Purchasers Efforts to Promote Better Information Technology

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1 Purchasers Efforts to Promote Better Information Technology Peter V. Lee Pacific Business Group on Health The Health Information Technology Summit West March 7, 2005

2 Measuring Provider Quality and Cost-Efficiency to Improve Value SAVE LIVES, SAVE MONEY 2 Adapted from Regence Blue Shield Pacific Business Group on Health, 2005

3 3 Putting the Consumer in the Driver s Seat

4 PBGH Plan Evaluation Process evalue8 RFP has been implemented in local markets by employer coalitions and national purchasers Standardized health plan performance evaluation and quality improvement process Applicable to HMOs, POS, Medicare+ Choice and PPOs Provides a data repository of benchmarking data for nearly 400 health plans nationally via collaboration with Watson Wyatt 4

5 5 Evaluation Components: New Health IT Module Plan Profile Health Information Technology Consumer Engagement and Support Web-based consumer support tools Provider Management: Incentives and Rewards Accessibility of provider performance information Use and adoption of IT, including electronic medical records, CPOE Primary Prevention and Health Promotion Accessibility of clinical guidelines Integration of Health Risk Appraisal information Chronic Care Management (CAD, Diabetes, Asthma, Depression) Data integration for member identification and targeting Member push communications Practitioner support care reminders Pharmacy Management Data integration Quality and safety Health Info Technology Detail: Plan HIT budget and resource allocation Community collaboration Compliance with data standards Provider support tools Administrative: Eligibility, benefits, claims look-up/processing Clinical: Referral, ordering of diagnostic services Electronic prescribing Member Support tools Provider selection Provider performance information Electronic personal health record Purchaser Support tools Plan administration Cost and utilization reports Incentives for HIT adoption Pay for Performance Performance measurement Ease of plan Web site use (CAHPS) Transaction timeliness and accuracy

6 NCQA Refreshing Accreditation Quality Plus PBGH Breakthrough evaluation feedback Major portion of accreditation linked to process measures many mandated through insurance regulators Current NCQA accreditation places more weight on HEDIS outcomes, but overall, inadequate for differentiating value New accreditation strategy Increase availability of comparable and actionable information among multiple plan types Focus on identifying value and efficiency Recognize effective strategies and tools for consumer engagement Distinguish efforts to measure provider performance and incent improvement 6

7 About Quality Plus Why? To strengthen NCQA s position as the leader in health plan evaluation Quality Plus will keep NCQA s accreditation programs responsive to the evolving needs and desires of employers and consumers What? Quality Plus consists of the following new programs and reports: New Accreditation Content and Reports (new content areas initially will be voluntary) Member Connection Health Improvement Physician and Hospital Quality New modules will incorporate measures of value New Report Chronic Care Report The Chronic Care Report features data from current accreditation surveys and HEDIS submissions 7

8 Member Connection Intent: To assess the effectiveness of an organization as infomediary and provider of assistance to consumers WHAT NCQA WILL EVALUATE (working draft) Breadth, usability and quality of information, assistance with: Benefits (copays, deductibles) Pharmacy benefits/functions Health decisions Preparing for MD visit Decision Support Health Plan Mechanics ID cards Changing PCP Focus Groups Claims Handling with consumers to inform content HOW NCQA WILL EVALUATE (working draft) CAHPS questions, such as: Ability to find and understand plan information Correct handling of claims HEDIS measures: Call answer timeliness Call abandonment Claims timeliness Performance standards for: Ease of use of website information, eg # of clicks Accuracy of website information Effectiveness of interactions with member services 8

9 Health Improvement Intent: To measure the value of an organization s management of populations Chronic Care Report health risks, chronic disease and severe cases provides 1 st phase of information; To be supplemented by new content WHAT WE LL EVALUATE (working draft) HOW WE LL EVALUATE (working draft) Use of data to stratify risk levels of entire population Preventive and acute-care advice for all members Engagement of patients and practitioners in management of chronic conditions Promotion of self-management Personalized DM for higher utilizers with chronic-conditions Effective case management for complex cases HEDIS measures, such as: Comprehensive Diabetes Care Controlling High Blood Pressure Performance standards for: Use of evidence-based content Use of HRAs Functions of case managers Value measures for plans and DM vendors, such as: Appropriate medication management Readmission rates 9

10 Physician and Hospital Quality Intent: To measure the effectiveness of an organization in identifying, measuring, rewarding high value providers, and steering consumers to them WHAT WE LL EVALUATE (working draft) Provider Directories completeness, usability, accuracy Hospital value information (move towards standardization) Physician value information (move towards standardization) Tools to help members identify value providers Incentives for high value providers Goal: Alignment with Leapfrog; large employer RFPs HOW WE LL EVALUATE (working draft) CAHPS questions such as: Ease of use of provider directory Ratings of providers Performance standards for: Quality of information in provider directory New metrics such as: PPSI* progress index, initially PPSI* complete measure in future Use of provider value measures developed by Value MAP 10 *Leapfrog Provider Performance Sensitivity Index

11 Hospital Choice Tools Hospital quality linked to treatment choice information Network, cost and quality information linked to tiered benefit design Member preference-based ranking: Volume Mortality Complications Length of Stay Leapfrog Cost Patient Experience 11

12 Why Pay for Performance? Shifts payment from toxic to performance-based Drives performance transparency & market rewards Promotes quality improvement & IT adoption 12

13 13 California P4P Key Stakeholder Roles Integrated Health Care Association The neutral table for plans, providers and consumers to design and administer program Health Plans Medical Groups Purchasers and Pacific Business Group on Health Early (1999/2000) promoter of pay for performance Representation on IHA program design committees Plan participation built into health plan performance guarantees Public and behind-the-scenes support during critical times Grant-funded technical development State of California Publishes consumer scorecard with results California HealthCare Foundation Funded technical development & program evaluation

14 Performance Metrics An Evolving Scorecard Clinical Quality (50% weighting) 10 HEDIS-based measures Reported with Administrative data Patient Experience (30% weighting) 5 measures ( i.e. access, specialty care, MD communication) Collected through common statewide CAHPS-like survey 14 Investment and Adoption of IT (20% weighting) 2 Measures: point of care and population management Collected through web-based survey plus audit

15 Information Technology (20% weight) 1. Identify populations of patients needing care integrates at least two electronic data sets at the patient level e.g. encounters, lab results, pharmacy, inpatient or ER, radiology 2. Provide physicians clinical decision support delivers patient clinical information electronically to physician s office e.g. lab results, patients due for tests, electronic prescribing 15

16 Physician Incentive Bonus Extra Credit for instituting a program to measure physician performance on clinical and patient experience; provide regular feedback to those physicians and offer rewards based on performance 16

17 P4P First Year Results Largest Program in Nation: 2004 Estimated $100 million in total paid to California physician groups for quality (includes all products and efficiency, e.g. including use of generics vs. brand) $50 million based on common P4P measures in

18 Future Steps for P4P in California Reward year-to-year improvement Dramatically increase in number of clinical metrics (from 12 to 50) Increase in percentage of revenue devoted to performance-based pay Develop efficiency metrics Expand to other product lines: i.e. Medicare, PPO 18

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