Pay for Performance for Physicians: WellPoints Perspective

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Pay for Performance for PhysiciansWellPoints
Perspective

• ACC Medical Directors Institute
• October 19,2006
• Lisa Latts, MD, MSPH, MBA
• Vice President, Programs in Clinical Excellence

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WellPoints Vision for Rewarding Clinical
Performance
Long-Term Goals
Value
Improve Member Health
Short-Term Goals
Outcomes
Structure / Process Meaningful Measures
Foundation
Build Trust / Collaboration
Quality broadens the dialogue beyond fees to
building a foundation of trust and collaboration.
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Physician Quality Programs Guiding Principles

• Comprehensive set of metrics that address quality
  of care, clinical outcomes, patient safety,
  processes of care
• Measures based on best practices, national
  guidelines (i.e., AQA) and developed through an
  interactive process
• Minimize administrative burden to participate
• Incorporate into contracting process
• Support health care delivery goals and public
  reporting of outcomes data

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Pay-for-Performance Programs at WellPoint
Partnerships with physicians and hospitals on
quality incentives
PCP Programs
Specialist Programs
Hospital Programs
Focused on primary care physicians. Typical major
components
Focused on specialty care physicians. Early
initiatives in Ob/Gyn, Cardiology, Orthopedics.
Measures similar to PCP programs
Focused on acute care hospital, typically full
service facilities. Hospital programs typically
have the following components

• Clinical Outcomes
• Evidence-based medical procedures
• Generic Prescribing Rates
• Technology streamlined administrative processes
• Patient Satisfaction

• Clinical Outcomes
• Evidence-based medical procedures
• Generic Prescribing Rates
• Technology streamlined administrative processes
• Patient Satisfaction

• Patient Safety
• Clinical Outcomes
• Patient Satisfaction

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Quality Programs
Rewarding high scores creates tangible
incentivefor quality improvement
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Measuring Physician Performance
Standardized measures of quality and valid
measures of cost or resource use improve the
quality and affordability of care provided by
network physicians.

• Select clinical measures endorsed by NQF/AQA
  (HEDIS-like)
• Select cost of care or resource-use measures for
  clinical diagnoses, e.g., diabetes, CV disease
• Measure physician performance on these measure
  widely across network, using sound methodology
  and data verification processes
• Seek input from physicians on measure selection,
  prior to reporting publicly, and the usefulness
  of the information
• Share information with consumers and purchasers
  and solicit input on usefulness of information
• Demonstrate using the information to improve
  network performance

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Virginia Quality Physician PerformanceProgram
(Q-P3sm)

• Pay for performance program for physicians in
  Virginia
• Opportunity to reward high quality performance in
  cardiologists
• Voluntary participation
• Developed in collaboration with ACC (VA chapter)
• Based on researched, published guidelines,
  medical society recommendations and
  evidence-based clinical indicators
• Opportunity to maximize indicator results in
  conjunction with hospital incentive program
  (Q-HIPsm)
• Ultimately emphasizes best practices to promote
  excellent cardiac care
• Recognizes critical impact of cardiologists in
  cardiac care

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Virginia Cardiology P4P Program Indicators (QP3)
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Increasing Physicians, Hospitals Engaged in
WellPoint Quality Improvement Programs
More than 100M paid to hospitals, physicians for
quality improvement
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Coronary Artery Bypass GraftVariation in Use
and Cost
Lexington, KY
Bridgeport, CT
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A Decade of Experience Lessons Learned

• Health plans, physicians and hospitals play a
  pivotal role in quality improvement and should be
  measured for quality performance
• Measuring quality improvement helps ensure
  performance levels are acceptable, guides
  performance improvement, and allows comparisons
  across hospitals, medical groups, physicians and
  health plans
• Performance measures should be robust,
  evidence-based, reflect national standards (e.g.,
  HEDIS, NQF, Ambulatory Care Quality Alliance) and
  be meaningful for consumers
• Measures should encompass specialty areas of
  chronic disease
• Financial incentives must be structured
  appropriately to effect behavior change (for
  example, 8 to 10 differential for physicians
  versus 2 to 4 for hospitals)
• Effective programs based on collaboration with
  sufficient flexibility to evolve over time
• Pay for performance can serve as a powerful
  incentive for quality performance improvement.