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Pennsylvania’s Pay for Performance Programs David K. Kelley MD, MPA

Pennsylvania’s Pay for Performance Programs David K. Kelley MD, MPA. Pennsylvania Office of Medical Assistance Programs. Pay for Performance (P4P). Access Plus- P4P program targeted to reward PCPs for quality of care and participation in disease management

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Pennsylvania’s Pay for Performance Programs David K. Kelley MD, MPA

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  1. Pennsylvania’s Pay for Performance ProgramsDavid K. Kelley MD, MPA Pennsylvania Office of Medical Assistance Programs

  2. Pay for Performance (P4P) • Access Plus- P4P program targeted to reward PCPs for quality of care and participation in disease management • Hospitals- P4P targeted to reward hospitals that improve care and focus on patient safety • HealthChoices ® - P4P targeted to managed care plans to improve 10 defined HEDIS ® measures 2

  3. What is the ACCESS-Plus Program? 1. Access Plus is an Enhanced Primary Care Case Management (EPCCM) medical home 2. Disease Management (DM) Program-CAD, CHF, Asthma, COPD, Diabetes 3. Complex Case Management 4. 280,000 members, excludes dual eligibles, 32,000 with chronic diseases covered by DM 5. Vendor has guaranteed cost savings, and is at risk for DM performance 3

  4. ACCESS-Plus Program Service Area ERIE Gateway MedPLUS+ Ion Health SUSQUEHANNAMedPLUS+ Gateway WARREN McKEAN BRADFORD TIOGA MedPLUS+ POTTER MedPLUS+ CRAWFORD MedPLUS+ UPMC WAYNE FOREST MedPLUS+ LACKAWANNA AmeriHealth Gateway MedPLUS+ WYOMING MedPLUS+Gateway SULLIVAN MedPLUS+ ELK CAMERON VENANGO PIKEMedPLUS+ Gateway AmeriHealth UPMC LYCOMING LUZERNE AmeriHealth MedPLUS+ Gateway MERCER Gateway MedPLUS+ UPMC CLINTON CLARION Gateway MedPLUS+ JEFFERSON Gateway MedPLUS+ MONTOUR Gateway MedPLUS+ COLUMBIA Gateway MedPLUS+ MONROE MedPLUS+ AmeriHealth LAWRENCE CARBONMedPLUS+Gateway AmeriHealth CLEARFIELD UPMC UNION BUTLER CENTRE ARMSTRONG SCHUYLKILL Gateway MedPLUS+ SNYDER NORTHUMBERLAND Gateway NORTHAMPTON BEAVER INDIANA MIFFLIN LEHIGH BLAIR CAMBRIA Gateway MedPLUS+ UPMC Ion Health Gateway MedPLUS+ UPMC Ion Health JUNIATA PERRY ALLEGHENY BERKS DAUPHIN BUCKS LEBANON WESTMORELAND HUNTINGDON MONTGOMERY WASHINGTON CUMBERLAND LANCASTER SOMERSET Gateway MedPLUS+ UPMC BEDFORD UPMC PHILADELPHIA CHESTER FRANKLINMedPLUS+ Gateway YORK FULTON DELAWARE FAYETTE ADAMS GREENE Mandatory Managed Care - HealthChoices ACCESS Plus and Voluntary Managed Care (where available) 4 September 2004

  5. Guidelines for Success • Involve stakeholders • Avoid relative scales and scoring • Link payment to clearly defined “widgets” • Reward quickly!! • Don’t “penalize” for patient non-compliance • AMA P4P guidelines 5

  6. ACCESS Plus P4P Program Design Payment to eligible* providers for 3 critical areas: • Assistance with enrollment of eligible patients in DM programs • Collaborationin care management of DM enrollees • Delivery of key clinical interventionsthat help improve quality of care and clinical outcomes * Any individual provider (including certified registered nurse practitioners) or provider entity participating in the Pennsylvania ACCESS Plus network who has any patient with at least one of the targeted diseases (i.e., congestive heart failure, diabetes, asthma, chronic obstructive pulmonary disease or coronary artery disease), regardless of risk level. 6

  7. P4P Payments • Support of Program-$200 per practitioner • Enrollment Support-$40/high risk pt contacted by a participating office • Enrollment Support-$30/high risk pt where office provides new contact information • Chronic Care Feedback Form (CCF) $60 per completed CCF 2X a year 7

  8. Clinical Interventions – Year One Based upon patient self-report at six-month telephonic assessment: • Payment for each instance when pt reports taking Key Medications for the target condition: • CHF: Beta Blocker • Diabetes: Aspirin • Asthma: A “controller” medication (persistent asthma) • CAD: Aspirin • Substitute medications will count in cases of contraindications • High risk patients only • Payment frequency: Every 12 months • Payment amount: $17 per patient 8

  9. Clinical Interventions – Year Two Based on claims data (one Rx or lab per year) • Key Medications and labs: • CHF: Beta Blocker • Diabetes: measurement of LDL-C • Asthma: A “controller: medication if patient has persistent asthma • CAD: Statins • Substitute medications count in cases of contraindications • Both high risk and low risk patients • Payment frequency: Every 12 months • Payment amount: $17 per patient 9

  10. Initial Six Month Assessment Results 10

  11. P4P Potential Revisions • Increase funding to $1 pmpm • Lead screening • Assessment and management of childhood obesity • Chronic Feedback Form for children with special needs • ACE/ARB use in CHF-- current self reported use <60% • B-Blocker use post-MI-- current self reported use <80% • Smoking cessation counseling 11

  12. Lessons Learned • Need more incentives for pediatric providers • Payment issues to large health systems that employ providers • Transfer of information via electronic format versus paper • Provider and consumer education • Provider and consumer feedback • Need to align incentives 12

  13. Hospital Care Incentive Program • Implemented 2005, first payment 4/06 • Provides incentives to hospitals that demonstrate commitment to improved management of the healthcare needs of Medical Assistance consumers – It rewards: • Better management of chronic disease • Better management of drug therapies • Better coordination with physicians, MCOs and Access Plus • Investment in quality related infrastructure • Uses data already reported by hospitals • Children’s Hospitals are treated separately 13

  14. Hospital P4P Program • Use scoring methodology to adjust rate increases provided to acute care DSH hospitals • Key measures are 7 day re-admission rates for the most common chronic diseases in the MA population, and measures related to left ventricular function (LVF) assessment and community acquired pneumonia • Re-admits are a reasonable proxy for • Appropriate care management in the hospital • Appropriate discharge planning • Effectiveness of patient education • Effectiveness of coordination with community physicians • Effectiveness of coordination with MCOs and Access Plus • Other measures focus on hospital treatment of chronic disease and common illness • Set aside pool for support of quality related investments 14

  15. Scoring Method(Acute – non Children’s DSH Hospitals) • Hospitals will be scored on the following system 2 pts if 7-day re-admit rate for asthma is below average 1 pt if 7-day re-admit rate for asthma is average 0 pts if 7-day re-admit rate for asthma is above average Same scoring for re-admit rates for Diabetes, CHF, and COPD 2 pts if hospital LVF assessment score is above average 1 pt if hospital LVF assessment score is average 0 pts if hospital LVF assessment score is below average 2 pts if mean time to first antibiotic dose for pneumonia is below average 1 pt if mean time to first antibiotic dose for pneumonia is average 0 pts if mean time to first antibiotic dose for pneumonia is above average 1 pt if hospital has implemented the use of a single medical record 1 pt if hospital has implemented a formal pharmacy error reduction program 1 pt if hospital is reporting to Leapfrog (Total possible score = 15 points) • Re-admits will be based on all payer data collected by HC4; remaining measures will be based on all payer data currently being reported by all hospitals 15

  16. Hospital P4P- Use of Scores • 13-15 points 150% of increase for inpatient DSH and med ed • 9-12 points 125% of increase for inpatient DSH and med ed • 6-8 points Average increase for inpatient DSH and med ed • 2-5 points 75% of increase for inpatient DSH and med ed • 0-1 points no increase 16

  17. Scoring Method for Children’s DSH Hospitals • Hospitals will be scored on the following system 2 pts if re-admit rate for asthma is below average 1 pt if re-admit rate for asthma is average 0 pts if re-admit rate for asthma is above average 1 pt if hospital has implemented the use of a single medical record 1 pt if hospital has implemented a formal pharmacy error reduction program 1 pt if the hospital has 24 hour intensevist coverage 1 pt if hospital is reporting to Leapfrog or is field testing pediatric quality measures for JCAHO (total possible score = 6) • Scores used to adjust base rate and DSH increases 6 points 150% of increase 5 points 125% increase 3-4 points average increase 1-2 point 75% increase 0 points – no increase 17

  18. Hospital Investment Incentives • Provide grants up to $100,000 to DSH hospitals who have made investments in the following • Pharmacy Error Reduction • Pharmacy Legibility Improvement Program • Participation in ECRI, ISMP and DVHC Regional Medication Safety Program • Completion of ISMP's Medication Safety Assessment for 2004 • Participation in PRHI's Medication Safety Program • Use of medication error reporting tool such as MEDMARX • Established confidential medication error reporting system • Implemented point of care bar coding medication administration system or CPOE • Automated Pharmacy System • 24 hour Pharmacist available • Single Medical Record • Other quality related investments as approved by the Department • Annual Incentive fund set aside = $1 million 18

  19. HealthChoices ® - MCO P4P Program • Implemented July 2005 • Uses 10 HEDIS® measures • Department identified areas for improvement or continued high performance • Financial incentives based on MCO specific goals 19

  20. Seven Core Measures: Controlling High Blood Pressure Diabetes: HbA1c Poor Control Diabetes: Cholesterol LDL Control < 130 Cholesterol Management: LDL Control <130 Frequency of Prenatal Care: > 81% Breast Cancer Screening Cervical Cancer Screening Three Sustaining Measures: Prenatal Care in the 1st Trimester Use of Appropriate Medications for People With Asthma Adolescent Well-Care Visits HealthChoices ® - MCO P4P Program 20

  21. Setting Goals – Core Measures • Based on the larger of the following criteria: • Increase to reach the 50th percentile benchmark; or • Statistically significant increase from the 2004 actual rate; or • Increase of 10% of the difference between the 2004 actual rate and 100%. 21

  22. Setting Goals- Sustaining Measures • If the prior year’s rate was below the 50th percentile benchmark; the larger of: • increase needed to reach the 50th percentile benchmark, or • a straight increase of 4 percentage points • If the prior year’s rate was above the 50th and below the 75th percentile benchmark; • the goal is a straight increase of 4 percentage points • If the prior year’s rate is above the 75th and below the 90th percentile benchmark; • the goal is a straight increase of 3 percentage points • If the prior year’s rate is at or above the 90th percentile benchmark • the goal is a straight increase of 2 percentage points. 22

  23. Payment Rules • Must reach 100% of goal unless 2005 rate is at or above the 90th percentile benchmark • If goal was met, and the 2005 rate is: • below the 50th percentile benchmark = 0% • above the 50th and below the 75th percentile benchmark = 50% • above the 75th and below the 90th percentile benchmark = 75% 23

  24. Payment Rules If the current rate is at or above the 90th percentile benchmark, and: • The prior year’s rate was below the 90th percentile benchmark but the MCO did not reach its goal; • Incentive = 90% of the maximum payment. • The prior year’s rate was below the 90th percentile and the MCO reached its goal; • Incentive = 100% of maximum payment. • The prior year’s rate was above the 90th percentile benchmark and there was a statistically significant decrease in the 2005 actual rate; however, the 2005 rate remains at or above the 90th percentile benchmark; • Incentive = 90% of the maximum payment • The prior year’s rate was above 90th percentile benchmark and there was not a statistically significant decrease but the 2005 rate remains at or above the 90th percentile benchmark; • Incentive = 100% of maximum payment. 24

  25. Timing Issues 25

  26. 2006 Performance Incentives 26

  27. Pay For Performance2006 Aggregate Rates and Goals * For this measure, lower rate indicates better performance. ** Due to changes in the technical specifications for this measure it cannot be trended from 2004 to 2005. Rate not calculated for P4P initiative. 27

  28. UPMC2006 P4P Results 28 * For this measure, lower rate indicates better performance. ** Due to changes in the technical specifications for this measure it cannot be trended from 2004 to 2005. Rate not calculated for P4P initiative.

  29. Unison2006 P4P Results 29 • For this measure, lower rate indicates better performance.

  30. Gateway 2006 P4P Results * For this measure, lower rate indicates better performance. 30

  31. Keystone 2006 P4P Results * For this measure, lower rate indicates better performance. ** Due to changes in the technical specifications for this measure it cannot be trended from 2004 to 2005. Rate not calculated for P4P initiative. 31

  32. What’s New in 2007 • Increased from 10 to 12 measures • Same 10 measures used in 2006 • Add Early Childhood Blood Lead Screening to core measures (19 months old & 3 years old) • Cholesterol Management: LDL Control lowered to <100 mg/dL • Finalizing 2007 goals 32

  33. Future Considerations • Increase quality incentive payout to MCOs (2-3% of premium) • Add 0.75-$1.00 pmpm for provider incentive program • Explore alternate measures • Explore use of incentives coupled with disincentives 33

  34. Lessons Learned • Use nationally accepted measures • Anticipate NCQA changes in parameters • Must plan ahead 10-12 months • Initial implementation- MCO discussion/feedback • Peoplestat- meet every 6 months with senior leadership of MCOs to discuss results and goals • Statistically significant improvement in 7 of 9 measures 34

  35. Questions??David K. Kelley MD, MPAc-dkelley@pa.state.us “Energy and persistence conquer all things”. Benjamin Franklin

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