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MARGARET E. O

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a strategic approach to implementing healthcare incentives margaret e. o kane october 20, 2008 about today s presentation ncqa: a brief introduction what, how ... – PowerPoint PPT presentation

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Title: MARGARET E. O


1
MARGARET E. OKANEOCTOBER 20, 2008
  • A STRATEGIC APPROACH TO IMPLEMENTING HEALTHCARE
    INCENTIVES

2
ABOUT TODAYS PRESENTATION
  • NCQA A Brief Introduction
  • What, How, and Why We Measure
  • Our Experience with P4P
  • The Need for Comprehensive Payment Reform
  • Recommendations

3
NCQA A BRIEF INTRODUCTION
  • Private, independent non-profit health care
    quality oversight organization founded in 1990
  • Mission To improve the quality of health care
  • Committed to measurement, transparency and
    accountability
  • Unites diverse groups around common goal
    improving health care quality

4
WHAT DO WE MEASURE?
  • HEDIS
  • Cancer screening, diabetes, cardiac care
  • Measures of effective, appropriate care
  • Address prevention, chronic care
  • Specifications vetted by health care
    stakeholders, thought leaders
  • Results are rigorously audited
  • CAHPS
  • Access, timeliness, satisfaction
  • Independently collected

106 millionAmericans are enrolled in a
planthat reports HEDIS/CAHPS
5
WHAT DO WE MEASURE?
  • Health Plans
  • HEDIS and CAHPS quality measurement
  • 2/3 of HMOs in U.S. are NCQA Accredited
  • Covering 75 of HMO lives
  • Only Accreditation program that scores programs
    on quality of care
  • 2008 NCQA extends many MCO Accreditation
    requirements to PPOs
  • Physicians/physician groups
  • HEDIS for Physician Measurement
  • NCQA Physician Recognition programs

6
IN THE BEGINNING...
  • Quality was widely assumed to be high
  • Measurement thought of as a novelty
  • Health plans went first
  • Employer demand, threat of regulation were key
  • Provider resistance was strong
  • Performance gaps revealed
  • Quality improvement efforts launched
  • Patient safety story unfolded
  • Notion of cost/quality tradeoff exploded

7
MEASUREMENT DRIVES IMPROVEMENT
Denotes measure specification change
8
BETA-BLOCKER TREATMENT AFTER A HEART ATTACK 1996
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Each of these dotsis a health plan.
Note the variability from plan to plan.
National average 62.6
9
BETA-BLOCKER TREATMENT AFTER A HEART ATTACK 1996
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
97.7
10
APPLYING MEASUREMENTTO FINANCIAL
INCENTIVESNCQAS EXPERIENCE WITH P4P
11
PHYSICIAN-LEVEL P4P PROGRAMS ARE GAINING TRACTION

estimate
Source MedVantage
12
NCQA PHYSICIAN RECOGNITION PROGRAMS
  • Identifies providers who deliver superior care
  • More than 11,000 physicians Recognized to date
  • Measure against evidence-based standards
  • Assess care for diabetes, heart/stroke, back
    pain, care delivery systems
  • New PPC-PCMH program serves to identify practices
    as medical homes

13
HOW NCQA RECOGNITION PROGRAMS WORK
  • Evidence-based measures
  • Voluntary
  • Practice self-assesses and collects data
  • Practice submits documentation to NCQA
  • NCQA reviews, scores audits submissions
  • NCQA reports Recognized physicians on website and
    licenses list to others

14
MANY PRIVATE P4P EFFORTS BUILD ON NCQA
RECOGNITION PROGRAMS
  • Integrated Healthcare Association P4P (Calif.)
  • Bridges to Excellence (19 states)
  • Health plans

15
HOW IS RECOGNITION USED?
  • Direct Financial Incentives
  • Network Entry
  • Active steering to Recognized MDs
  • Recognition in Provider Directories
  • Data Collection assistance

16
THE NEED FOR COMPREHENSIVE PAYMENT REFORM
17
  • The rate at which health care costs grow is the
    central determinant of our long-term fiscal
    future.
  • --CBO Director Peter Orszag
  • September 25, 2007

18
WE CANT AFFORD TO THINK SMALLINCENTIVES FOR
OVERUSE STILL SWAMP THE SYSTEM
19
P4P IS JUST THE FIRST STEP
  • Incentives are not strong compared to underlying
    payment system
  • While gaining traction, penetration remains
    limited
  • Programs target primary care, but few exist for
    specialty care

20
P4P FIRST-GENERATION INCENTIVE REALIGNMENT
  • Different solutions are needed for different
    local conditions
  • Population/risk adjustments necessary
  • Paying for achievement vs. improvement it cant
    be an either-or proposition
  • Aggregation of physicians does not necessarily
    equal integration
  • Incentives for QI need to be clear

21
INCENTIVES MUST ALIGN WITH THE INTERESTS OF THE
PATIENT AND SOCIETY
Health care spending
Healthy/ Low Risk
At-Risk
High Risk
Active Disease
Early Symptoms
20 of people generate 80 of costs
A value-based health care system
Source HealthPartners
22
THOSE INTERESTS ARE...
  • Patients
  • The right care at the right time
  • Good health
  • Good health care
  • Affordable, accessible health care
  • Society
  • The right care at the right time
  • Healthy, productive citizens
  • Predictable, affordable care

23
NOT PAYING FOR THE WRONG CAREA PLACE TO START
  • Public, private payors increasingly refuse to pay
    for never events
  • E.g. wrong-side surgery, mismatched blood
    transfusions, severe pressure ulcer
  • Aligns payment incentives with patient safety
    interests
  • Signals that bad care wont be rewarded

24
THE NEED FOR ACCOUNTABLE ENTITIES
25
CHANGING OUR APPROACH
  • Up to now, P4P has been structured around
    specific measures
  • Result improvement on specific measures
  • More meaningful reforms address
  • Delivery systems
  • IT adoption
  • Planned care

Addressed by the Patient-Centered Medical Home
26
MEDICARE BENEFICIARIES WITH CHRONIC CONDITIONS
SEE AN AVERAGE OF SEVEN DOCTORS
Rx
Dx
Rx
Tx
Rx
Rx
Dx
Tx
Tx
Tx
Dx
Dx
Dx
Dx
Dx
Rx
Rx
Tx
Tx
Rx
Tx
confusing, dangerous gaps in care often result.
27
WHOS IN CHARGE HERE?
?
28
CLINICALLY ACCOUNTABLE ENTITIES
  • Medical Home
  • Primary care
  • Specialty care (for select conditions)
  • Coordinated group practice
  • Hospital-centered network
  • Other integrated, accountable systems

29
ALTERNATIVE DELIVERY SYSTEMS AND ACCOUNTABLE
MODELS
MedicalHome
PCP
Accountable Clinical Entity
SpecialtyCare
Specialists
HospitalCare
Patient, provider incentives most easily aligned
here
Hospital
30
THE MEDICAL HOME POSSIBLE LIMITATIONS
  • Highly coordinated care is a team sport
  • Marrying the medical home to the specialist side
    needs to be more fully fleshed out
  • Fully maximizing the promise of this model
    requires broad IT adoption, benchmarking this
    goes beyond practice-level initiatives
  • The buzzword trap must be avoided practices
    must be held to clear standards of what is and
    isnt a medical home

31
CHALLENGES TO INCENTIVES IN THE CURRENT DELIVERY
SYSTEM
  • Fragmented care results in gaps in care because
    of gaps in accountability
  • Simply aggregating physicians does not make for
    an integrated delivery system
  • Larger group practices allow for integration of
    primary, specialty care into larger units of
    accountability

32
COMPREHENSIVE PAYMENT REFORM NEEDED
  • Revisit capitation / payment bundling
  • There is far more transparency now than 10 years
    ago
  • Public understands more about quality measurement
  • Some incentives make sense
  • Area of caution physician backlash
  • Policymakers are taking note
  • Medicare Implemented demonstration programs on
    medical homes (8 states), group practices
  • Several state initiatives underway, notably
    including North Carolinas Medicaid medical home
    program

33
HOW DO WE GET TO VALUE (MISS.)?
  • Payments must be substantial to counteract
    massive incentivesfavoring overuse
  • But micromanaging incentivesdoesnt work
  • Setting a destination and allowingproviders to
    solve for efficiency allowscreativity to come
    into play

34
INCENTIVES MUST ALIGN WITH THE INTERESTS OF
PATIENTS, SOCIETY
Health care spending
Healthy/ Low Risk
At-Risk
High Risk
Active Disease
Early Symptoms
20 of people generate 80 of costs
A value-based health care system
Source HealthPartners
35
DISCUSSION
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