMS) and Premier Inc.
•     Cigna (CA)                              Western Health Advantage (CA)
    Oklahoma Foundation for Medical Quality
                  AMA’s 5 Ps 4 P4P
                  (5 Principles for paying for Performance)



          1.     Ensure quality of Care
          2.     Fosters the patient-physician
                 relationship
          3.     Voluntary participation
          4.     Accurate data and fair reporting
          5.     Fair and equitable incentives


Oklahoma Foundation for Medical Quality
The light at the end of the tunnel may be…
               the train coming.

But the train represents Physician reporting
 and the caboose is Pay for Performance. In
  the 21st Century, none of us can afford to
                miss the train.


 Oklahoma Foundation for Medical Quality
                  All Aboard!!




Oklahoma Foundation for Medical Quality

								
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