New York State Demonstration Grant Pay for Performance The New York Quality Alliance Performance & Measurement to Dr

1. New York State Demonstration Grant Pay for Performance The New York Quality Alliance Performance & Measurement to Drive Quality of Care NY Chapter of the American College of Physicians and the Physician Alliance

2. Presentation Outline Health Care Quality: The Case for Change Pay for Performance as a Driver for Change New York State Department of Health Demonstration Projects New York Quality Alliance (NYQA) Physician Alliance (PA) Chartered Value Exchanges: The Next Wave

3. Learning Objectives The physician will understand the extent of concerns about the quality, cost & availability of health care services in the US. The physician will become familiar with national organizations addressing health care quality and learn about standards for development and use of performance (quality) measures; The physician will understand the potential benefits and limitations of performance measurement and pay-for-performance programs. The physician will learn about the New York State Department of Health P4P projects and be able to define the terms New York Quality Alliance (NYQA) and the Physician Alliance (PA). The physician will understand Chartered Value Exchanges and the four cornerstones of value driven health care.     The physician will understand the specifics regarding the NYQA/PA and their role within the NYDOH Grant. The physician will be educated regarding the 10 HEIDIS measures that will be utilized in the NYSDOH P4P Grant including their specifications. The physicians will be provided information regarding best practice guidelines for the selected measures including, where available, tools to facilitate provision of efficient effective care, complete documentation and accurate billing. 

4. The Need to Change

5. Why The Status Quo is Not Acceptable • Costs continue to rise • Over 47 million citizens are without insurance • No clear association between spending and quality • Perception that current payment methodologies are misaligned- pay the same for care regardless of the quality of care provided. Pay for Performance (performance based reimbursement) programs are designed to align incentives

6. The Needs Of The Uninsured Are Not Being Met • Declines in health insurance coverage have been recorded in all but four years since 1994. • 1994: 36.5 million nonelderly individuals were uninsured • 2006: 46.5 million nonelderly individuals were uninsured • In spite of substantial growth of the Medicaid population • 83% of uninsured are from working families • Additional cost of the uninsured: over $100 billion annually • Worse health outcomes for the uninsured • 25% increase in mortality • Cancer diagnosed in later stages • Use of ER for routine care Sources: Agency for Healthcare Quality and Research; American College of Physicians, Employee Benefit Research Institute

7. 2005: 16.0% 1929=4% Source: CMS

8. Source: Congressional Budget Office report, The Long-Term Outlook for Health Care Spending, Nov. 13, 2007

9. Health care outstrips inflation Source: Kaiser Family Foundation (2005)

12. Average 54.9% Source: McGlynn, et. al., The quality of health care delivered to adults in the United States, N Engl J Med 2003; 348:2635-45

13. National Health Care Spending 2005 • $2 trillion ($6,697 per capita) • Growth higher than inflation for decades • 6.9% increase from 2004 • 16.0% of GDP • Highest in the world • Other developed countries: 8-12% • 7th largest economy in the world • Medicare $408 billion • Medicaid $291 billion Figures in actual dollars. Data from CMS

14. The Future • Health Care spending in 2016 • $4.1 trillion • 20% of GDP • Annual rate of increase 6.5-7.0% • Estimate based on projection of current trends • Assumes: • optimistic economic projections • conservative spending projections • no change in fundamental structure of the system • Medicare will grow 7.5-9.0% annually • Unknown cost of new technologies and standards of practice • Implantable defibrillators • Apo-A1 Milano • 64-slice CT scanners for cardiac disease Data from CMS reported in Poisal, JA. et. al., Health Spending Projections Through 2015, Health Affairs web exclusive Feb 21, 2007

15. The New Vision • The Value Equation • Are we currently getting value? • Medicare spending: 50% in the last year of life • Many studies: more Medicare spending does not prolong life, improve quality of life or result in higher quality of care • US ranks low vs. other countries in commonly accepted measures of health care quality and efficiency

16. The Future is Here Clearly, the focus of the health care debate is moving toward demanding efficient and effective care and only paying when such care is provided. Quality measurement is embraced as fundamental to quality improvement and increasingly Pay for Performance is being investigated and implemented in multiple forms.

17. The Field of Quality Measurement & Reporting is Getting Crowded • National Committee for Quality Assurance (NCQA) • -- Founded 1990 to ensure quality of care to health plan members, develops Health Effectiveness Data Information Set (HEDIS) measures • -- www.ncqa.org • New York Quality Assurance Reporting Requirements (QARR) • NYS Department of Health (NYSDOH) collects QARR measures from all NY managed care plans health plans, based on HEDIS since 1996 • www.nyhealth.gov/health_care/managed_care/reports/ • National Quality Forum (NQF) • -- Created in 1999 to develop a national strategy for health care quality measurement and reporting. • -- A not-for-profit, public-private, membership organization with broad participation from all sectors of the health care system including consumers • -- www.qualityforum.org/about/

18. Quality Measurement & Reporting • Institute of Medicine Reports • To Err is Human, 2000; www.iom.edu/?id=12735 • Crossing the Quality Chasm, 2001; www.iom.edu/?id=12736 • AMA Physician Consortium for Performance Improvement • -- Established 2000 to develop performance measures for physicians from evidence-based clinical guidelines for select clinical conditions • -- Broad representation from the “house of medicine” with AHRQ and the Center for Medicaid and Medicare Services (CMS) • -- www.ama-assn.org/ama/pub/category/2946.html • Hospital Quality Alliance (HQA) • Established 2002 to make information about hospital performance accessible to the public and to encouraging efforts to improve quality • www.hospitalqualityalliance.org; www.HospitalCompare.hhs.gov

19. Quality Measurement & Reporting • AQA Alliance • In 2004 medical specialty societies, insurance plans and the Agency for Healthcare Research and Quality (AHRQ), joined to determine how to most effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting • Originally known as the Ambulatory Care Quality Alliance • www.aqaalliance.org/ • Quality Alliance Steering Committee (QASC) • Established in 2006 to develop an overall framework for the effective use of standard health care quality and cost measures nationwide • www.brookings.edu/projects/qasc.aspx

20. Quality Measurement & Reporting • Value Driven Health Care Initiative • Established 2006 by executive order • Four cornerstones: interoperable health information technology; measure and publish quality information; measure and publish price information; promote quality and efficiency of care. • Certified Value Exchanges (CVE): local and regional multi-stakeholder collaborative organizations working to improve quality and value in health care by measuring the performance of local health care providers and reporting these findings publicly. • NYQA designated one of 14 nationally recognized CVEs • www.hhs.gov/valuedriven/index.html • 64-slice CT scanners for cardiac disease

21. Pay For Performance

22. Pay For Performance • Pay-for-performance programs are growing, but there is little evidence on their effectiveness or of their potential unintended consequences and effects on the patient-physician relationship. • Pay-for-performance has the potential to help improve the quality of care if it can be aligned with the goals of medical professionalism. Annals Int Med 2007;146:792-794

23. Pay – For -Performance “It is no longer enough to take good care of the patient in front of you. To improve results, we must find ways to help patients who do not come to the office regularly. Keeping track of all this data requires a whole new set of skills and resources; this is new work, it costs time and money and it has to be compensated.” Dr Janet (Jessie) Sullivan, Chief Medical Officer of Hudson Health Plan)

24. PROFESSIONAL ISSUES Pay-for-performance programs stir debate Ethics Forum. Nov. 6, 2006.

25. Examples of P4P Initiatives CMS Hospital Core Measures PQRI Ambulatory “Core Measures” NY State NYQA Grant and other similar pilots Commercial and Medicaid Health Plans in NY Purchaser/Employer Bridges to Excellence

26. Pay For Performance: Issues To Consider Measures Data collection Data validation/reconciliation Reports Impact on care and cost, desired and otherwise

27. Measures Ideal Measures • Valid • Evidence based • Reliable • Identify real differences in provider quality • Must be risk adjusted • Actionable • Measure what is intended • No unintended consequences • Measures should be Feasible

28. Measure Collection • Types of Measures • Process • Outcomes • Structural • Data sources • Administrative/claims and billing data • Medical Record Abstraction • Electronic clinical data: EHR, registries, RHIOS • Hybrid combinations • Data reconciliation • Opportunities to review and correct errors prior to publication • Discrepancies between data sources • Missing Data • Transcription and coding errors

29. Reports • Attribution issues • Whose patient is it? • Reports for group vs. individual • Small numbers • Samples too small for valid conclusions • Report timeliness • Time for claims to be filed and processed • Time for abstraction, aggregation, processing data • Report actionable • Identified vs de-identified data • Current but incomplete vs. complete but out-of-date

30. Potential Benefits System • Reduce costs and improve quality • underuse, overuse, misuse Physician • Economic • Quality of Care • Preparing for the Future

31. Ethical Concerns • Inequitable impact • Inefficient use of resources and tendency to focus on efficiency (cost) not other facets of quality • Unreliable (therefore unfair) measures • Concern that Pay for performance is deprofessionalizing Matthew Wynia, MD, MPH Institute for Ethics at the American Medical Association

32. Inequitable impact • Physician • Large practices with HIT will win • Those already doing well will win • Patient • Non-adherent patients will be shunned • Minorities/elderly/immigrants will be shunned

33. P4P Aimed At Hitting Target Performance Level Might Be Counterproductive Organizations in this area have little hope of gaining the bonus Organizations in this area have an incentive to improve Organizations in this area will get the bonus with no additional work Quality P4P Target

34. Will the Vulnerable be Neglected? • Some evidence from public reporting… • Pt transfers to Cleveland Clinic from NY increased 31% after public reporting on CABG, sicker patients more likely to be sent. (Omoigui 1996) • 59% of internists in PA say harder to find surgeon for high risk patients after public reporting (Schneider 1996) • Such programs could also result in the de-selection of patients, “playing to the measures” rather than focusing on the patient as a whole…….. Annals Int Med 2007;146:792-794

35. What do physicians say? • “Dr. Brook correctly states that the use of physician-specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.” • Stephen Clement, MD, Annals of Intern Med 1994 • “If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.” • Physician in a 2006 survey on P4P • “39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent or questioned the physician’s decision-making.” • Farber et al. JGIM 2007

36. Inefficient Use of Resources • Documentation (rather than quality) improves • Inappropriate emphasis on what’s measured • Little more $ for lots more work – not enough to offset costs of measurement • “ Incentives based on a handful of measures of quality may encourage physicians to focus their efforts on improving quality in the areas targeted by the programs, neglecting other important aspects of care” (Epstein et al. 2004)

37. Unfair Measures: Reliability • Importance of data aggregation • “The largest participating plan in the IHA program has about 1.4 million members, less than 23% of the entire 6.2 million population. Even a plan of this size using its own data often lacks sufficient sample size to allow for statistical reliability.” (Integrated Healthcare Association, 2006)

38. Unfair Measures: Data Reliability • Assigning responsibility (attribution) • Medicare beneficiaries see a median of 2 PCPs and 5 specialists working in 4 different practices per year • 35% of patients’ visits are with their assigned physicians • 33% change PCP each year • A PCP’s “assigned” patients are only ~39% of the Medicare patients they see (Pham et al. 2007)

39. Unfair Measures: Data Reliability • Not enough patients per practice for reliable results year to year • Among 232 PCPs, 4% of the variance of their diabetic patients’ outcomes was attributable to physician practice patterns • Reliability of measures never better than 0.40 • Would need >100 diabetic patients to get reliability of 0.80 • Outliers could dramatically improve performance by dropping 1-3 patients Hofer 1999

40. Impact on the Profession of Medicine • Doctors shouldn’t be motivated by greed… • “…P4P programs insinuate that the existing moral and social incentives for providing excellent care are not sufficient – that financial incentives will succeed where the clinician’s professional character failed.” (Satin, 2006)i.e., If they work… it would be embarrassing. • “Increasing external incentives reduces internal motivation… [so the worst problem with P4P would be] “if you ended up with a system where… doctors only did anything because they were paid for it and had lost their professional ethos.” Martin Rowland, NHS (Health Affairs interview, Sept 2006)

41. A Possible Path to TakeNew York State Department of Health Demonstration Grant

42. The legislative intent of the demonstration project is to promote the development of pay-for performance programs, involving multiple payers that achieve increased quality and cost effectiveness. The legislation extended authority to the Commissioner of Health to: A. Convene a workgroup to delineate the ambulatory and inpatient measures of performance to be used in the demonstration programs; B. Oversee a grant program which will provide funding to purchaser and provider coalitions to establish regional pay-for-performance programs New York State Demonstration P4P Grant

43. The Process • The NYS DOH Commissioner’s Workgroup convened in July 2005 . The workgroup consisted of representatives from managed care plans, hospitals, statewide and regional provider associations, payers, labor unions, and consumers. • Charged with seeking consensus on the inpatient and ambulatory measures to be included in the pay-for-performance demonstrations, the workgroup met on four occasions between July and December 2005. • In May 2006 DOH issued a RFP making $9.5 million available to support demonstration projects for a period of two years. • The workgroup agreed to begin with administrative data, but acknowledged that this was just a first step and over the long run administrative data needed to be replaced with outcome data.

44. Elements of The Demonstration Grant • To study and test incentive programs, including performance-based payments to physicians, hospitals and clinics that provide high-quality care to their patients. • The state funding will pay project costs and help fund rewards to providers. • Participating health plans will select the incentive structure they use, but typical incentives include bonuses or increases in reimbursement rates provided to physicians, hospitals and clinics based on their performance meeting various measures of quality.

45. The projects are part of the State Health Department’s efforts to encourage providers and insurers to work collaboratively to improve the quality of care that is delivered in New York State. • State Health Commissioner Richard F. Daines, M.D. said: “Evidence-based care that improves patients’ ability to live healthier, productive lives is crucial to reforming our health care system and reducing health care costs. This is an area where the public and private sectors can work together to foster change.”

46. The Four State Demonstration Projects • Independent Health Association Inc. (Buffalo) • Taconic Health Information Network and Community Regional (THINC RHIO) in Hudson Valley Region) • Montefiore Medical Center (Bronx) • *New York Health Plan Association (NYHPA) This project is a statewide collaboration involving 12 health plans – Aetna, Affinity, CDPHP, Elderplan, GHI HMO, HealthNet, HealthNow, HIP, Hudson Health Plan, Independent Health Association, MVP, and Oxford. HPA will partner with physician, business and consumer groups, Capital District hospitals and RHIOs .

47. New York Health Plan Association (NYHPA) Demonstration Grant

48. NYHPA Demonstration Grant Overview • Goal • Collaborators • Structure • Clinical Measures • Data Collection/Management/Validation • Timelines • Physician Reports • Incentives

49. NYHPA Demonstration Grant Goals • Project is to promote patient safety and quality of care through the development of pay-for-performance programs in New York State. • A two year demonstration Project. • Brings all the stakeholders together Patients, Physicians and Health Plans, and consumer advocates. • Develop policies and procedures for long lasting P4P programs in New York. • Develop a mechanism to have ongoing Dialogue with the Health Plans

50. Grant Elements • The New York State Health Plan Association through the grant has created the New York Quality Alliance (NYQA), which is a multi-stakeholder collaborative partnership that will guide the adoption and use of evidence based measures to: measure, report and drive improvements. • The reports generated under the guidance of NYQA will be used in pay for performance programs initiated by the Health Plans so that physicians will be financially rewarded that have good patient outcomes.