The steering committee assembled to guide the development of this project
included practicing physicians, chief medical officers at health
plans and employers with direct experience in pay-for-performance
programs. We have formed a representative group from this committee
to shed additional light on design and execution of these initiatives
and the key issues involved. These experts currently are involved
with PFP programs ranging from Hawaii to Minnesota and from Nashville
to New York. They are available for media interviews and speaking
engagements.
DOUGLAS HIZA, M.D.
Blue Cross Blue Shield of Minnesota
Dr. Hiza is the Medical Director for Provider Relations at Blue
Cross Blue Shield of Minnesota (BCBSMN). His responsibilities include
working with physician leaders around Minnesota to improve care
provided to their patients. He is on the steering committee of
the Minnesota Community Measurement Project, which is made up of
all of the major health plans in Minnesota. The project produces
statistically significant comparisons of clinics across Minnesota
by combining plan data. He also is the medical director for BCBSMN’s
Recognizing Excellence (pay for performance) program.
Experience with P4P
Dr. Hiza has helped implement a PFP system at Blue Cross Blue Shield
of Minnesota that recently completed its first year of measurement.
Approximately 55 clinics have signed up for the voluntary program,
representing about 80 percent of BCBSMN members. The system is
almost entirely based on outcomes and derives data from chart reviews,
not claims data.
Clinics are asked to audit their own charts to ensure accuracy
of the findings and add credibility to the process. The first year
results showed extremely high levels of variability across clinics,
suggesting that some groups were striving to improve the quality
of care provided to their patients and thus deserved financial
rewards, while others were simply maintaining the status quo.
For each specialty, two clinical measure sets are used to rank
quality or care. In addition to generic utilization measures and
analysis of access to gauge next available appointments, measurements
for each specialty include:
Primary care - clinical tests and values
for diabetes and hypertension
Pediatrics - treatment of asthma
and otitis media
Cardiology - rate
of statins, aspirin and beta blockers prescribed
at the time of discharge from the hospital and control
of heart rate for atrial fibrilation patients.
OBGYN - rate of
papsmears and chlamydia testing
To
finance the first year of the PFP program, BCBSMN set aside funds
previously used for other reward programs since no new
funds were injected into the system. The results of the program
will
not be available for public consumption the first year but plans
are to make them public in the future. However, some of BCBSMN’s
measures were also part of a new Minnesota-wide initiative called
the MN Community Measurement Project, and those results were
made public this year at www.mnhealthcare.org.
According to Dr. Hiza:
Disclosure is the Driver; Data is the Difference
“
I think one driver of this movement is the growing abundance of
public disclosure of variance of care among medical practices.
The people who pay for care, employers and consumers, are becoming
more interested in where they go and what they get for their health-care
dollar. One of the challenges moving forward will always be validity
of data and differentiation of clinics enrolled in the program.
We’ll also need to definitively answer the question of whether
incentives really improve care. If they don’t, we need to
find other answers. I believe we’ll find that incentives
do make a difference, because when you combine financial rewards
with recognition of quality rankings, you get a powerful formula.”
A Stamp of Approval for Providers
“ The Johns Hopkins - American Healthways project will add a degree of
legitimacy among the provider community because it comes with a stamp of approval
from
leading physicians across the country. This is a very thoughtful approach
to the discussion, the pros and cons and the key considerations involved. I can
use this to talk to providers and show them the physician point of view has
been represented.
I think it will also serve as a way to standardize to an extent. These principles
are good. We are looking at them here in Minnesota to see how we stack up
and what’s right for us. It gives us a benchmark to work against. I
can see other organizations using it exactly the same way.”
About Dr. Hiza
Dr. Hiza received his undergraduate degree in 1968 from the University of
Nebraska in Lincoln, Nebraska. He received his medical degree from the University
of
Iowa College of Medicine in Iowa City, Iowa in 1974 and also was awarded
a concurrent MS degree in anatomy. He completed his residency in Family Medicine
at the Duluth Family Practice Residency Program in Duluth, Minnesota in 1977
and practiced family medicine in Duluth for 21 years.
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ALAN E. SOKOLOW, MD,
FACEP
Empire Blue Cross Blue Shield
Dr. Sokolow joined Empire Blue Cross Blue Shield in February 2000 as Vice
President and Chief Medical Officer. In this role he is responsible for all
aspects of health care services and network management, including Medical
Policy, Provider and Hospital Contracting, Medical Management, Disease Management,
Quality Management, Provider Relations, Pharmacy Services and Behavioral
Health. Since joining Empire, he has led the development of a population-based
program of health management and in 2003 led the organization through a successful
NCQA review.
Experience with PFP
Empire just completed a three-year program on the hospital provider side
of its business, paying participants according to quality measures developed
by the Leapfrog Group. The health plan also is close to developing a report
of quality ratings on hospital performance to be shared with its members.
Meanwhile, Dr. Sokolow’s group is working to create a physician pay-for-performance
pilot and is currently developing clinical data measures on which it will
be based. The pilot should be functional by the end of 2005.
Dr. Sokolow cites several major considerations in the design of the pilot,
including creating and validating data, disseminating the data in a meaningful
way, understanding the relevance of the data and getting providers to focus
on the program and report their outcomes. Empire will continue its progress
in physician incentives as dictated by the success of the pilot project.
According to Dr. Sokolow:
The Jury Is Out on PFP…For Now
“We are at the beginning of a ground swell. Hospitals are clearly well
on their way to compensation reform after recent changes by the federal government,
and physicians are not far behind. At this stage of the game, data quality
is not quite as good as it needs to be. The industry is making lots of efforts
to pool data and develop measurement guidelines that will effectively address
the issues.
The jury is still out on pay-for-performance. It’s just another arrow
in the quiver, another tool to influence behavior. Whether it becomes a dominant
one hinges on whether we can integrate different aspects of performance,
different types of care and different domains into measure sets. It also
will depend on whether consumers use the information to make decisions on
health care. We’ve been down some of these roads before as an industry,
and we failed because the data was bad, or at least questioned. What we have
learned is that we have to get buy in early, and we have to get input all
along the way. It has to be a transparent process for both doctors and patients,
and the data has to be acknowledged and validated.”
Employers Have Reached Their Limits
“Separate from the items discussed during our recent summit, there
are a number of assumptions that exist in the market about how health care
has to evolve. One thing that is pretty clear is that employer sponsored
health care is reaching its limits of tolerance among the organizations footing
the bill.
We must alter the course of the marketplace to accommodate their growing
concerns and needs. We have to find some source of efficiency, and we must
modify the way providers interact with patients. We can’t continue
to increase costs and the sheer volume of services with no regard to quality
of outcomes. Everyone is demanding that providers give them a better product,
but in doing that we all have to help them.”
Crystallizing the Concept
“This consensus document we have developed crystallizes many of the
thorny issues involved in paying physicians for performance. It rapidly evolves
the discussion on things such as transparency and relevance of reporting,
and it highlights top issues in a way that facilitates discussion. It’s
a very timely document for Empire as we are in the process of creating the
necessary relationships to make our pilot a success. You can burn a lot of
time talking to physicians about creating a program from scratch, but this
document will help channel the discussion. This will help alleviate some
initial concerns and move us to much more meaningful debates.”
About Dr. Sokolow
Dr. Sokolow has extensive clinical experience as well as in the managed care
industry. Prior to joining Empire, he was Chief Medical Officer for intelliClaim,
LLC, an Application Services provider specializing in claim auditing and
adjudication management. In addition, he served as a Medical Director and
Officer of Oxford health Plans from 1986 until 1998. Dr. Sokolow also served
as Chairman of the Department of Emergency Medicine at Norwalk Hospital in
Connecticut.
Dr. Sokolow is a graduate of Pomona College and UCLA School of Medicine.
He completed his residency in Internal Medicine at the University of Utah.
He is board certified in Internal Medicine and Emergency medicine. He is
a fellow of the American College of Emergency Physicians.
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RICHARD CHUNG, M.D.
Dr. Chung is the vice president and medical director for the Care Management department of HMSA. His responsibilities include the development and implementation of quality improvement initiatives, credentialing, pharmacy management, and administration of medical director responsibilities for HMO and pay for performance initiatives. In addition, he is responsible for developing clinical protocols, standards of best practice and programs for chronic disease management.
Experience with PFP
HMSA developed and implemented a pilot program to measure individual practitioner performance in 1997. In 1998, the Quality and Service Recognition program was implemented. With feedback from community providers and the assistance of the consultant Health Benchmarks, Inc. of Woodland Hills, California, HMSA, in the first year of the QSR program, distributed over $2.0 million in awards to 854 practitioners who volunteered to participate in the program. Over the seven years of the program, more than $40 million has been distributed to about 2,300 physicians for their performance on over 70 clinical indicators of care, satisfaction, formulary compliance, etc.
Overall, the QSR provides an operational tool that is a comprehensive, systematic measurement tool for individual practitioner performance in a PPO environment. It appears to be the only tool for clinical performance measurement used on a wide scale in a PPO delivery system. It is able to demonstrate variation and measure the relative change in performance for both the individual practitioner and for the population of practitioners. The acceptance of the tool has been very favorable. Enhancements are being made to meet the requests of providers who desire a list of their patients who do not appear in the numerator of specific tests or procedures for the purpose of confirming through the practitioner's medical records or to improve rates of their population of patients.
Preliminary analysis of the impact of incentives on physician performance suggests positive influence on several of the clinical measures. Six out of twelve measures that have been in place for the seven years of the QSR program show 16-42% increased likelihood of receiving the indicated clinical measure. For the other six measures, the changes did not reach statistical significance. (See the following Table)
| Impact of the PQSR Program: |
| Logistic Regression Analysis |
| After PQSR program implementation, members were more likely to receive recommended care if they visited a participating physician |
| Measure | Percent
Greater Likelihood
of Receiving
Specified Care |
| Breast Cancer Screening | 42% |
| Cervical Cancer Screening | 52% |
| Colorectal Cancer Screening | 13% |
| ACE Inhibitor Use in CHF | 51% |
| Diabetic Retinal Exam | 38% |
| Annual A1c | 16% |
| Use of Long Term Asthma Control Drugs | -17%* |
| Compliance with Antihypertensives | -1%* |
| Compliance with Lipid Lowering Drugs | 7%* |
| MMR Vaccinations | -6%* |
| VZV Vaccinations | 14%* |
| Complications Following Cataract Surgery | 51%* |
| |
| * Result not statistically significant |
| Copyright HMSA and Health Benchmarks, Inc. |
These results are, in general, replicated when the data is examined annually or longitudinally over four years.
The Quality and Service Recognition program has gained wide acceptance and has proven to provide a data infrastructure for multiple quality improvement initiatives, including reducing medical errors in the PPO and HMO lines of business.
According to Dr. Chung:
Casting Wide Net is Key to Success
"We believe we've been successful because more and more physicians have volunteered or requested to be included. We're up to 2,200 participants currently, about 90 percent of all eligible physicians. We've made the process easy, and have continually sought feedback. For instance, we don't do report cards because of feedback we've gleaned from the physicians in our community. We want all providers to be participating, and we don't want to winnow our networks. We are trying to raise the entire level of the ocean, not just catch the big one. To do that, you first have to reach consensus among your provider community and get them onboard."
Enriching PFP Discussions
"As a result of this conference, we've become more focused on the role of electronic medical records and how to best leverage this data for public consumption. This document will spur a lot of discussion and lead to greater collaboration, because every major health-related group out there is looking for answers on how to build this. What we've started by this conference is a set of guidelines that should be a part of any program built moving forward."
About Dr. Chung
Dr. Chung joined HMSA in 1996 from the Merit Behavioral Care Corporation, known in Hawaii as Biodyne, where he was an Executive Vice President and the chief clinical officer. He attended medical school at Boston University School of Medicine and began his training in internal medicine at Bay State Medical Center. He completed a psychiatric residency and was Chief Resident at the UCLA/Sepulveda Veterans Administration Medical Center affiliated with the UCLA School of Medicine's Neuropsychiatric Institute. He is board certified in psychiatry.
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JAMES K. GERAUGHTY, M.D.
NewQuest (HealthSpring)
Dr. Geraughty is currently Chief Medical Officer for NewQuest, the parent company of HealthSpring of Tennessee, HealthSpring of Alabama, Texas HealthSpring, and GulfQuest, Inc. NewQuest currently owns and operates Medicare and commercial HMOs, PPOs, and IPA management organizations in three distinct marketplaces.
SID KING, M.D.
Sumner Medical Group (Tennessee)
Dr. King is managing partner with the Sumner Medical Group in Tennessee.
Experience with P4P
In August 2004, HealthSpring initiated a pilot "outcomes-based compensation" program in partnership with the Sumner Medical Group (SMG) that includes a dozen primary care physicians and approximately 1,400 patients in the HealthSpring Cares disease management program. This program created an outcomes baseline for measurement purposes and set up an active exchange of information between physicians and chronic care nurses to track patient interactions and adherence to standards of care.
The goal of the pilot is to more closely align the health plan, the patient and the provider with the goals of the disease management program and drive further improvements in health outcomes, in patient and physician satisfaction and in health-care cost reductions. Although results are very preliminary at this point, Dr. Geraughty said HealthSpring has seen improvements in connectivity with members and reduced costs for members in both Medicare and commercial populations.
Dr. King and the physicians at Sumner Medical Group had been working with patients in the HealthSpring Cares disease management programs for a couple of years when Dr. Geraughty approached them about developing a pay-for-performance pilot. SMG drew on that experience to help HealthSpring build a better system. Under the new system, participating physicians are eligible for a 20% performance bonus based on improved quality and outcomes measures, and patients are more accepting of the program because they are introduced to it by their physician.
Dr. King on Pay-for-Performance
"It's about developing a system to allow doctors to do a better job. We all want to do a good job. Doctors don't start the day saying, 'Hey, I'm going to be 60 percent compliant with diabetes patients. You're trying to do 100 percent all the time, but you just don't have the system in place to prompt you. That's what this is all about, especially with the disease process where the complexity is problematic, and that's where you need some help.
"I've noticed that the patients in the HealthSpring Cares pilot are more accepting of the disease management initiatives. They're asking more questions in the encounter. As for me, I'm doing a better job of managing their chronic illnesses. I've got a better system, a better process. Whether ultimately it reaches the financial goals of HealthSpring, we'll see. As far as meeting patient care goals, I know that's going to happen."
HealthSpring's Dr. Geraughty on Pay-for-Performance
"We have recently begun paying some of our providers bonuses for achieving a variety of quality and outcome targets. We recognized early in the design process of our PFP program that additional funds would be necessary for the practices to enhance their chronic care services and to develop the information systems necessary for state-of-the-art, evidence-based medicine. As a purchaser of health care services, we chose to bear the burden of these new costs equally with the physician practices. It is my strong belief that in the next few years, this new 'investment' will more than pay for itself with reduced high-cost services."
The Johns Hopkins - American Healthways Consensus Document
"I don't think this document is necessarily a cook book, but I think its purpose is to give guidance to those parties involved in P4P or at least give them insight into how physicians perceive P4P," said Dr. King. "I think it will influence our existing pilot. For example, the issue of fairness, where we have physicians in rural or economically deprived areas versus those in urban and more economically advantaged areas. That's an issue in this document, but right now, there's nothing built into our system to adjust for risk like that.
"Going through the steering committee process was a very meticulous process. We considered all the ramifications, including fairness, social and socio-economic. We really didn't consider those things at all in the design of our pilot with HealthSpring. We're a small group and work off productivity and everyone pretty much understands that. We were trying to find something that works with our group, and I think we've done that, but you couldn't roll that out to the Mayo Clinic."
About Dr. Geraughty and Dr. King
Previously, Dr. Geraughty was president and chief executive officer of Vanderbilt Management Services, which provides management services for Vanderbilt Health Plans, a Medicaid HMO; and Health 123, a commercial and Medicare risk HMO. Dr. Geraughty also previously worked in progressive roles, including president, for Aetna Health Plans of Tennessee.
He earned a doctor of medicine in 1982 from the University of Missouri-Kansas City, and he completed his residency at Carraway Methodist Medical Center in Birmingham, Alabama. He is board certified in internal medicine.
Dr. King earned his doctorate of medicine from the University of Tennessee in Memphis in 1976. He completed an internship and a residency with the City of Memphis Hospitals and also received board certification from the American Board of Internal Medicine.
He is past Chief of Staff for the Sumner Regional Medical Center and has served as Chairman of the Board for the Tri-County Physicians Association since 1996.
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TIMOTHY J. CRIMMINS, M.D.
General
Mills
Dr. Timothy J. Crimmins is Vice President and Director of Health, Safety
and Environment at General Mills. His responsibilities include providing
both acute
and primary care services and improving the health of about 40,000 employees
and their families. He is also involved with the National Business Group
on Health, a consortium of many of the largest employers in the United States.
The Large Employer Perspective
There seems to be general agreement that the current “pay for procedures” system
is flawed – and managed care with all its initial good intentions,
did not live up to expectations. Dr. Crimmins shares his viewpoint on pay-for-performance
with the National Business Group on Health.
Understanding the position of large employers hopefully will assist in discussions
regarding outcomes based compensation.
- Large employers are committed to improving the
quality and safety of the health care system and payment methodologies
are the most powerful and fastest
way to achieve this.
- Physicians must lead in defining quality and
developing the systems to measure it. Some patient involvement
and consumer
advocacy is important,
however physicians
must be the leaders in the design of the system.
- Employers want to reward teamwork and
collaboration that results in improved outcomes and we are particularly
interested
in rewarding systems
that address
the patient’s behavioral factors that contribute to improved
outcomes. Accordingly, payment rewards are best directed at the
physician group or
organizational level.
- Individual physicians, depending on the
local practice environment can be rewarded for performance – but
only if the individual physician has sufficient control of the
outcomes;
the
metric is valid for small numbers;
and there is
risk adjustment of the patient population.
- We believe that payment increases (bonus payments),
for achievement of given quality thresholds, is the best way
to begin; but we anticipate
a time
of non-payment
or restricting networks for systems that consistently fail
to meet minimum threshold quality criteria.
- We support transparency of the system
of payment, and public disclosure of those organizations or systems
that
meet target thresholds
of
quality performance. However, risk adjustment is essential,
and those with “small numbers” must
be excluded when the data is not reliable.
- We strongly urge standardized national
data sets and uniform metrics. Rewards should be paid toward
activities
directed toward
the “gaps in quality” identified
by the payer and providers in a given community. Incentives
must first drive improvements in patient safety and quality,
then later for efficiency and patient “centeredness” metrics.
Incentives may change over time as quality is achieved in some
areas and quality gaps are discovered in other areas of the
local health care system.
- Finally, Pay for Performance programs
are new and experience is limited – we
must proceed in a cautious and deliberate manner. Ideally,
payers and providers in a given community should identify quality
gaps; align incentives across
multiple providers and payers to drive the greatest awareness
and incentive to change, where the greatest need is identified.
Rewards should be paid as
frequently as valid data can be collected and properly risk
adjusted, and as cost effectiveness allows. All pay for performance
initiatives should be periodically
evaluated to determine the payment methodology’s effect
on quality, access and cost.
About Dr. Crimmins
Much of Dr. Crimmins career was in Emergency Medicine, most recently
practicing at Hennepin County Medical Center in Minneapolis. Dr.
Crimmins earned his Doctor of Medicine from the Indiana University
School of Medicine and is Board Certified by the American Board
of Emergency Medicine and is a Fellow of the American College of
Emergency Physicians. Dr. Crimmins has been active in the Minnesota
Medical Association where he was the past Chairman of the Board.
He was also Deputy Medical Director of Hennepin County Medical
Center and an Assistant Professor of Emergency Medicine at the
University of Minnesota.
He has been very active in safety activities. He is currently on
the Board of Directors of the Minnesota safety Council, and is a
past President of the Minnesota Seat Belt Coalition and past Chair
of the Governor’s Transportation Safety Advisory Commission.
He has held several teaching positions in basic and advanced cardiopulmonary
life support. He has recently been practicing Occupational and Preventive
Medicine at General Mills.
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