California Pay for Performance
Dolores Yanagihara, MPHIntegrated Healthcare Association
Mendocino Health Information ExchangeJune 18, 2008
2
Agenda
• California P4P Program information• P4P Results
– Performance– Public Reporting– Payment– Stakeholder Feedback
• Overcoming Program Challenges– Technical– Political / Legal
3
Integrated Healthcare Association (IHA)
• Statewide leadership group that promotes quality improvement, accountability, and affordability of health care in California
• Mission: to create breakthrough improvements in health care services for Californians through collaboration among key stakeholders
• Principal projects:– pay for performance– medical technology assessment and purchasing– measurement and reward of efficiency in health care– prevention programs directed at obesity
4
Background
Institute of Medicine (IOM) reports a call to action to improve quality and safety of U.S. healthcare with specific recommendations including:
• Quality measurement and reporting
• Public Transparency
• Incentives for quality improvement (Pay for Performance)
5
California P4P: History
• 2000: Stakeholder discussions started
• 2002: Testing year– IHA received CHCF Rewarding Results Grant
• 2003: First measurement year
• 2004: First reporting and payment year
• 2008: Sixth measurement year; fifth reporting and payment year
6
The California P4P Players
• 8 health plansAetna, Blue Cross, Blue Shield, Cigna, Health
Net, Kaiser, PacifiCare, Western Health Advantage
• 40,000 physicians in 235 physician groups
• HMO commercial membersPayout: 5.5 millionPublic reporting: 11 million*
* Kaiser medical groups participate in public reporting only starting 2005
7
Program Governance
• Steering Committee – determine strategy, set policy• Planning Committee – overall program direction• Technical Committees – develop measure set• Payment Committee – recommend payment method• IHA – facilitates governance/project management• Sub-contractors
NCQA/DDD – data collection and aggregationNCQA/PBGH – technical supportThomson – efficiency measurement
Multi-stakeholders “own” the program
8
Goal of California P4P
To create a compelling set of incentives that will drive breakthrough improvements in clinical quality and the patient experience through:
√ Common set of measures √ Data aggregation√ A public report card√ Health plan payments
9
Organizing Principles• Measures must be valid, accurate, meaningful to
consumers, important to public health in CA, economical to collect (admin data), stable, and get harder over time
• New measures are tested and put out for stakeholder comment prior to adoption
• Data collection is electronic only (no chart review)
• Data from all participating health plans is aggregated to create a total patient population for each physician group
• Reporting and payment at physician group level
• Financial incentives are paid directly by health plans to physician groups
10
The California P4P Process
TestingYear
MeasurementYear
Data Aggregationand Payments
Public Comment Reporting
Year
Development Year
Public Comment
11
MY 2008 Clinical Measures• Acute Care
Treatment for Children with Upper Respiratory Infection
Appropriate Testing for Children with Pharyngitis
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis
Use of Imaging Studies for Low Back Pain
• Preventive Care Breast Cancer Screening Cervical Cancer Screening Childhood Immunizations Chlamydia Screening Colorectal Cancer Screening
• Chronic Disease Care Appropriate Meds for Persons
with Asthma Cholesterol Mgmt: LDL
Screening & Control <100 Monitoring of Patients on
Persistent Medication
12
MY 2008 Patient Experience Measures
• Specialty Care
• Timely Care and Service composite
• Doctor-Patient Interaction composite
• Care Coordination composite
• Overall Ratings of Care
• Office Staff composite
• Health Promotion composite
13
MY 2008 IT-Enabled “Systemness” Domain
1. Data Integration for Population Management
2. Electronic Clinical Decision Support at the Point of Care
3. Care Management• Coordination with practitioners• Chronic care management processes• Continuity of care after hospitalization
4. Access and Communication Standards
5. Physician Measurement and Reporting
14
New Domain for MY 2008
Coordinated Diabetes Care Domain– Diabetes Clinical Measures
• HbA1c screening, poor control >9, good control <7• LDL screening, control <100• Nephropathy Monitoring
– Diabetes Population Management Activities • Diabetes Registry (including blood pressure)• Actionable Reports on Diabetes care• Individual Physician Reporting on Diabetes measures
– Diabetes Care Management
15
New Measures for “Testing” in 2008
• Test in 2008 for potential inclusion in MY 2009
• Clinical– Depression Screening and Assessment of High Risk
Patients
– Inpatient Readmissions within 30 Days
– Asthma Medication Ratio
– Evidence-based Cervical Cancer Screening (re-test)
– Potentially Avoidable Hospitalization (re-specify and re-test)
16
Efficiency Measurement
• Purchasers and Health Plans are demanding that cost be included in the equation
Quality + Cost = Value
• Use both population-based and episode-based methodologies
• Use both standardized costs and actual costs to account for utilization and pricing
17
Efficiency Measures
1. Generic prescribing (MY 2007)
• Calculated by cost and by number of scripts
2. Overall Group Efficiency (MY 2009)
• Episode and population based methodologies • Calculated using both standardized and actual costs
3. Efficiency by Clinical Area (MY 2009)• Calculated using standardized costs
4. Actual to Standardized Pricing Indices (MY 2009)
18
Plans
OR
Group
CCHRI
Group
ClinicalMeasures
IT-EnabledSystemness Measures
PatientExperienceMeasures
Audited rates using
Admin data
Audited rates using
Admin data
PASScores
Survey Toolsand
Documentation
Data Aggregator: NCQA/DDD
Produces one set of scores
per Group
Physician
GroupReport for QI
HealthPlan
Report for Payment
ReportCard
Vendor forPublic
Reporting
CA P4P Data Collection & Aggregation
EfficiencyMeasures
Vendor/Partner: Thomson (Medstat)
Produces one set of efficiency scores
per Group
PlansClaims/encounter data files
19
Aggregating Data
Benefits:• Increase sample size
– More reportable data– More robust and reliable results
• Measure total patient population• Produce standardized, consistent performance
information
Requirements:• Consistent unit of measurement• Standard, specified measures
20
The Power of Data AggregationAggregating data across plans creates a larger denominator and allows valid reporting and payment for more groups
Health Plan Size
# of Health Plans
% physician groups with sufficient sample size to
report all clinical measures using
Plan Data Only
% physician groups with sufficient sample size to
report all clinical measures using the Aggregated Dataset
< 500K members 3 16% 70%>1M members 4 30% 65%
P4P Results
22
Overview of P4P Program Results
• Year over year improvement across all measure domains and measures
• Single public report card through state agency (Office of the Patient Advocate)
• Incentive payments totaling over $210 million for measurement years (MY) 2003-2006
• Physician groups highly engaged and generally supportive
23
Clinical Results MY 2003-2006
0
10
20
30
40
50
60
70
80
90
Breast CancerScreening
Cervical CancerScreening
HbA1c Screening ChlamydiaScreening
ChildhoodImmunizations
MY 2003 MY 2004 MY 2005 MY 2006
24
Regional Variation in Clinical Performance
50
55
60
65
70
75
80
85
90
Inland Empire
Los Angeles
Central Coast
Central Valley
San Diego
Orange County
Bay Area
Sacramento/North
Statewide
MY 2006 Results by Region
Top Performing Groups
25
IT Measure 1: Population Management Activities
0
10
20
30
40
50
60
Patient Registry Actionable Reports HEDIS Results
Percentageof Groups
MY 2003 MY 2004 MY 2005 MY 2006
26
IT Measure 2:Point-of-Care Activities
0
5
10
15
20
25
30
35
40
45
Electronic
Prescribing
Electronic
Check ofPrescription
Interaction
Electronic
Retrieval ofLab Results
Electronic
Access ofClinical
Notes
Electronic
Retrieval ofPatient
Reminders
Accessing
ClinicalFindings
Electronic
Messaging
MY 2003 MY 2004 MY 2005 MY 2006Percentage of Groups
27
Correlation Between IT Adoption and Clinical Performance
50
55
60
65
70
75
80
Clinical Score
No IT Adoption Full IT Credit
28
Public Report Cardhttp://opa.ca.gov/report_card/medicalgroupcounty.aspx
29
Health Plan Payment Results
• Each health plan determines their own reward methodology and payment amount (http://www.iha.org/ftransp.htm)
• Most plans pay on relative performance, after meeting thresholds
• $38 M paid out in 2004• $54 M paid out in 2005• $55 M paid out in 2006 • $65 M paid out in 2007 (about 1.5-2% of base pay on average)
30
Paying for Performance & Improvement
Earning Quality Points ExampleMeasure: Pneumococcal Vaccination
Attainment Threshold.47
Benchmark.87
Attainment Threshold.47
Benchmark.87
Attainment Range
performance
Hospital I
baseline•.21
.70•
Attainment Range1 2 3 4 5 6 7 8 9
Attainment Range1 2 3 4 5 6 7 8 9
Hospital I Earns: 6 points for attainment7 points for improvement
Hospital I Score: maximum of attainment or improvement= 7 points on this measure
Improvement Range1 2 3 4 5 6 7 8 9• • • • • • • • •
• • • • • •• • •
Score
Score
Excerpt from CMS Hospital Value-Based Purchasing Listening Session #2, April 12, 2007
31
Physician Group Engagement
Program Strengths – Physician groups are highly engaged– 74% believe the measures are reasonable– Widespread support for increased incentives– Belief the program has increased the focus on quality
improvement and IT capabilities
Program Weaknesses– Lack of consumer interest in public reporting– Concern about the potential for too many measures
Overall Rating– Mean score of 3.86 for importance (on a 1 to 5 scale)
32
Health Plan Engagement
Program Strengths– Increased collaboration– Push toward QI– Investments in IT– Greater accountability and transparency
Program Weaknesses– Improvements viewed as marginal– Concerns about “teaching to the test”– Lack of a positive ROI– Failure of clinical data feed to raise HEDIS scores
Overall Rating - 2.5 mean score (1 to 5 pt. scale)
Overcoming Program Challenges
34
The Data Problem
The data you want:
• Easy to collect• Clinically rich• Complete and consistent• Across product lines/payors• Whole eligible population
Claims Data
Y
N
N
N
Y
PaperMedical Record
N
Y
Y?
Y
N
Electronic Medical Record
Y?
Y
Y
Y
Y
35
Addressing the Data Problem
Enhancing claims data
• Identify and address data gaps • Encourage use of CPT-II codes• Develop supplemental clinical data
– Lab results– Preventive care / chronic disease registries– Exclusion databases
• Push EMR adoption
36
Addressing the Data Problem
Example: Blood pressure control
– Previously a chart review measure
– Creation of CPT-II codes allows administrative measurement
– Incentivize inclusion in registry Create system for routinely collecting information
37
Data Exchange
• Standard format and data definitions
• Defined data flow process
• Enhanced member matching
• Adequate documentation
38
Data Exchange Issues
LDL<130 Rates - Diabetes Population NAdmin-
Only MeanAll-Data
Mean
National HEDIS Rates, MY 2003 313 25 59.8
P4P Plan HEDIS Rates, MY 2003 7 8.4 60
P4P Plan-Specific Rates, MY 2004
Plan 1 (not used in aggregation) 0.0
Plan 2 (not used in aggregation) 0.5
Plan 3 (not used in aggregation) 1.0
Plan 4 (not used in aggregation) 6.3
Plan 5 21.4
Plan 6 25.9
Plan 7 26.3
Self-Report Average 51.0
39
Intermediary
Physician Group
Third party lab data repository
Lab
Plan
Physician Group
Facilitating Data Exchange
40
Legal and Political Issues
• Complying with HIPAA regulations
• Overcoming Non-Disclosure Agreements
• Addressing Data Ownership
41
Addressing Legal and Political Issues
Example #1: Lab results– Code of Conduct for bi-directional data
exchange– Lab authorization form– Disease Management Coordination initiative
42
Addressing Legal and Political Issues
Example #2: Efficiency measurement– BAA– Antitrust Counsel– Consent to Disclosure Agreements– No group-specific results shared first two
years– Publicly available sources of data
43
Conclusions on Data Issues
• Data is a limiting factor in performance measurement
• Administrative data can be enhanced by supplemental sources
• Data transfer of supplemental sources needs to be standardized
• Aggregation can make results more robust
• Legal and political issues carry as much weight as technical issues
44
Summary
• Initial process goals achieved
• “Breakthrough” outcome goal not achieved
• Strong collaborative “platform” established
• Fundamental changes in direction and implementation required to address emerging affordability goal
45
California Pay for Performance
For more information:
www.iha.org
(510) 208-1740
Initial support for IHA Pay for Performance provided
by California Health Care Foundation
Top Related