Summary of Efficiency Measurement Workshop Meeting by homers


									                Summary1 of Cost of Care Measurement Workshop Meeting
                             Thursday, September 7, 2005

Todd D. Anderson, Government Accountability Office
Anne-Marie J Audet, The Commonwealth Fund
Michael Barr, American College of Physicians
Gifford Boyce-Smith, Blue Shield of California
Kathy Coltin, Measures to Market Project
Tim Cuerdon, American College of Physicians
Trudie Cushing, American College of Radiology
Lou Diamond, Medstat
Irene Fraser, Agency for Healthcare Research and Quality
Sheldon Greenfield, University of California, Irvine
David Gregg, Mercer Human Resource Consulting
Stuart Guterman, The Commonwealth Fund
Sam Ho, PacifiCare
David Hopkins, Pacific Business Group on Health
George J. Isham, HealthPartners
Michael S. Johnson, Kaiser Permanente
Michele Johnson, Medical Group Management Association
David C. Kibbe, American Academy of Family Physicians
Karen Kmetik, American Medical Association
David Knutson, Park Nicollet Institute
Tammie Lindquist, HealthPartners
Leonard Lucey, American College of Radiology
Sharon L. McGill, American Osteopathic Association
Karen Milgate, MedPAC
Arnold Milstein, Mercer Human Resource Consulting
Anne Mutti, MedPac
Ryan Mutter, Agency for Healthcare Research and Quality
Erin T. O’Brien, American Medical Association
Margaret O’Kane, National Committee for Quality Assurance
Greg Pawlson, National Committee for Quality Assurance
Chris Queram, Employer Health Care Alliance Coop
Michael Rapp, CMS
Mark Rattray, United Healthcare
Philip Renner, National Committee for Quality Assurance
Sarah Hudson Scholle, National Committee for Quality Assurance
Cary Sennett, American Board of Internal Medicine
Richard Snow, American Osteopathic Association
Rosemarie Sweeney, American Academy of Family Physicians
J. William Thomas, University of Southern Maine
Phyllis Torda, National Committee for Quality Assurance
Sally E. Turbeyville, National Committee for Quality Assurance
Howard Underwood, Aetna Integrated Informatics
Thomas Valuck, CMS/CMM

 Please note that to better organize this summary; some of the comments have been taken out of
chronological order.

Jonathan P. Weiner, Johns Hopkins HSR&D Center
Anne Weiss, Robert Wood Johnson Foundation
Kevin Weiss, American College of Physicians
Pamela A. Wilcox, American College of Radiology
Nancy Wilson, AHRQ
Reva Winkler, National Quality Forum
Herbert Wong, AHRQ
Timothy C. Zeddies, Independence Blue Cross

AHIP Staff
Carmella Bocchino
Rebecca Hayes
Joni Hong

Kevin Weiss, as chair of the performance measurement workgroup, convened the
meeting, reviewed the consensus process that has been utilized by the AQA, and
discussed the objectives of the meeting – to gain a broader understanding of the term
efficiency measurement, how these measures are currently being used in the marketplace
to evaluate performance and to reach consensus on areas of common agreement across
stakeholders. He also acknowledged the interest in efficiency measures and the challenge
that these measures have not been pilot-tested similar to many clinical quality measures
have and they are not currently under review by NQF. Dr. Weiss encouraged
participation from all attendees and asked participants to review the “Parameters”
document as the parameters have been agreed upon by AQA participants and may inform
today’s discussion.

Framework, Definitions and Principles
Greg Pawlson, Executive Vice President, NCQA Creating a Practical Framework for
Measuring “Efficiency,” summarized the following: working definitions for key terms of
efficiency; starter set of principles and guidelines for efficiency; unmet challenges; and
the consequences of not developing efficiency measures.

Tim Cuerdon, Senior Associate, American College of Physicians, (Ambulatory Care
Efficiency Definitions and Discussion) reviewed the classical economic definition of
efficiency and medical efficiency, as well as provided several caveats for further

   Resource use should be tied to health status for it to be considered a measure of
   It is challenging to measure health status as an outcome measure.
   Current algorithms for resource utilization use “groupers” (episode treatment groups)
    efficacy of “groupers” remains undetermined, especially for measures of chronic
   Health plans currently compare physicians within local markets, but larger
    geographic comparisons should also be made (national/ regional).

   Operationalizing measures that appropriately define effective care, waste, overuse,
    underuse, and misuse, will be difficult.
   Recommendations:
       o Identify ways to measure waste and eliminate it.
       o Identify and/ or develop the appropriateness criteria that can be used to
           develop overuse measures.
       o Develop, test and validate misuse measures.
       o Be aware of unintended consequences of measuring resource consumption of
           physicians (which could result in appropriate care not being provided).
       o Specific measures of overuse, waste and misuse are currently more accurate
           than composite measures of efficiency.

Objectives for efficiency measurement were presented by George Isham to promote the
 Identify and apply a system of tools for:
    o Maximizing value and efficiency driving toward optimal states of health for
       individual patients, subgroups with like conditions (or health states), populations
       in regions, and the nation as a whole.
    o Improving value and efficiency in the short and long term for consumers and
    o Reducing variation, waste, misuse and overuse to achieve optimal resource
    o Making policy decisions around resource allocations within the health care sector
       and between other sectors of the economy.
    o Encouraging innovation in health care delivery and changing physician behavior
       to improve quality and efficiency.

Issues for further discussion:
 Some participants agreed that measures to decrease waste, misuse, and overuse
    should be aggressively pursued;
 Potential objectives/ parameters for efficiency use; and
 Common definitions.

Discussion of Presentations
After a lengthy discussion of the different possible definitions of efficiency, it was
decided to create two working definitions of efficiency, -- “cost efficiency” that would
measure relative resource consumption and “economic efficiency” which would represent
resource consumption for a given level of health quality or health benefit.

The participants agreed on several key points:
 Developing a common language (i.e. standardizing definitions) was necessary to
   move forward.
 Measuring resource use without taking quality into account was only part of the
   equation and insufficient to measure physicians. However, purchasers would want a
   construct that had total cost as the denominator.
 It was suggested that efficiency could be applied to different providers and settings:

           o Efficiency from a systems-perspective (overall health and spending): amount
               of resources devoted to a population as graded by their outcomes in health.
           o Service efficiency (services more or less applied to certain population): for a
               given procedure, when and how much benefit per procedure.
           o Provider efficiency: how effective a provider delivers services: cost of
               provider; how much benefit provider gives to health plan enrollees.
      Because efficiency is so dynamic (depending on users and developers of measures),
       efficiency itself should be looked at as a multi-dimensional construct for the purposes
       of this group.
      Physicians must have a central role in developing efficiency measures.
      Efficiency measure development should be transparent and include reports to
       physicians. This is an important function of efficiency measurement and will provide
       a basis for influencing physician behavior change.

Possible standardized terms and definitions were drafted by a core volunteer work group
(p. O’Kane, A. Milstein, and C. Sennett) of the participants.2

      Definitions related to performance measures of efficiency were proposed:

“Cost-efficiency”3 is a measure of the total health care spending, including total
resource use and unit prices, by payor and consumer combined, for a single health care
service or group of health care services, associated with a specified patient population,
time period and unit(s) of clinical accountability.

“Quality of care” is a measure of performance on the five other IOM-specified health
care aims (safety, timeliness, effectiveness, equity, and patient centeredness).

“Economic efficiency” is a measure the cost-efficiency associated with a specified level
of quality or the quality associated with a specified level of cost-efficiency.

“Value” is a measure of specified stakeholder’s (such as an individual patient’s,
consumer organization’s, payor’s, provider’s, government’s or society’s) utility-
weighted assessment of a particular combination of quality and cost-efficiency
performance scores.

State of the Art in Measurement and Research: Measuring Quality – “Total Quality

Sarah Hudson Scholle, Assistant Vice President, Research and Analysis, NCQA,
Measuring Quality at the Physician Level: State of the Art and Challenges for the Future.
Sarah Hudson Scholle reviewed basic concepts in quality performance measurement:

    Discussion on these terms continued post-workshop; edited versions were inserted here for clarity.
    Terms are in quotes to indicate that they may be modified after further discussion.

   Summary review of quality measure development, including review of potential users
    of measures, desirable attributes of quality measures and approaches for choosing
    measures for clinical performance.
   Attribution of care to correct physician:
    o Health plan assignment of primary care physician or number of visits physician
        saw patient.
    o Service provided is within the physician’s scope of expertise (specialty-based
        visit, claims, or diagnosis code.
    o Influence of office practice effects.
    o Impact of multiple physician practices.
   Reviewed possible scoring methodologies, aggregate/ composite measures, and
    overall quality scores.
   When comparing overall quality scores, sample size, thresholds for quality, case-mix
    adjustment and consistency over time should be evaluated.
   Data that is reported should have a clearly defined, transparent process and have
    physician involvement.
   Challenges to Performance Measurement
    o Measures need to be understandable and meaningful to consumers.
    o Attribution of care among different providers is challenging.
    o There are considerable differences in structure and models of health plans, DM
        companies, and physician groups.

George Isham, HealthPartners, Reactant
 One physician versus a physician group is important and relevant to the discussion.
 Between developing version 1 and version 2 of a measure set, there will be a
   significant change and revision because of other factors informing the process.
 Efficiency work should anticipate the development of an electronic health record.
   Standards for aggregation of data on physicians should be developed accordingly.
 Quality and efficiency measures should be biased towards clinical measures versus
   system measures.
 Attributable physicians should be held accountable but methodology should also
   include exclusions to measurement.
 Case-mix and risk- adjustment should be addressed.
 Measures should be patient-centered. The patient should be the building block. For
   example, with a diabetes composite measure, the patient should be scored on
   achieving a certain level of quality and every patient should be evaluated based on
   aggregate experiences of the physician group.
 While measures that are easily understandable to consumers are important, measures
   should first be developed for the health care system. “Consumer-friendly” measures
   should come secondarily.

Discussion items:
 Participants agreed that defining the level of accountability would be challenging but

   Risk-adjustment is also necessary. That being said, if certain levels of quality are
    difficult to achieve, they should not be “adjusted away.”
   Current experiences and examples of measures will help inform the work of this
    group and should be consider before going forward.

State of the Art in Measurement and Research: Measuring Resource Consumption
– “Total Resource Consumption Score”

William Thomas, Institute for Health Policy, University of Southern Maine,
Economic Profiling of Physicians
Bill Thomas reviewed several critical questions regarding economic profiling of
 Claims data is used to calculate costs of services and resources used by a physician in
    treating a group of patients.
 Costs are compared to expected costs for those patients, given clinical and
    demographic characteristics.
 Physicians whose actual costs are less than expected costs are considered efficient;
    those physicians whose actual costs are greater than expected costs are considered
    inefficient. (As discussed earlier in the meeting, this type of efficiency would fall
    under the definition of “cost-efficiency.”
 Efficiency scores are developed using software that “groups” patient claims into
    episodes of care based on diagnostic and demographic characteristics.
 These episodes of care costs are compared to a physician’s actual costs.
 Reliability depends on several factors, if a group is partitioned into three groups,
    efficient, average, and inefficient, 15-30% will be misclassified at any time.
 Reliability is very sensitive to sample size; sample size needs can vary by specialty.

Sheldon Greenfield, Director, Department of Family Medicine, University of
California – Irvine, Reactant
Sheldon raised several questions that need to be answered when economically profiling
 Does the profiling have a primary care focus?
 What is the attribution level?
 What is the statistical and financial meaning of differences (i.e., between physicians)?
 Where are the costs? What savings is the focus?
 More work needs to be done on the time period for each episode of care.

Gifford Boyce-Smith, Director, Quality Improvement, Blue Shield of California,
provided examples used by BS California and offered several recommendations:
 The state of California is a little different because of the preponderance of network
 The denominator is critical; the sample size should be at least 20 per physician.
 The attribution logic does matter, especially in the PPO environment where it is
   harder to hold one physician accountable for patients who see multiple providers.
 Physicians with large resource use need to be evaluated as potential outliers.

   Cost/ price variation should be removed.
   Risk adjustment should be done according to the episode index not the calendar (360
    days for a chronic condition too short).
   Comparisons should be made locally so that variations in prices of different regional
    areas will not skew results.
   Some national aggregation is needed to make broader comparisons.

At the end of this discussion Kevin Weiss requested several participants work together to
create a document that would describe how efficiency measurement could be accelerated
to market.

State of the Art in Measurement and Research: Measuring Resource Consumption
– “Building Evidence-Based Measures for the Furture”

Irene Fraser, Director, Center for Organization and Delivery Studies, AHRQ,
presentation, Building Evidence-Based Efficiency Measures for the Future: Towards
Version 2.0, provided an overview of AHRQ’s initiative on health care efficiency
 AHRQ has commissioned a report, Identifying, Categorizing, and Evaluating
    Healthcare Efficiency Measures. The contract regarding the report will be awarded
    in September.
 Steps include
    o Scan and review literature and practice. (January 2006)
    o Develop typology: consult with experts, provide definitions and meanings.
        (March 2006)
    o Identify evaluation criteria. (April 2006)
    o Evaluate measures and identify future needs: Produce report of potential measures
        for use by AQA and HQA. (Final report October 2006)

Implementing Efficiency Measurement for Physicians- Lessons from the Field/
Good Practices

Mark Rattray, National Medical Director, UnitedHealth Premium Designation
Programs, UnitedHealthcare, Clinical Performance Measurement and Value
Improvement , reviewed his experience with combining clinical and value data on

Value derived from performance measurement:
 Engagement of physicians around the opportunities.
   o Costly practice patterns that don’t add value.
   o The need to deliver timely and effective recommended care.
 Health plan member education and decision support.
   o Identified high value providers for condition-specific care.
 Cost and quality can and must be improved.
   o Cost and quality variations exist, however most clinicians are largely unaware of
       their own performance.

    o There is an untapped physician’s enthusiasm for improvement.
    o Health plans have a unique opportunity to add value.
   What is happening now and in the near future?
    o More entities are launching measurement efforts
    o Engaging clinicians to examine care variation and improvement.
    o Aligning incentives with performance.
    o Developing decision tools for providers, members, and purchasers.

Timothy Zeddies, Senior Director, Research and Evaluation, Independence Blue
Cross, Reactant
 You must look at very specific episodes of care to have accuracy and reliability.
 Reporting and rewards are very important, otherwise care (and physician behavior)
   will not change.
 Question to ask: What are the right conditions needed to move ahead even with

General Discussion
 There needs to be a sense of urgency to reduce variations in care; this is an
   opportunity to change physicians behavior.
 Urgency to market is doable and necessary.
 The electronic health record (EHR) is the theoretical savior, however there has only
   been a small amount of discussion on items to include in the EHR.
 Physicians need to improve quality and embrace public reporting.
 Example, the Wisconsin Collaborative for Health Care Quality:
   o Voluntary public reporting, partnerships with local purchasers, there is a data
      repository, data includes both claims and pharmacy, as a result 25% of
      community’s data is being collected.
   o Pooling data primarily for physician profiling.
 Regence has been working for 8 years with public disclosure and incentives; did one-
   time bonuses to physicians and realized overall savings.
   o Need to pay attention to unintended consequences, it is unknown if there was any
      reduction in quality that balanced out the savings.
   o The appeals and overturn rates are still the lowest in the region, low hassle index
      and HEDIS scores are rising.
 Move forward with the imperfect. Proceeding with the imperfect should be evaluated
   with the cost consequences of not doing anything to stop the increasing amounts of
   uninsured, inadequate care, and waste.

Next Steps
 Invite to the Efficiency Workgroup, three major vendors producing efficiency
   groupers to present their products, how they are used in the marketplace to evaluate
   performance, and the rules and logic applied to groupers.


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