ON PERFORMANCE MEASURES AND P4P

Transcription

1 B E YO N D B O N U S E S P H YS I C I A N P E R S P E C T I V E S ON PERFORMANCE MEASURES AND P4P

2 BEYOND BONUSES Physician Perspectives on Performance Measures and P4P Financial incentives are no doubt important for driving physician participation in Pay For Performance (P4P) programs nationwide; however, there are many other reasons why physicians are choosing to participate in programs that measure individual performance. Frost & Sullivan spoke with three physician thought leaders- - Dr. Susan Nedza * with the Special Program Office, Value Based Purchasing at the Center for Medicare and Medicaid Services; Dr. Ralph Brindis, the Chief Medical Officer and Chairman of the National Cardiovascular Data Registry and past Chair of the American College of Cardiology Quality Strategic Oversight Committee and Dr. Bruce Bagley, medical director for quality improvement of the American Academy of Family Physicians to find out about their perspectives on performance measures. Two case-studies of family physicians Dr. Rob Lamberts and Dr. Christopher Crow, who have profitably adopted performance measures in their practices, are also presented While there has been a lot of buzz recently around Performance Quality Measures, they are neither new nor unprecedented in the healthcare setting. Numerous medical groups and physician societies have been collecting data about different processes of care provided, and measuring national benchmarks for years. Many health plans have been analyzing data collected through claims processes, and providing feedback to physicians about comparisons to peer groups. However, what is new is the concerted effort to define and standardize quality measures, design efficient ways to implement them in different types of practices and make these the basis of some financial and regulatory compliance initiatives. In this paper, we examine some of these initiatives and examine some of the trends. OVERVIEW OF PERFORMANCE QUALITY MEASURES Performance quality measures are specific metrics to assess clinical performance and quality of care given to patients. Performance measures can be of many types. Some are structural, which measure the readiness of the infrastructure to provide optimal patient care, such as the adoption of healthcare technology to track patient data. Others are clinical measures, focused on preventative services (e.g. immunizations, influenza); common clinical conditions (diabetes, heart attack, congestive heart failure, pregnancy, newborns) or complications (e.g. surgical infections). The clinical measures can measure medical care processes, i.e. whether the medical care provided to the patient is consistent with the recommended guidelines for patient care, or patient outcomes i.e. the result of medical interventions. Common process measures for diabetes may include the number of diabetic patients who had a foot exam in the past 12 months, while the outcomes measure would include the percent of diabetic population that has HbA1c value less than 7% over the last year. Other types of performance measures include patient experience measures, which take into account patient satisfaction, the average time for getting a physician appointment etc. Over 90% of the health plans use performance measures which are based off existing HEDIS measures, but some other organizations are also working to develop measures. HEDIS measures consist of 71 measures across 8 domains of care, and measure performance on overuse, underuse, 2 * Currently, Dr. Nedza serves as Vice President, Clinical Quality and Patient Safety at the American Medical Association

3 value, process and outcomes measures. The AMA convened Physician Consortium for Performance Improvement has been an important contributor of measures, and the Joint Commission, formerly the JCAHO, develops measures pertaining to patient safety, infection control goals etc. for organizations that it accredits hospitals, freestanding ambulatory care centers, office based surgery centers and long-term care facilities. National selection and endorsement of measures done by organizations such as the National Quality Forum (NQF) and Ambulatory Care Quality Alliance (AQA), while they are implemented by private and government payors, NCQA, medical specialty boards, continuing medical education (CME), electronic health record vendors, physicians/practices etc. Figure 1: Various players involved in developing, endorsing and implementing performance quality measures Develop Performance Measures HEDIS (NCQA) AMA-Physician Consortium for Performance Improvement The Joint Commission Select and Endorse Performance Measures National Quality Forum (NQF) Ambulatory Care Quality Alliance (AQA) Implement Performance Measures Centers for Medicare & Medicaid Services (CMS) Commercial Health Plans NCQA Medical specialty boards Continuing Medical Education EHR Vendors Physicians, Hospitals etc. Currently, performance is being measured mainly through use of administrative data (claims data, pharmacy data, referral data, lab order data), although recent measures are increasingly using medical data. Dr. Bagley of AAFP explains, Health plans are coming out with performance quality programs or tiered networks based on administrative data because that is what they have but that is pushing it beyond its design limits, since claims data was not set up to be used for anything other than billing. The CPT category II codes that the AMA physician consortium are developing is an effort to look at clinical measures that physicians can report along with their claims data, in addition to CPT and ICD-9. It is a way to get clinical measures into the data set that is not present in the administrative data. How do performance measures benefit physicians? The physician community has been guarded in its adoption of performance measures, regarding these measures largely as a tool for health insurers and employers to monitor provider performance. However, there are a number of benefits to physicians including: Helping Physician Self-Assessment: Most physicians who have not measured their own performance in any systematic fashion have little idea about how they are actually performing in comparison to their peers or important national benchmarks. Dr. Crow from Texas recounts that when his practice first started tracking cholesterol for high cholesterol patients, they realized that they weren t meeting national benchmarks. The EMR told us that we weren t doing as well as we thought we were doing. This led to a reorganization of their care teams around this measure and the results improved in just 6 months. (See attached Case Study) 3

4 Improving patient care: Many physicians find that the very act of measuring performance has helped them improve on their patient care. It forces physicians and their staff to reexamine processes and focus on designing workflows that enhance data collection and analysis, but more importantly utilize this data to actually improve care. Dr. Lamberts participates in the Physician Quality Reporting Initiative (PQRI) and has to pull up the EMR records for his Medicare patients to report on some measures, We found with participation in PQRI, that performance measures do serve as reminders and improve quality. Sometimes, it is while filling out the forms that we realize Oh! this person does need a bone density test (See attached Case Study) Financial incentives: More and more health insurers and other payors are beginning to tie performance measures to financial incentives in an effort to increase quality and reduce costs. Some of these programs are labeled as Pay For Performance (P4P) where providers are given incentives if their performance on pre-determined measures meets a certain threshold or improves over their past performance. In other instances, some financial penalties may be imposed on certain providers whose performance measures fail to meet some standards. Driving Business: Based on quality and efficiency metrics, some health insurers are experimenting with placing providers and medical groups in tiered networks. Members are encouraged to utilize providers with high performance by having lower co-pays and other financial incentives. Several employers groups and payors are also using the public reporting of performance measures and direct-to-consumer programs to encourage their employees/members to utilize providers with high levels of performance on quality measures. Preparing for the future: While performance measures and programs that employ them are still evolving, it is clear that these will be around in some form in the future. According to the CEO Survival Guide to Pay for Performance put out by the National Committee Quality Health Care, i P4P programs will likely become more demanding over time in terms of both reporting requirements and performance expectations. To comply with and perform well under future P4P programs, providers must begin NOW to invest in electronic health records and reengineer care processes. A number of physician practices have already chosen to begin preparing for P4P programs by participating in the Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI) program during its first year in Accreditation requirements: Increasingly, certifications and accreditations by industry organizations are beginning to use quality measures. Several certification boards, such as the American Board of Internal Medicine (ABIM) now have requirements for recertification that relate not just to Continuing Medical Education credits and passing tests, but also to demonstration of quality at the bed side by an individual physician. P4P PROGRAMS: A SIGNIFICANT NEW DIRECTION IN HEALTHCARE Pay For Performance (P4P) programs are instituted by payers and purchasers, government, private and large employer groups, to reward medical groups and clinical practitioners who have i. CEO Survival GuideTM Pay for Performance, 2006, National Committee for Quality Health Care 4

5 met identified performance goals or have shown a demonstrable improvement in their performance and/or quality scores. These programs represent a significant change in direction of medical payment earlier payment arrangements have paid physicians based on procedures performed and services rendered (fee-for-service models), or DRG-based payment systems, but never on quality. In fact, it can be argued that better performance in many cases actually penalized physicians in many cases, for instance, disease prevention measures that resulted in fewer physician visits adversely affected the physician s compensation. The P4P programs are an important effort to correct the trend. Rising Trend of P4P Programs: Results of a Longitudinal Survey A recent study by Med-Vantage and The Leapfrog Group ii found that at the end of 2007, there are over 57 million patients enrolled in commercial health plans offering P4P programs. The study surveyed health plans, government agencies and purchases coalitions and concluded that today there are 148 Pay for Performance program sponsors, offering 258 P4P programs. The majority of the sponsors are commercial health insurance plans (92), but Federal government (CMS) and State Governments (Medicaid) and Employer groups also offer P4P programs. There has been a steady growth in P4P sponsors since Med-Vantage started collecting data five years ago, from 39 in 2003 to 148 at the end of Figure 2: Growth in P4P Program Sponsors Commercial Health Plans Employer Medicaid Only Government Others The largest P4P sponsor today is the California based IHA (Integrated Healthcare Association) with over 12 M subscribers and $200 Million in payments to approximately 40,000 physicians in over 220 medical organizations. In 2008, Medicare is likely to be the largest sponsor, as it has set aside $1.35 Billion for physician bonuses based on 119 quality and clinical IT measures. This survey also yielded interesting information about common P4P program designs, which is discussed below: Multiple P4P programs per sponsor: Most sponsors have more than one P4P program to target different provider types (primary care physicians PCPs, specialists, or facility), with the average being 1.8 P4P plans per sponsor. A majority of the P4P sponsors surveyed (91%) had plans to directly reward individual physicians, small physician practices or organized physician groups (IPAs and medical groups), while a smaller number paid financial incentives to hospitals (35%) and health plans (3%). There were other ii. Baker and Delbanco, 2007, Pay for Performance: National Perspective: 2006 Longitudinal Survey Results with 2007 Market Updates, Med-Vantage, Inc. and The Leapfrog Group 5

6 incentives employed by these sponsors that were directly made to the consumers for healthy behavior (participation in health promotion activities), for choosing high-value pharmaceuticals, and for choosing high-value providers. Figure 3: Growth in P4P Program Types PCP Practice Facility Specialty Specialties targeted: Of the P4P sponsors that had programs to target individual physicians in 2006, 41% targeted only PCPs while 59% had programs for both PCPs as well as specialists. Obgyns and cardiologists were the most frequently targeted specialties. Figure 4: Specialties Targeted by P4P Sponsors Ob-Gyn Endocrinology Other GI 0% 10% 20% 30% 40% 50% 60% 70% 80% % of P4P Sponsors Incentives: A majority of P4P sponsors incentivize participating physicians by giving them bonuses, but other incentive plans (withholding payments, differential fee schedule, additional reimbursement) are also popular. Figure 5: Types of Financial Incentives to Providers What type of incentive PAYMENTS do you make to Providers? 2006 survey respondents Bonus 73% Additional reimbursement for specific tasks 18% Differential fee schedule, paid prospectively 15% Payments from a withhold pool 11% Quality grants 5% Increased capitation payment, paid prospectively 5% Other 11% Data from Delbanco and Baker,

7 Scoring Methodology: This survey showed that in 2006, 72% of the P4P sponsors had programs where physicians were scored on an absolute threshold, while 51% had programs rewarding them on their relative ranking in a peer group and 43% rewarded them for improving performance. P4P Evaluations: 61% of those surveyed had evaluated their P4P programs to understand its impact on clinical quality, patient experience, financial indicators etc. In an overwhelmingly large number of these cases, the sponsors concluded that the P4P had led to improvements in quality of care, cost containment (a positive Return on Investment (ROI), a net cost savings, or the trend in cost increases has slowed) and patient satisfaction. Figure 6: Quality Improvements Through P4P Programs Performance on clinical measures has improved 76% Cost performance has improved Physicians have invested in QI or electronic systems Performance on patient surveys has improved Too early to tell the effects 30% 30% 21% 18% Other 9% None of the above have taken place Members have shifted to high performing physicians 6% 3% 0% 20% 40% 60% 80% Data from Delbanco and Baker, 2007 Examples of P4P Programs: P4P programs are now being offered by government agencies, large employer groups and private health plans. Here, three important examples, from each type of sponsor, are discussed. Physician Quality Reporting Initiative (CMS): With 44 million beneficiaries, Medicare exerts a great deal of influence over health policy. PQRI is a voluntary reporting program wherein physicians who choose to participate have to report a designated set of quality measures in order to earn a bonus payment of 1.5% of total allowed charges for covered Medicare physician fee schedule services. The bonus payment may be capped if relatively few measurements of the quality measure are reported. The first version of PQRI program was unveiled on June 1st 2007 to run until the end of 2007, when the United States Congress extended it to cover 2008 as well. PQRI included 74 quality measures in 2007 and in 2008, it includes 119 measures including 2 structural measures (for adoption of EMRs and for use of e-prescribing), requiring physicians to report on at least 3 of these measures for at least 80% of their eligible Medicare patients to be eligible for the bonus payment. 7

8 While participation numbers have not been calculated yet, Dr. Nedza of CMS reports that PQRI has seen penetration across many types of practices. We have participation from large academic medical centers to small practices; from single group specialties to multi-group specialties. On the non-physician side, there has been participation from dietitians, CRNAs, PAs. Amongst the specialists, physicians from emergency medicine, ophthalmology, anesthesia all fields with strong linkages between their clinical information systems and their claims systems have shown strong participation. The reporting for PQRI is through claims based systems, utilizing CPT Category II codes or Medicare-created G-codes, in cases the CPT-II codes do not exist. In 2008, 5 measures are also being tested for EHR based and clinical-registry based reporting. These include some of the most widely used measures. The clinical conditions covered by PQRI measures include asthma, cancer (breast, colon, CLL, etc), chest pain, COPD, CAD, depression, diabetes, GERD etc. These measures cover a range of clinical topics, such as advance care planning, screening for fall risk, imaging medication reconciliation, perioperative care, and address various aspects of quality care ranging from prevention, chronic care management, acute episode of care management, procedural related care, resource utilization, care coordination. iii More information is available from Bridges to Excellence (BTE): BTE is a multilateral effort of employers, health plans and patients that rewards quality by offering financial incentives to physicians to improve care. There are four programs currently: Physician Office Link, Diabetes Care Link, Cardiac Care Link, and Spine Care Link, one potential one: Internal Medicine Care Link. Each of these programs consists of a set of measures, and each measure is assessed a point value which contributes to the total score. Physicians are rewarded for each patient covered by a participating employer or a health plan on an annual basis, and can earn bonuses of $50 to $160 a year per patient. The program is currently operational in 13 states, and through Dec 2007, it has recognized 9,642 physicians and 1,838 practices, handing out $10 million in rewards. Physician Office Link aims to promote use of health information systems in physician offices, and rewards physicians up to $50 per covered patient for implementing specific processes which reduce errors and increase quality. Diabetes Care Link intends to improve the quality of care for diabetic patients and rewards the top performers amongst physicians with $100 for each eligible diabetic patient. Cardiac Care Link aims to improve the quality of care for patients with cardiovascular disease. Top performing physicians who demonstrate high quality of cardiac care can earn up to $200 per year for each eligible cardiac patient covered by a participating employer. Spine Care Link is focused on improving the quality of care for patients with sub acute or chronic back pain. Physicians who can demonstrate high performance quality of spine care can earn up to $50 per year for each eligible spine care patient. The programs are largely funded through the money that the employers save due to lower health care costs and increased employee productivity as a result of the delivery of higher quality patient care. The NCQA and some other organizations, such as some Quality Improvement iii. 8

9 Organizations, evaluate and certify physician data to select physicians which qualify for the rewards. Besides recognizing and accrediting top performing physicians and practices, these organizations also act as a data conduit for submitting the data from the recognized physicians to BTE's data platform, the Recognition Data Exchange (RDE), which distributes it to BTE administrators. BTE carried an evaluation of the Diabetes Physician Recognition Program from 1997 to 2003, and concluded that participation in this program led to better quality scores for diabetes measures amongst physicians. The average rate of diabetes patients who had HbA1c levels of less than 7% increased from 25% to 46%, the rate of diabetes patients who had controlled low-density lipoprotein (LDL) cholesterol below 100 mg/dl rose from 17% to 45% and the rate of diabetes patients monitored for kidney disease rose from 60% to 85% among participating physicians. iv More information on the program can be obtained from The Integrated Healthcare Association (IHA) is a California based group that promotes quality improvement, accountability, and affordability of health care in California. IHA membership includes major health plans, physician groups, and hospital systems, plus academic, consumer, purchaser, pharmaceutical and technology representatives. IHA s P4P program is the largest physician incentive program in the United States, with 228 medical groups, representing 40,000 physicians and 12 million HMO members. IHA uses a consistent set of performance metrics, which include process and outcome of care measures, patient satisfaction and adoption of information technology, as the basis for supplemental payments to medical groups and IPAs by health insurance plans. The program seeks to drive improvements in clinical quality through: (1) a common set of measures; (2) a public scorecard; and (3) health plan incentive payments. Seven California health plans Aetna, Blue Cross, Blue Shield, CIGNA, Health Net, PacifiCare, and Western Health Advantage offer both public reporting and incentive payments, and Kaiser Permanente participates in public reporting. Each plan determines its own budget and bonus design for medical groups, but uses the common IHA set of performance metrics. The participation of so many health plans using the same metrics improves the reliability of measurement data, and also reduces the administrative burden on insurers and providers. In the 2006, the seven participating health plans paid P4P bonuses totaling more than $140 million. Different plans established different rewarding criteria for physicians one plan used absolute thresholds to determine payment, while the others used relative percentile ranking. The measures used in 2008 include clinical measures (such as encounter rates, childhood immunizations, cervical/breast/colorectal cancer screening etc.), IT Enabled systemness (data integration for population management, care management, decision support, access and communication, and physician measurement and reporting), patient experience domain (patient satisfaction with physician, office staff, ease of getting appointment etc.) and Relative Improvement domain (improvement over measures from previous years). IHA s results for P4P program in 2006 indicate that 50% of physician groups showed improvements across all 14 of P4P s clinical quality measures, while patient satisfaction measures iv. 9

10 have also improved since inception of the program. In a very significant finding, the evaluation noted the close correspondence between adoption of information technology and clinical scores physician groups meeting all P4P criteria for IT had clinical scores 18 percent higher than those groups that did not meet any of the IT criteria. More information is available at Other examples: Some state Medicaid programs also offer P4P designs, such as QCare Quality Care and Rewarding Excellence program created by the state of Minnesota. This program covers all individuals enrolled in state health program, and those in MinnesotaCare or Medical Assistance and covers four areas: diabetes care, preventative services and screenings, cardiac care and hospital care. Figure 7: Examples of P4P programs ROLE OF PHYSICIAN SOCIETIES Physician societies are best positioned to define and develop physician performance measures, and educate their membership on them. Some physician societies, such as the AMA, have indeed taken a leadership position in this area having convened the Physician Consortium on Performance Improvement. Other specialty societies too, such as the American Academy of Ophthalmology (AAO) and the American College of Cardiologists (ACC) are playing a significant role in development of performance measures, setting up registries and engaging in outreach and educational activities amongst their membership. Some state medical societies have also hosted 10

11 meetings and provided information to their membership, held webinars, provided links on their website. The specialty societies are more involved in developing the implementation tools. A 2007 study conducted by Ferris et al. v surveyed 31 specialty physician societies in the US and found great variability in their engagement with the issue of physician performance measures. While the vast majority of them (close to 90%) had developed guidelines on these, only 3 of them had already completed the process with at least one actual performance measure. A growing number of these societies (35%) were involved in developing physician performance measures. This study also listed some key barriers for physician societies to engage with performance measures member reluctance, lack of sufficient resources, time consuming approval process and difficulties associated with data collection. Figure 8: Performance Measure Activity in Specialty Physician Societies % of Physician Societies 100% 80% 60% 40% 20% 0% Guideline Development Education/Outreach Planned Activity Completed Activity Development of Measures PPM Implementation Data from Ferris et al., 2007 Guidelines on Development of Performance Measures and P4P Programs: Different physician societies have issued different criteria and guidelines around performance measures. All agree that performance measures should be relevant to physicians, patients and stakeholders, consistent with other widely accepted criteria (such as the criteria established by physicians organizations), evidence-based, risk-adjusted (in order to perform comparisons with other measures), accurate and feasible. Reviewing the criteria from AAFP, ACC and AAO for successful P4P programs, several common themes emerge: Physician participation is important in establishing new performance/ quality measures P4P programs should aid the adoption of Health Information Technology (electronic health records; electronic data collection, transfer and sharing; etc) Programs should include physician s further accreditation / certification, as a mean of assuring physician quality Physician incentives should be based on quality of results rather than the number of patients Use positive criteria to reward physicians: outcomes, prevention, effectiveness in improving care for populations groups, value of time with patients, etc v. Ferris et al. (2007), Health Affairs, Physician specialty societies and the development of physician performance measures, 26 (6) 11

12 The physician societies also caution against the creation of perverse incentives through P4P programs, which would lead to adverse selection, gaming and treating the metric rather than treating the patient. Development of Measures: The AMA PCPI, convened in 2000 by AMA, consists of more than 100 national medical specialty and state medical societies, Council of Medical Specialty Societies, American Board of Medical Specialties and its member boards, experts in methodology and data collection, Agency for Healthcare Research and Quality (AHRQ), CMS. The Consortium has developed performance measures for 27 clinical topics or conditions, comprising 184 individual, physician-level clinical performance measures. The consortium is highly respected amongst the physician community since it develops performance measures that are evidence based, clinically relevant and statistically valid. Other pioneers in the field of performance measurement include the ACC, which has been working with CMS, the American Heart Association (AHA), the Joint Commission and AHRQ to develop the standard set of measures for cardiovascular disease. The ACP and the AAFP are part of the Ambulatory Care Quality Alliance (AQA) that also includes the Academy of Health Information Professionals (AHIP) and AHRQ. Their focus is ambulatory care. Maintenance of Registries: Specialty physician societies play an important role by maintaining key registries that allow for national benchmarking and risk-adjusted comparisons with peers. Important examples include the efforts by the ACC as well as the Web-based data entry systems made available to members by American Society of Clinical Oncology, the Society of Thoracic Surgeons, and the ACS. National Cardiovascular Data Registry (NCDRTM), an initiative of the ACC Foundation, is a confidential quality measuring program for cardiac and vascular facilities. It maintains five registries, including CathPCI RegistryTM, for measuring quality in a Cathlab and the IC3 Program (Improving Continuous Cardiac Care), which is an office-based registry designed to look at the continuum of cardiac care for patients with cardiovascular disease, before and after hospital discharge. CHALLENGES TO ADOPTION While the number of P4P programs has been steadily rising and the amount of physician compensation tied to quality measures is also starting to rise, the physician community still faces several challenges in terms of adoption of these programs. Some of these are listed below. Physician reluctance to adopt outcomes based measures: Physicians are concerned about being held accountable for outcomes since there are a number of factors that physicians do not have direct control that can influence the results (e.g., patient compliance, socio-economic conditions that may limit patient s access to certain procedures, etc.). Dr. Bagley of the AAFP explains the physician perspective thus, Physicians would rather focus on structure and process measures such as ordering HbA1c tests, adding data to registries because that is under their control. But if you ask them to take responsibility for results of those tests, they are not anxious to do that because there are so many variables over which they have no control patient lifestyle, compliance, whether the patients can afford their medicines, etc. Dr. Brindis with the ACC warns that penalizing physicians or hospitals involved in taking care of lower class or socio- 12

13 economically disadvantaged people can lead to negative unintended consequences. Hospitals or healthcare systems that actually need the extra money the most, could inappropriately be financially disadvantaged in a Pay for Performance model, unless it is well thought-out. In face of these concerns, the various physician societies recommend that P4P programs should reward improvement and not just absolute measurement, and the measures should employ risk adjustment methodologies that account for variations in patient populations, co-morbid conditions, socio-economic levels etc. While Dr. Bagley sympathizes with the physicians concerns, he feels that they should be held somewhat accountable for the outcomes. We know that the system in which a physician works has a lot to do with patient outcomes. If a physician is working all alone, and does not have a team approach, or a registry, or community linkages or support staff, the outcomes are not going to be very good. In order to get the physicians to take responsibility for the system in which they work, they need to be measured to some degree on outcomes. Another reason, he thinks, why some physicians are reluctant to adopt some outcomes measures is because they think that 100% is always the right answer. However, for any outcomes measure, such has having HbA1c <7%, we all know that we can never get all our diabetics to into the normal range, and the measure is never going to be 100% for any one practice, adds Dr. Bagley. Public reporting of measures: Most stakeholders in the healthcare industry are comfortable with the concept of transparency from physician societies to health insurers. There are still several issues though, that need to be addressed including how to present these measures to consumers, what measures to make public, and whether to report individual-level physician performance scores. Regardless, the public reporting of measures should only be undertaken when the data is of a high enough quality to provide value to consumers. Additionally, physicians should have an opportunity to review and comment on any data before it appears publicly. Dr. Brindis, who sits on the California Board s Clinical Advisory Panel overseeing public reporting says, You need to have an auditing strategy, you have to make sure the data is completely risk-adjusted, and there has to be physician opportunity to review and adjudicate the data before it is actually reported. Attribution of quality measures to different physicians: For many disease states, including chronic conditions, multiple providers are involved in patient care. Attributing who is responsible for delivering that care among different providers is a challenge particularly for outcome-based measures. Medicine is really a team based effort, says Dr. Brindis of ACC, but when you start having pay for performance programs at the individual physician level, attribution becomes a real challenge, because often times, there are a lot of handoffs between doctors so how do you decide which doctor is responsible for that patient? Creation of conflicts of interest: There is some concern that P4P programs might encourage physicians to avoid caring for high-risk and socially disadvantaged patients, who may have lower ability to comply with care guidelines. Furthermore, since most P4P programs focus on certain disease states, there is a concern that focusing on the performance measures may lead to the neglect of other aspects of care. P4P programs also have the potential to create conflicts of interest where the physicians are rewarded based upon utilization to over-use or under-use some services in order to reach a target. While it is still not known if the negative consequences will occur, careful design of P4P incentives, including having a mix of structural, clinical and patient experience measures, and using robust risk-adjusted performance measures will help alleviate some of these concerns. 13

14 Administrative burden: Although a number of hospitals have some ability to automate some level of data collection and reporting, as well as personnel to perform this work, most physicians practices outside of large medical groups or IPAs, lack these resources. This is particularly an issue for primary care practices that are run on a razor thin margin, where the additional costs incurred and time spent for data collection and reporting are the biggest challenges to P4P adoption. While small paper-based offices can still collect data on a few measures for a limited number of patients, each additional performance measure adds considerably to the administrative burden of the practice. Information technology and EMR systems that can facilitate automated generation of quality measures will streamline these processes but considerable work remains. ROLE OF INFORMATION TECHNOLOGY INFRASTRUCTURE A robust health IT infrastructure is crucial for collecting quality data and providing clinical decision support systems. A fully-functional EMR helps physicians to comply with P4P programs in several ways. This includes offering improved reporting functionality including generating reports on the entire patient database in a few minutes. Additionally, the EMR allows physicians and their staff to quickly pull up a patient s complete medical record, and check whether a particular test has been performed or not. EMR systems are also starting to offer specific modules and products for supporting performance measures and P4P programs. Besides data collection and reporting, EMR systems are also beginning to offer more robust clinical decision support tools and applications including allowing a higher level of customization for clinical reminders. The role of IT in improving quality of care is evident from the 2006 evaluation of IHA s P4P program, where physician groups meeting all P4P criteria for IT had clinical scores 18 percent higher than those groups that did not meet any of the IT criteria. The role of IT in the future implementation of P4P programs is only going to increase. In 2008, CMS is conducting a series of pilot tests regarding the submission of performance data for 5 common measures in PQRI program using EMR systems and clinical data registries. Dr. Nedza affirms that as an agency, CMS is strongly committed to moving towards electronic health care records. For PQRI, the claims system was convenient there was already an existing infrastructure to enable reporting, she says, but it has its own issues. With wider spread adoption of EMR systems, a richer data set would be available for CMS and other P4P program sponsors to utilize. Many of the smaller practices will require financial incentives in order to invest in clinical IT systems. Talking specifically of family medicine practices, Dr. Bagley notes that primary care services have been systematically undervalued for over a decade, and as a result, these practices are running on very narrow margins. They are capital depleted and getting tired of running on a treadmill to make the arithmetic work. There needs to be some recognition that this kind of information system takes extra capital, substantial process change in the practice and a team approach to care. Meaningful incentives will be necessary to drive the necessary changes. Dr. Bagley approves of incentives that tie P4P money to acquiring, improving or upgrading the capability of IT systems for physicians. EMR functions and clinical information systems, such as registries, are essential to improving quality. We figured out that it may take only $1-$2 per member per month to stimulate this kind of a change in an office, if all payers participate, including CMS. 14

15 As national registries become more popular for benchmarking, clinical IT systems will also play an important role in building accurate registries. Explains Dr. Brindis, Right now, from the hospital viewpoint, registries are built inefficiently leading to so-called registry fatigue. Each time a hospital is involved in any national registry, they find themselves reentering similar data in multiple registries. We are working nationally to try to minimize this registry fatigue, so for example, when the patient comes in with an acute coronary syndrome, the data that is entered into the MI registry automatically gets populated into the PCI registry, since about 70% of the data elements are common. But when we have a true robust EHR record then everything becomes patient centric and the registries can automatically pull data out of the EHR record as opposed to having it needed to be directly entered into a registry. That is really the long term goal here. FUTURE TRENDS IN P4P PROGRAMS P4P programs have grown more than four-fold in the past five years and P4P has definitely established a presence on the healthcare scene. P4P programs are still evolving though and their design in several years may well be different from how they are structured and implemented today. It is quite certain that measuring performance and quality of care will continue to grow, and become an increasingly important component of medical practice in the United States. In fact, Dr. Bagley of AAFP estimates that in another 3-5 years, around 30% of an average physician s compensation will be tied to these various performance measures. Some of the future trends in P4P programs are discussed: Increasing number of performance measures: P4P programs have generally required the measurement of a limited number of measures largely to make their programs attractive to paper-based offices. It is anticipated though, that as EMR systems gain higher penetration, the number of measures required by P4P program sponsors will also increase. Look at the UK, says Dr. Bagley, They have 140 measures, which are automatically extracted from the EHRs. That is the future of EHR systems here as well the system automatically pulls up the appropriate template for a patient, and reminds the physician which exams might be needed for the patient. The physician only has to fill in the boxes on the template, and the measures are automatically extracted and reported. This not only leads to instant quality improvement but also helps in data collection. This trend is confirmed by the Med-Vantage survey for 2006, in which over 70% of P4P sponsors said that they plan to expand the scope or the number of measures used. P4P programs for specialists: P4P programs have largely focused on primary care physicians due to performance measures focusing on preventive measures and certain common chronic conditions. According to the most recent Med-Vantage survey, this is changing, as there were over 60 P4P programs that focused on specialists in This represents a nearly three-fold increase in just 3 years. Data from the Med-Vantage also revealed that a third of P4P program sponsors talked about expanding to include specialists in programs which did not do so already. CMS has also worked hard to ensure that every physician specialty will be able to participate in the PQRI program in Gradual shift to outcome-based measures, longitudinal measures: P4P programs for physicians have largely focused on structural and process measures due to the reliance upon claims data or limited self-report from paper charts for data collection and reporting. There have been some 15

16 attempts to move to outcome-based measures by bringing in additional sources of data (e.g., lab test results) but this has generally been limited to a select number of measures. However, as physician practices get the requisite systems in place that allow them more easily collect and report performance measures, then the P4P incentives will gradually shift to more outcomesbased measures. Also, longitudinal measures will be increasingly use to assess quality of care provided received by chronically ill patients from multiple providers and over extended periods of time, incentives for care coordination. These longitudinal measures will encourage institutional and community-based providers to work together to improve performance. Increasing use of registry data: Clinical data registries can provide a rich data source that allows for national benchmarking and also assist in the development of risk-adjusted measures. Some registries like ACC s registry are already submitting data to United Healthcare on behalf of their members. The use of registries is currently limited by the fact that there is a multitude of data registries in use and each registry has a different model of data management. Much greater coordination between EMR systems, registries and billing software is required in order to make wider use of registry data. Varied coordination of measurement sets and data collection methodologies: Most P4P programs use different measures and different methods of gathering data. This can create a data integrity problem when the P4P program sponsor has a statistically insignificant number of events during the measurement period. There have been a few select examples, such as the IHA program in California, where different health insurers have agreed to use a common set of measures and policies for data collection. As the number of P4P programs increases, it will be critical that there is greater coordination to avoid provider exhaustion and potential backlash against P4P programs. Unless widespread adoption of a common performance measurement set, such as the CMS PQRI performance measures, occurs though, it is likely that the coordination of measurement sets for physician-based P4P programs will remain limited on a geographical basis. CONCLUSION Performance measures and linking to them P4P programs have emerged as a potential way to increase quality and reduce costs. Predicting the overall growth rates of P4P programs and how P4P programs will evolve remains inexact but clearly there is a great deal of emphasis being placed on them by the federal and state governments, employers, and health insurers that is not likely to dissipate anytime soon. For the widespread adoption though of P4P programs by physicians, it will be necessary to invest in clinical IT systems. In particular, the effectiveness of EMRs for use in P4P programs will be a key element on in determining how readily physicians are willing and successfully able to participate in various P4P programs. 16

17 CASE STUDY 1: PHYSICIANS ARE ALREADY MOTIVATED TO PERFORM BETTER; THE QUESTION IS HOW? While P4P programs are based on the premise that financial incentives will encourage better physician performance, Dr. Rob J Lamberts says that the physicians are already motivated to improve performance. The real value of measuring performance lies in the self-assessment that it allows the providers to perform, which makes self correction possible. Dr. Rob J Lamberts is an Internist and a Paediatrician, working at a suburban, medium-sized, 5 - PCP, private practice outside of Augusta, Georgia. Dr. Lamberts is an early adopter of EMR systems having already introduced these systems into his practice over 10 years ago. Dr. Lamberts is currently participating in the Physician Quality Reporting Initiative (PQRI) rolled out by the CMS for Medicare patients. Each physician in the practice has also obtained the Diabetes Physician Recognition Program (DPRP) certification from the NCQA, allowing each of them to earn an additional $5,000 from the Blue Cross Blue Shield (BCBS) program in South Carolina. Dr. Lamberts acknowledges that financial remuneration was a big motivator for getting the DPRP certification, but says that the more important incentive was a non-financial one: doing a better job. P4P programs financially reward you for being a good physician, but there is already a lot of motivation to be a good physician. The biggest motivation for documenting your quality is just to know that you are doing a good job. Dr. Lamberts explains that the very process of measuring performance actually improves it. We found with our reporting for PQRI, that occasionally we do pick up on tests we might have missed, a bone density test here or there. It does serve as a reminder and that does improve quality. I have personally run reports on physicians to tell them things like these are your colon screening numbers and let them react to it. It is important to know how you are performing in order to improve. The other big motivation, Dr. Lamberts points out, is positioning themselves for the future. CMS is showing that they are serious about P4P with the introduction of PQRI. Once P4P programs get underway, our practice will be in the top 5%, which will be able to best capitalize on that trend. He adds that currently, there is not much money in these programs overall, but it is important to get processes in place to report quality data using EMR, which is going to become crucial in the future. For Dr Lamberts, the biggest reason for physicians to use EMR is that they get to own the clinical data, and this gives them a lot of leverage to negotiate with the insurance companies. But he fears that until a larger number of physicians start to use EMRs with good reporting capabilities, this advantage cannot be leveraged for any systematic changes. The GE Centricity EMR system that the practice uses has been indispensable for their performance quality measurements and certifications. The NCQA certification for the diabetes program is very straightforward now, using reports generated by the Medical Quality Improvement Consortium (MQIC) data repository that Centricity users can access. MQIC is a data warehouse maintained by GE Healthcare in a HIPAA-compliant manner, where users can pool their data and knowledge. Dr. Lamberts estimates that it takes less than 10 minutes to generate the diabetes care report for submission to NCQA using these tools. And since MQIC 17

18 can query the entire database of diabetes patients of a physician, it is a more reliable measure of quality than just collecting data from a random collection of 20 diabetes patients, as required by NCQA in paper-based offices. The EMR system is also crucial for their participation in PQRI, though the office also employs low-tech solutions. The front office reminds the physician that the patient is a Medicare patient, by putting a bright yellow sheet on the patient file. Using the EMR, the physician can just pull up the patient record and fill in the data needed for the eight measures they are reporting on for PQRI in less than a minute, and send it to billing. Dr. Lamberts adds that eventually, they will use a customized template with their EMR for Medicare patients, which will stream line this process further. According to Dr. Lamberts, the two main roles of EMR today are alerting and finding information. In his practice, accessing the information is the most time-consuming task, and the ideal solution is having an electronic record that not only has all the information, but also has it organized so that it is in the same place in every single chart. This would help the physician quickly determine whether or not a particular test has been done, would save time and help in clinical decision making. Dr. Lamberts adds that efficiency in collecting data is critical, especially in small family practices, where physicians are operating on very thin margins. At the very least, we have to remain time neutral when we are collecting data; we cannot pull our physicians out too much to collect data, since they generate revenues. It is of crucial importance to design an efficient workflow one in which the data gathering process is concise, takes very little time and allows the data to be put in a structured format. This can be an issue when external data (such eye exams results from ophthalmologists office, or bone density scans from the radiologists lab) needs to be integrated into the EMR systems. As P4P becomes more prevalent, the workflow processes will become more complicated if not designed well. Many physicians believe that EMR slows you down. But that is not true for us. says Dr. Lamberts. Even outside of P4P, our income is far above the national average because we have a high throughput and are able to bill well. There is no question in my mind that our system is efficient because of our EMR and we are profitable because of our EMR. CASE STUDY 2: NEGOTIATING POWER: USING PERFORMANCE MEASURES TO DEMONSTRATE QUALITY TO PAYORS Dr. Crow does not currently participate in any P4P programs, but he can see them coming. We are prepared for them. We have our EMR systems ready and we are already mining our clinical quality data. And Dr. Crow has already seen his quality data paying off through increased remunerations he has been able to use it to successfully negotiate with payors for increased reimbursement rates. Dr. Crow runs a family practice office in Texas which sees pediatric as well as adult patients. His family practice specializes in women s health, sports medicine, disease prevention and management. His practice is different from other practices in the area given his investment in information technology it was declared the 2006 Davies award winner by HIMSS for excellence in the implementation and use of health information technology. 18

19 Dr. Crow uses the GE Centricity EMR system. I first started using the EMR to track cholesterol for high cholesterol patients, and we realized that we weren t meeting national benchmarks. The EMR told us that we weren t doing as well as we thought we were doing. This led the practice to reorganize their care teams around this measure, and within just 6 months, they were able to show a tremendous increase in their performance measures around care of high cholesterol patients. Dr. Crow took that data to the health insurance plan with whom the practice was getting ready to renew their contract. That s all the data I showed how we have been able to increase our quality in this measure. I told them that we are tracking other quality measures as well, such as preventative measures, and this was enough to convince them to sign onto a 3% across-theboard increase in our rates. Dr. Crow attributes this to the fact that clinical data is a far better indicator of quality than claims data, which is the only data available to insurers. Just the mere fact that we had this performance data, which is better than the data they have about our practice, was enough to raise our rates. There is no claims data that can tell whether I talked to a patient about smoking or whether I did a foot check which is why the clinical data is so important. Since then, Dr. Crow s practice has been able to successfully track many other clinical measures, and leverage them in his contract negotiations with payors as well. He estimates that this has allowed each physician in his practice to receive an additional compensation of $15,000-20,000 per year. They use three different arguments for their negotiations: Open Access Clinic: They can give appointments to any patient within 24 hours. Quality of clinical care: Today they are tracking a multitude of measures diabetes care measures such as the percent of diabetes patients whose HbA1c results are less than 7%; screening for patients cervical and breast cancer, checking blood pressure for hypertensive and high cholesterol patients, seeing patients on anti-depressants every 6 months etc. Customer satisfaction: The practice routinely does customer satisfaction ratings and the results have always demonstrated a high quality of patient experience. And this effort to collect all these performance measures has certainly paid off in financial terms. I was told by one of the payors that I am averaging $309 on a certain diagnosis code where the average for the community is $292 per patient. But I could tell them that I am able to provide additional value and quality for that extra $17, and I had all this data to support my argument, said Dr. Crow. Dr. Crow s argument prevailed and the payor had to acquiesce to higher reimbursement rates. His practice has also obtained the Physician Connection Certification as well as the Diabetes Physicians Recognition Program certification from the NCQA. This will allow the practice to be listed in certain tiered networks and drive more business. It is relatively easy to pull all the quality measures using our existing EMR. The Centricity EMR has a central data repository, which allows the physicians to collect all the required data and to compare it not only to the national benchmarks, but to any doctor using Centricity. There are 7 million patient lives in that database right now. Once we are able to benchmark our measures, we can concentrate on improving those measures where we are not performing well. 19

20 Dr. Crow implemented this system himself I have an executive MBA and realized that EMR allowed better quality and reduced waste. It was a major transition point to go from unstructured data (free text) to structured data, to ensure that all patient information is correctly coded. But the value in that is tremendous: Dr. Crow estimates that the practice makes an additional $65-80,000 per doctor per year because of it. He explains it thus: We don t need a staff member to move physical charts around, don t need a staff member following prescription refills and giving patient reminders; we have almost half the number of staff members than is the national average, and there are additional savings on coding improvements and quality of care improvements that turn into revenue with P4P programs Dr. Crow understands that there are significant costs associated with implementing the EMR, for IT and network support, but if you do it right, it s worth it. Much of the structure needed to implement performance measures is ready to go out of the box. Point-of-care reminders based on USPTF (US Preventative Task Force) guidelines are already embedded in the system, and reports can be easily obtained by accessing the central database. Some customization is required for the forms that capture data from an interaction with the patient, and to ensure a smooth interface with the lab data. The value in that is tremendous, explains Dr. Crow, and allows immense savings in time and effort. He gives the example of the case when a drug is recalled (there were five big recalls in the last year including Vioxx) it takes me 5 seconds to run a report and see all patients who have been prescribed that drug and to get in touch with them. It would take days if all I had were paper records. The next step for Dr. Crow s practice is to look at utilization rates now; they are currently tracking their generics prescription writing and other cost drivers like diagnostic services. The payers are already considering these matters with larger provider groups and it is only a matter of time before they come to family practices as well. As before, Dr. Crow will be prepared for them. 20