Performance Data Reporting: Impact on Primary Care Practices

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Performance Data Reporting Impact on Primary
Care Practices
Philip D. Sloane, MD, MPH, Jacquie Halladay, MD,
MPH, Sally Stearns, PhD, Thomas Wroth, MD, MPH,
Paul Bray, MA, Lynn Spragens, MBA, Sheryl
Zimmerman, PhD From the North Carolina Network
Consortium and the Cecil G. Sheps Center for
Health Services Research, University of North
Carolina at Chapel Hill Funded by the US Agency
for HealthCare Research and Quality (AHRQ)
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Disclosure

• I have no relationships to disclose, and
• I will not discuss off label or investigational
  use in my presentation

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Background

• 2006 AHRQ publication barriers and challenges to
  collecting and reporting healthcare data
• Barriers Identified
• Data system inefficiencies of data systems
• Variation in indicators
• Technological barriers
• Competing priorities
• Economic pressures
• Organizational and cultural issues.

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Objectives

• Detail the costs of implementation and
  maintenance of performance data reporting
• Gather information on how practices successfully
  overcome challenges to data reporting.

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Programs Evaluated

• Physician Quality Reporting Initiative (PQRI)
• Bridges to Excellence
• Improving Performance in Practice (IPIP)
• Community Care of North Carolina (CCNC)

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PQRI

• Medicares reporting program.
• 74 quality measures (practices can choose).
• G codes are added to billing submissions.
• Must have 80 of cases reported on three quality
  measures.
• Incentive payment of lt 1.5 of Medicare
  allowable.

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Bridges to Excellence

• Started in 2006 as a three-year pilot program by
  BC/BS.
• Incentive , based on achieving quality
  thresholds and of patients with BCBS insurance.
• Two programs studied
• Diabetes Care HbA1c, BP, LDL, Eye exams, Foot
  exams, Nephropathy assessments, smoking
  status/cessation.
• Physician Office Connections Office systems and
  processes such as electronic prescribing,
  referral tracking, performance reporting (9 items
  total).

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Improving Performance in Practice (IPIP)

• State-based, nationally led QI initiative
• Pilots in CO and NC.
• Uses quality improvement coaches (QICs) who go
  into physicians offices and work with the
  practice on improvement efforts, including
• Data system assistance
• Decision support and protocol development
• Office team involvement in quality improvement
  and measurement

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Community Care of North Carolina (CCNC)

• Statewide system of 14 regional Medicaid care
  networks
• Each has a program director, medical director,
  steering committee, case managers
• Attention to chronic diseases (mainly diabetes
  and asthma)
• Guideline dissemination case management
• Yearly statewide audits and reports with
  comparison data to local practices

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Eight Practices Selected For Variety and Program
Participation
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Quality Data Reporting Programs Represented
Of the 8 practices in the COMP project, 4
participated in PQRI, 3 in IPIP, 2 in
BTE-Diabetes, 1 in BTE- PPC, 1 in a chronic
disease collaborative
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Conditions Evaluated
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Medical Data Systems
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Study Methodology

• Intensive site visits by economist, QI specialist
  qualitative researcher
• Meticulous detailing of costs (see next slide)
• Interviews with
• quality champion,
• care providers,
• other practice staff
• Quantitative and qualitative analyses

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Cost Categories - 1
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Cost Categories - 2
Cost Categories - 2
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Cost Phases
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PQRI Implementation Costs in Four Practices
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PQRI Implementation in Practices A and H
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Cost Per FTE of Implementing CCNC vs IPIP
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Average Practice Program Costs per FTE of
CCNC, IPIP, and PQRI
Maintenance Phase 6 practices 3
practices 4 practices
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Estimated Costs and Reimbursement for
Participation in B to E Diabetes
Estimates are per provider FTE
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Estimated Costs and Reimbursement for
Participation in B to E Medical Home
Estimates are per provider FTE
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Lessons from Qualitative Interviews

• Methods
• Interviews with practice champion
• Group interviews with practice staff
• Medical director joined for lunch
• Dedicated note taker present case reports
  generated research team reviewed for themes and
  lessons

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Motivation to Participate is a Key to Success

• Pay for performance seems inevitable, and we
  wanted to prepare our practice for it
• If we are providing quality of care, we want to
  separate ourselves out and be recognized

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Leadership is Crucial to Getting Started

• Leaders with quality improvement experience and
  an interest in participation staff who then get
  motivated
• The providers set the tone and empower the
  staff

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Three Major Logistical Challenges

• Staff time and effort
• "The clinicians and staff are being driven to a
  frazzle
• IT challenges
• Im sure that the EHR vendor could develop a
  query to do this, if we paid them enough
• Difficulties changing physician behavior
• Once you start to measure quality, the first
  thing the providers do is question the measures

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Going Through Hoops to Achieve Data Consistency

• One practice had to train the physicians to
  record feet instead of extremity
• Another had to create a report on smoking
  cessation counseling three times before it was in
  an acceptable format

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Involving the Team

• Practices reported difficulty finding enough time
  to review and act on quality data reports
• (The practice manager) presents the data in a
  fun wayshe puts time into preparing it for you,
  in charts, so that we have clarity
• "Initially providers are burdened by a new
  reporting activity. But after a while it takes
  less effort because they figure out how to give
  it to nursing"

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Perceived Effects on Productivity Finances

• Slowed down productivity initially, but overall
  productivity increase over time
• Positive "Good income for good medicine"
• Negative They are taking money out of my
  pocket"

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Theoretical Model Factors Involved in
Developing and Maintaining Quality Assessment,
Improvement, and Reporting in a Primary Care

External and Internal Barriers and Facilitators
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