48 - Conference of Consulting Actuaries by wulinqing

VIEWS: 5 PAGES: 38

									“What’s Driving P4P and Where Are We”




    R. H. Walker MD
    October 25, 2006
National Pay for Performance (P4P) Programs

 • Momentum started with IOM reports
 • Employer market is looking for better quality
   ROI for health care dollars – Bridges to
   Excellence
 • Medicare Initiatives in P4P
 • President Bush’s goals for EMRs
Medical Errors –
Institute Of Medicine Report

  • 44,000 – 98,000 Americans die from medical errors
    annually
  • Only 55% of patients received recommended care
  • Medication-related errors of hospitalized patients
    cost roughly $3.5 billion annually
  • Medical errors kill more people per year than
    breast cancer, AIDS, or motor vehicle accidents




To Err is Human, Crossing the Quality Chasm, Preventing Medication Errors: The IOM Health
Care Quality, 1999, 2001, 2006
                Condition      % Recommended
                                Care Received
Low back pain                       68.5
Coronary artery disease             68.0
Hypertension                        64.7
Depression                          57.7
                                                  RAND Study
                                                  Confirms Quality
Orthopedic conditions               57.2
                                                  Gap
Colorectal cancer                   53.9
Asthma                              53.5
Benign prostatic hyperplasia        53.0
Hyperlipidemia                      48.6        Elizabeth McGlynn, et al,
Diabetes mellitus                   45.4        “The Quality of Health
                                                Care Delivered to Adults
Headaches                           45.2        in the United States,”
                                                NEJM, Vol. 348:2635-2645
Urinary tract infection             40.7        June 26, 2003 (No. 26).

Hip fracture                        22.8
Alcohol dependence                  10.5
 Health Care Quality Defect Rates Occur at Alarming Rates

                             Overall Health Care in U.S. (RAND)
         Breast cancer
                                       Outpatient ABX for colds
         screening (65-69)
    1,000,000                                 Hospital acquired infections

     100,000                                           Hospitalized patients
              Post-MI                                  injured through negligence
      10,000 b-blockers
Defects                                                 Airline baggage handling
                   Detection &
  per 1,000
                   treatment of Adverse drug                      Anesthesia-related
million                            events
         100        depression                                    fatality rate

          10                                                        U.S. Industry
                                                                    Best-in-Class
           1        1     2           3       4      5      6
                  (69%) (31%)       (7%)   (.6%) (.002%)
                                                       (.00003%)
                                 s level (% defects)
                                                    Source: modified from C. Buck, GE
2005 National P4P Study

                     90
                     80
Number of Programs




                     70                              25% increase
                     60                               from 2004
                     50
                     40
                     30
                     20
                     10
                      0
                          Commercial     Medicaid      Medicare       Employer             Other
                          Health Plans                                 Groups

                                    2005 National Pay for Performance Study, Med-Vantage
Key Findings from the National P4P Study


 • Expansion to PPO and CDH Products
 • Expansion to specialists – 52%
 • Increasing use of tier fee schedules rather than
   bonus payments
 • Demonstration of ROI
 • Growing interest in public reporting
 • CMS in the P4P market


                           2005 National Pay for Performance Study, Med-Vantage
    Transparency



    – Provide health care consumers
      information to make the right
      decision




"If you don't want people to see your data, you're in the wrong century,"
                  Dennis O'Leary, Chief Executive Officer JCAHO, Aug 2006
Why Transparency ?


 • Market Demand – Employers
 • Consumerism
 • Impact on quality outcomes
   and affordability
President Bush Calls On Hospitals To
Share Price And Quality Data, AHA Issues
“Roadmap” To Price Transparency
      May 1, 2006 address to the annual meeting for the
      American Hospital Association

“Every hospital represented here should take action to make
information on prices and quality available to all your patients.
If everyone here cooperates in this endeavor we can increase
transparency without the need for legislation from the United
States Congress,” said Bush



                                  American Health Lawyers Association website – May 2006
Three Components of Transparency

 Helping consumers make informed health care choices as
 consumers are asked to pay a greater portion of the cost of care




                                              Decision
      Cost                Quality
                                              Support
Cost of Care

 Cost Sources                Issues
 • Hospital Claims    • Relative Scales vs
   • Inpatient          Absolute Dollars
   • Outpatient       • Costs by Treatment
 • Physician Claims     Episodes vs single CPT
 • Other services       codes
   • Pharmacy         • Differences in benefit
   • DME                designs
                      • Global rates
Quality of Care

      Metrics                     Issues
• National Measures such   • Issue of small
  as HEDIS                   numbers
• Satisfaction surveys     • Need for national
• Needs to be both by        benchmarks
  hospital and physician   • All payer data bases
• Focus on quality not     • Risk adjusted data
  cost efficiency
Decision Support


• Information needs to be relevant for a member’s
  plan and benefit design
• Absolute necessity with consumerism
• Needs to include a comparison tool
• Needs to be linked to both quality and cost
Virginia Pay for Performance Programs

   Strategy to match reimbursement to evidence
   based medicine and quality of care outcomes
    • Quality-In-Sights Hospital Incentive Program –
      (Q-HIPSM)
    • Quality Physician Performance Programs - (Q-
      P3SM)
      • Cardiology
      • Gastroenterology
      • Cardiac Surgery
    • Performance Extra - PEX
Q-HIPSM - Successful in Aligning with National
Performance Based Incentive Principles

   • AMA, JCAHO, CMS, AHA, MGMA all have P4P
     principles
   • Q-HIP
      • Is voluntary
      • Consistently applies nationally vetted and recognized
        evidence based indicators
      • Aligns reimbursement with the practice of high quality
        and safe health care for all consumers
      • Is transparent with PSO validation and auditing of data
      • Available to all network hospitals
Quality-In-Sights Hospital Incentive Plan




 “By working together we can improve
 the quality and reduce the variation in
    care delivered across the entire
       program coverage area”
Q-HIPSM- A Collaborative Effort
Q-HIPSM- VHI-Developed Web Tool
 Q-HIPSM in Virginia
• 60 hospitals to participate in Q-HIPSM by 2006
• 11 large health systems
• 92.7% of Anthem inpatient admissions in Commonwealth
  of Virginia
• Rural, local and tertiary care hospitals
• All regions of the Commonwealth represented
• Outside Virginia
   • Northeast Region (ME, NH, CT): 24 hospitals
   • Georgia: 20 hospitals
   • New York: 40 hospitals (planned)
   • Western Region: (CO, NV): 19 hospitals
   Scorecard Components
Patient Safety Section                              Patient Health Outcomes Section (60% of
(25% of total Q-HIP Score)                          total Q-HIP Score)

•JCAHO Hospital National Patient Safety Goals       ACC-NCDR Section
                                                    •7 ACC-NCDR Indicators for Cardiac Catheterization
•Computerized Physician Order Entry (CPOE) System
                                                    and PCI

•ICU Physician Staffing (IPS) Standards             JCAHO National Hospital Quality Measures
                                                    •Acute Myocardial Infarction (AMI) Indicators
•NQF Recommended Safe Practices
                                                    •Heart Failure (HF) Indicators
•Rapid Response Teams                               •Pneumonia (PN) Indicators
                                                    •Surgical Care Improvement Project (SCIP)
•Patient Safety and Quality Improvement Measures    •Pregnancy Related


Member Satisfaction Section
(15% of Total Q-HIP Score)
                                                    CABG Indicators
•Patient Satisfaction Survey                        •5 STS Coronary Artery Bypass Graft (CABG) Measures

•Hospital-Based Physician Contracting
Upfront Costs by Hospitals to Implement Q-HIPSM



 • ACC-NCDR:       $2,995
 • STS Database: $2,850
 • Additional FTE*: NA
Outcomes (All-Payer): Serious complications –
Cardiac catheterization

  3.5%   22% decrease                      29% decrease
                            3.00%
  3.0%    2.70%

  2.5%              2.10%                  2.10%

  2.0%

  1.5%

  1.0%

  0.5%

  0.0%
         2003      2004     2003           2004
            National               Q-HIP

                                                   Confidential for internal use only
Outcomes (All-Payer): Serious complications – PCI
(angioplasty)

 6.0%                      5.40%          47% decrease
         20% decrease
 5.0%    4.50%

 4.0%              3.60%
                                          2.90%
 3.0%

 2.0%

 1.0%

 0.0%
        2003      2004     2003           2004
           National               Q-HIP

                                                  Confidential for internal use only
Outcomes (All-Payer): Door-to-balloon time of 90
minutes or less
                             17% increase
                                            58.6%
  60.0%    12% increase
                             49.7%
  50.0%              46.0%
           41.0%
  40.0%

  30.0%

  20.0%

  10.0%

   0.0%
          2003      2004     2003           2004
             National               Q-HIP
                                                    Confidential for internal use only
 Surprising Developments


• One large hospital reports Q-HIP scores to its
  board of directors annually.
• A number of hospitals include Q-HIP scores
  as part of their own internal corporate
  performance reporting
• A major academic medical center ties Q-HIP
  scores to front-line staff salary bonuses
Because (Q-HIP) uses aggregated hospital-wide performance data, it
overcomes problems with small numbers and difficulties with attributions.
Because the rewards are based on shared performance, the program is
intended to create incentives for competing physician groups to work
together with hospital administration in a cooperative manner to achieve
continuous quality improvement.
Congressional Testimony of John Brush, MD, American
College of Cardiology July 27, 2006



This is a win-win situation in my mind. As health care providers, we always
strive to do the right thing for our patients. The reality is this sometimes
costs more in terms of putting in place new structures and processes to
support a better way of delivering services.
Ron Clark, MD, Chief Medical Officer, VCU Health System
Quality Physician Performance
Program – Q-P3SM
Q-P3SM - Cardiology
• Voluntary Program
• Based on an all payers data base except for the
  pharmacy measure
• Mirrors QHIP indicators to align incentives
• Final Scorecard results are based on hospital
  market share
• Rewards are based on excellence
                           QUALITY PHYSICIAN PERFORMANCE PROGRAM (Q-P3SM)
                                            Practitioner Report
Physician Group                           SAMPLE CARDIOLOGY GROUP JULY 1, 2006 - JUNE 30, 2007
Scorecard for Q-P3
Market Share based on cardiac cath codes only for 07/01/2006 - 06/30/2007
                                                                                                         YOUR GROUP'S MARKET DISTRIBUTION
                                                                                                                            Your Group -     % of your
                                                  Points  Max      Low        Mid      High                                     Total       group total
                    Indicator                    Awarded Points Benchmark Benchmark Benchmark                                Patients at patients seen
ACC-NCDR Measures                                                     3.00       4.00      6.00       Q-HIP Hospital        this hospital at this hospital
Rate of serious complication-diagnostic caths              6.00    N/A        N/A     ≤2.5%                          Centra       0              0%
Door to balloon time for primary PCI ≤ 90 min              6.00 70%-80%     80%-90%    ≥90%                   Chippenham          0              0%
Door to balloon time for primary PCI ≤ 120 min             6.00    N/A        N/A      ≥82%        Carilion Medical Center        0              0%
% of patients receiving clopidogrel                        6.00    N/A        N/A      ≥90%               Danville Regional       0              0%
% of patients receiving statins @ discharge                6.00    N/A        N/A      ≥90%                         DePaul        0              0%
Rate of serious complication-PCI                           6.00    N/A        N/A     ≤3.75%               Henrico Doctors        0              0%
Risk-adjusted mortality rate                               6.00    N/A        N/A     ≤1.5%                     Lewis Gale        0              0%
JCAHO AMI Measures                                                     2.00      3.00      4.00           Martha Jefferson        0              0%
Aspirin at arrival                                         4.00 75%-90%     90%-95%    ≥95%          VCU Health System            0              0%
Aspirin prescribed at discharge                            4.00 75%-90%     90%-95%    ≥95%                       Maryview        0              0%
ACEI for LVSD                                              4.00 75%-90%     90%-95%    ≥95%             Memorial Regional         0              0%
Beta blocker at arrival                                    4.00 75%-90%     90%-95%    ≥95%                  Riverside Reg        0              0%
Beta blocker prescribed at discharge                       4.00 75%-90%     90%-95%    ≥95%              Sentara CarePlex         0              0%
Smoking cessation advice                                   4.00 75%-95%       N/A      ≥95%                  Sentara Leigh        0              0%
JCAHO Heart Failure Measures                                          1.00       2.00      3.00            Sentara Norfolk        0              0%
LVF assessment                                             3.00 75%-90%     90%-95%    ≥95%             Sentara VA Beach          0              0%
ACEI for LVSD                                              3.00 75%-90%     90%-95%    ≥95%                      St. Mary's       0              0%
Smoking cessation advice                                   3.00 75%-90%       N/A      ≥95%                University of VA       0              0%
Discharge instructions                                     3.00 75%-90%     90%-95%    ≥95%         Sentara Williamsburg          0              0%
                                                                                                               Winchester         0              0%
Generic Dispensing - Statins - BONUS                       2.00    N/A        N/A            48%
                                         TOTAL            80.00




                                           PAYMENT MATRIX
                 If total score is                   the additional fee schedule impact is
                  68.00 - 80.00                                       High
                  56.00 - 67.99                                       Low
                     < 56.00                                           0%



Your Group's Reward is
Q-P3SM - Cardiac Surgery
• Voluntary Program
• Based on an all payers data base from the
  Society of Thoracic Surgery
• Developed in collaboration with Virginia
  cardiac surgeons - Virginia Cardiac Surgery
  Quality Initiative
Sample Scorecard for Cardiac Surgery

                                                 Points for          Points for
                                         Low       Low      High       High
               Indicator              Benchmark Benchmark Benchmark Benchmark
    STS Clinical Indicators
     CABG Operative Mortality
    Rate - Risk Adjusted                ≤2.20       10       ≤1.32       20
     Surgical Re-exploration - Risk
    Adjusted                            ≤3.3%       10       ≤2.3%       20
     Prolonged Intubation - Risk
    Adjusted                            ≤8.3%       10       ≤6.4%       20
     Pre-Operative Beta Blockade        ≤75%         5       ≤85%        10
     IMA Use                            ≤80%         5       ≤90%        10
     Discharge Medication
    Compliance
         Anti-platelet                 ≥93.1%      N/A       ≥93.1%     N/A
         Beta Blocker                  ≥84.7%      N/A       ≥84.7%     N/A
         Anti-Lipid                    ≥80.2%      N/A       ≥80.2%     N/A
             Combined Result            2 of 3      5         3 of 3     15
    Point of Care Usage
     Increased transactions             ≥5%         2        ≥10%         5
 QP3SM - Gastroenterology

• Statewide offered to all participating physicians
  whose primary specialty is Gastroenterology
• Program applies to all products (Par/PPO & HMO)
  except Medicaid & Medicare which are excluded
• 4 Clinical Indicators & 1 Non-Clinical Indicator
• Clinical Indicators are measured based on
  Anthem claims data
Gastroenterology Indicators

      Appropriate Use of PPI Therapy Prior to Endoscopy
      for the Management of GERD
      Repeat Colonoscopy for Patients with a Diagnosis of
      Polyps
      PPI Generic Dispensing Rate (GDR)
      Appropriate Testing for Helicobacter Pylori Infection
      Prior to Empirical Therapy
      Ambulatory Endoscopy Site Accreditation for
      Outpatient Safety and Effectiveness
Performance Extra - PEX

• Statewide from for HMO
• Annual bonus
• Indicators
  •   Asthma
  •   Diabetes
  •   Cholesterol
  •   Hypertension
  •   Mental Health
  •   Generic Drug Utilization
  •   Preventive Care
  •   Quality of Service (Member satisfaction, open practice,
      Point of Care, and EMR)
EMR Criteria

•   Decision Support Tool
•   Formulary Management Tool
•   Chronic Disease Management Tool
•   Preventive Medicine Tool
•   Links to Diagnostic Providers (lab & x-ray)
•   Database Query Capability
•   Ambulatory Computerized Physician Order Entry
    System
Timing Is Right for Pay for Performance

•   Represents a Wellpoint strategy
•   Market place is looking for a solution
•   Impact on quality of care and affordability
•   Transparency movement is gaining momentum
•   Win-Win solution for providers, members and
    employers

								
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