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California Pay for Performance Dolores Yanagihara, MPH Integrated Healthcare Association Mendocino H

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Statewide leadership group that promotes quality improvement, accountability, ... Incentivize inclusion in registry. Create system for routinely collecting information ... – PowerPoint PPT presentation

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Title: California Pay for Performance Dolores Yanagihara, MPH Integrated Healthcare Association Mendocino H


1
California Pay for Performance Dolores
Yanagihara, MPHIntegrated Healthcare
AssociationMendocino 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 plans
  • Aetna, Blue Cross, Blue Shield, Cigna, Health
    Net, Kaiser, PacifiCare, Western Health Advantage
  • 40,000 physicians in 235 physician groups
  • HMO commercial members
  • Payout 5.5 million
  • Public 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 aggregation
  • NCQA/PBGH technical support
  • Thomson 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
11
MY 2008 Clinical Measures
  • 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 lt100
  • Monitoring of Patients on Persistent Medication
  • 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

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
  • Data Integration for Population Management
  • Electronic Clinical Decision Support at the Point
    of Care
  • Care Management
  • Coordination with practitioners
  • Chronic care management processes
  • Continuity of care after hospitalization
  • Access and Communication Standards
  • Physician Measurement and Reporting

14
New Domain for MY 2008
  • Coordinated Diabetes Care Domain
  • Diabetes Clinical Measures
  • HbA1c screening, poor control gt9, good control lt7
  • LDL screening, control lt100
  • 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
CA P4P Data Collection Aggregation
Audited rates using Admin data
Physician Group Report for QI
Plans
Clinical Measures
OR
Audited rates using Admin data
Group
Data Aggregator NCQA/DDD Produces one set of
scores per Group
Health Plan Report for Payment
CCHRI
Patient Experience Measures
PAS Scores
Group
Report Card Vendor for Public Reporting
IT-Enabled Systemness Measures
Survey Tools and Documentation
Vendor/Partner Thomson (Medstat) Produces one
set of efficiency scores per Group
Efficiency Measures
Plans
Claims/ 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 Aggregation
Aggregating data across plans creates a larger
denominator and allows valid reporting and
payment for more groups
21
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
24
Regional Variation in Clinical Performance
25
IT Measure 1 Population Management Activities
26
IT Measure 2Point-of-Care Activities
Percentage of Groups
27
Correlation Between IT Adoption and Clinical
Performance
28
Public Report Cardhttp//opa.ca.gov/report_card/m
edicalgroupcounty.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
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)

33
Overcoming Program Challenges
34
The Data Problem
Paper Medical Record N Y Y? Y N
Electronic Medical Record Y? Y Y Y Y
Claims Data Y N N N Y
  • The data you want
  • Easy to collect
  • Clinically rich
  • Complete and consistent
  • Across product lines/payors
  • Whole eligible population

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
39
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
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