Transcript Physician tiering, ranking

Transparency in Health Care Quality
What you need to know about public reporting
Elizabeth Mort, MD, MPH
Vice President Quality & Safety, MGH
Associate Chief Medical Officer, MGH
Team Leader for Uniform High Quality,
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Partners HealthCare Inc.
Transparency in health care
• Transparency involves being open about what you do,
how you do it, and the results that you get.
• In health care, transparency encompasses
– Clinical quality and safety
– Service and access
– Pricing and cost
• Purpose:
– Increase public accountability
– Inform consumers’ decision-making
– Rationalize resource use (costs) in health care
– Inspire providers to improve
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Outline
• How did we get here?
• What information is out there?
• A short primer on quality measurement, ranking, tiering
• Landmark litigation
• Current initiatives in MA
• Discussion
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How did we get here?
• Rising cost of health care
– Longstanding problem, now in crisis
• Gaps in quality
– Striking variation in quality and service delivery
• Consumerism
– Consumer empowerment driving transparency
and accountability
– Consumer directed health plans as a new tactic
to reduce costs
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RISING COSTS
International Comparison of Spending on Health, 1980-2005
Average spending on health
per capita ($US PPP*)
$7,000
$6,000
United States
Germany
Canada
France
Australia
United Kingdom
Total expenditures on health
as percent of GDP
16
14
12
$5,000
10
$4,000
8
$3,000
6
$2,000
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19
80
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82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
$-
2
0
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
$1,000
United States
Germany
Canada
France
Australia
United Kingdom
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2007, Version 10/2007.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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GAPS IN QUALITY
Mortality Amenable to Health Care
Deaths per 100,000 population*
1997/98
150
2002/03
130
103
103
104
Portugal
90
101
Ireland
84
113
United Kingdom
84
96
128
Denmark
88
82
93
New Zealand
77
82
115
Finland
74
80
Austria
89
Greece
89
97
Sweden
71
84
74
Norway
88
Canada
76
65
81
71
Italy
100
97
Netherlands
99
116
106
Germany
109
134
115
110
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United States
Spain
Australia
Japan
France
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* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.
See report Appendix B for list of all conditions considered amenable to health care in the analysis.
Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality
files (Nolte and McKee 2008).
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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GAPS IN QUALITY
Recommended Screening & Preventive Care for Adults
Percent of adults (ages 18+) who received all recommended screening and
preventive care within a specific time frame given their age and sex*
U.S. Average
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2002
50
2005
U.S. Variation 2005
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400% + of poverty
200% –399% of poverty
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<200% of poverty
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Insured all year
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Uninsured part year
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Uninsured all year
0
20
40
60
80
100
* Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,
fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See report Appendix B for complete description.
Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008
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Emerging models of payment reform:
new combinations of old ideas
• Incremental reforms such as nonpayment for
never events
• Primary care payment reform, medical home,
tiered case-management fees, capitation
• Episode-based payments, global case rates
• Shared savings models, providers share in
savings, quality monitored
• Consumer directed plans
Rosenthal MB, NEJM 359;12 Sept 18, 2008
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Consumer-directed health plans are
emerging
• Rationale: patients with more out of pocket
expenses will drive more rationale use of
resources (hopefully data-driven)
• Several varieties
– Higher co-payments and deductibles
– Health savings accounts
– Tax credits
– Tiering of physicians
• Tiering has been the tactic of choice in MA
used by the Group Insurance Commission
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“For Your Benefit,” Group Insurance Commission Newsletter, Fall 2008
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So, what’s at issue?
• “The appropriate way to measure
physicians’ (quality and) efficiency is a
matter of disagreement between those
that pay for (use) health care and those
who provide it.”
Arnold Milstein, MD Thomas Lee, MD
NEJM 357:26 December 27, 2007
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Providers worry about…
• Poorly designed performance reporting
can lead to risk aversion
• The risk of misclassifying a physician
threatens their reputation and livelihood
• There are more effective ways to address
cost of care
• There are more accurate ways of
measuring quality
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Consumers and purchasers
• Consumers want more information about
the quality of care their doctor’s provide
• Consumers want more information about
the value they are purchasing
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Our challenge
• Not measuring MD competency in some way is
simply not an option
• Not controlling costs in some way is simply not
an option
• Goal this afternoon:
– Review the current measurement initiatives
– Discuss what we can get behind in terms of
assessing the quality of care of MDs
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What’s out there?
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Sources of MD-specific information
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Word of mouth
BORIM physician profiles
Health grade profiles
MHQP profiles
Health plan products tiers
Angie’s list
Vitals.com
Consumers checkbook
Rate MD
Google
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BORIM
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DPH specialty profiles: CABG
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DPH specialty profiles: CABG
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http://www.mhqp.org
Healthgrades
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Vitals.com
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Benefits manager
• Husband and wife have just moved to
Boston and are employed by the state and
covered through the GIC
• They’re signing up for a health plan and
need access to: Cardiology
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GIC members pick a plan
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A short primer on quality
measurement
• Measures of quality and efficiency
• Physician profiling
• Tiering methodologies
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Defining quality is a challenge
• Donabedian: structure, process, outcome
• IOM six aims: safe, effective, patientcentered, timely, efficient, equitable
• FACCT domains: staying healthy, getting
better, living with illness or disability,
coping with end of life
• Internal vs. External audience
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What we need for a good system
• Standardized performance measures
representing all relevant domains
• Access to pt level data
• Data verification and auditing
• Comparative analyses and reporting
Performance Measurement Accelerating Improvement
IOM 2007
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Health care settings are not
equally covered
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Hospitals - most mature
Groups - somewhat developed
Provider-level - very spotty
Systems – nascent
Health plans – NCQA led the way
States - spotty
Community - undervalued
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Service line coverage is spotty
Confidential and Proprietary © March 2008 Sg2
Steps toward transparency: where
are we on this steep climb?
Confidential and Proprietary © March 2008 Sg2
Meanwhile….on-line tools are
proliferating…
Source: The Advisory Board Company. Drivers of Consumer Choice Implications from the 2007 Consumer
Loose talk about accuracy
• Accuracy of measurement
– Reliability
– Validity
• Misclassification of physicians
– Reliability and validity
– Cut-off points
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Reliability
• Reliability speaks to the consistency of a
measure
– Internal consistency, (Cronbach’s Alpha)
usually measured between 0-1.0)
– Test-retest
– Inter-rater
• Reliability is a prerequisite for validity!!!
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Validity
• Face validity (sounds good)
• Content (are all dimensions of the construct
measured, assumes this is possible)
• Construct (considered with that which is being
measured cannot be operationally defined)
• Predictive (cholesterol and CAD risk)
• Concurrent (high scores on safety culture and
low rates of SREs)
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Risk of mis-classification
Score Significantly below
Significantly above
0.7
0.8
0.9
Risk of misclassification is low <2.5 % with
sample size of 45 and measurement
reliability of 0.7
50th percentile
Dana Safran. et al; J Gen Intern Med 2006; 21:13-21
= area of uncertainty
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Efficiency measures
• Currently, the majority of efficiency
measures rely on the MD as the unit of
analysis
• Data sources: encounter and claims data
• Risk adjustment relies on same source
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Efficiency measures
• Episode of treatment groupers (ETGs)
– Pooled claims data are used to derive the
total cost for a particular episode
– Care is then attributed to a physician
– Physicians average cost is determined for
each ETG
– Cost per ETG is averaged across all ETGs
that relate to that doc
– Proprietary
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Commentary on ETG validity
• We have reason to be concerned
Elizabeth McGlynn, PhD Associate Director, RAND Health;
Distinguished Chair in Health Quality
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Tiering
• Measure cost efficiency via
“ETG” methodology
• Measure quality via HEDIS,
etc.
• Squeeze quality and cost
scores from claims data
• Incent patient and physician
behavior via differentials
in co-payments
• Implemented in 2006
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GIC’s rules for 2008-2011
• Must individually rate MD’s in six specialties
Cardiology
Orthopedics
Rheumatology
Endocrinology
Gastroenterology
OB-GYN
• Three tiers for all plans predetermined
Tier 1: 20%
Tier 2: 65%
Tier 3: 15%
• Must use GIC’s data
• Standardized reports to make the rankings
interpretable for the physicians (developed
collaboratively with MMS input)
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Tufts Navigator (GIC): Tiering Explanation
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Tufts Navigator (GIC): Tiering Explanation continued
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Landmark litigation
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NY Principles for MD Tiering
• Core principles of the settlement
– Accuracy
– Transparency of information
– Oversight of process
• Ratings examiner: a 501 c 3 organization
– National standard setting organization
– Regular reporting to NY AG
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MMS sues GIC
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What Physicians Are Saying
• “I am apparently treating patients for epilepsy, according to
the GIC. Somewhat unusual for an ophthalmologist.”
• “Several patients listed couldn't possibly be mine, as I don't
perform the designated type of surgery.”
• “There are procedures on my list that I have never performed.
I called GIC and there was only voice mail.”
• “We received our data March 11 and were told that all
feedback was due by March 14. I called the health plan to
give feedback March 12. I left a message and my call was not
returned.”
• “This program is unfair, and I'm hopping mad. Please let me
know what I can do.”
Courtesy MMS
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The Litigation
• Asks courts to “correct the wrongs” of the CPI
• Defendants: GIC, Tufts, Unicare
• Allegations
– Physicians falsely ranked and defamed
– Patients misled and financially penalized
• Petition: Stop tiering, or require that it been done
right, e.g.:
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Transparency and 60 days prior notice
Feedback and correction process
Meaningful physician input
Accuracy, validity and reliability
Courtesy MMS
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MMS Principles for MD Tiering
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Aim to strengthen patient-physician relationships
Involve physician in the design and implementation of all programs
Use clinically important and sound performance measures
Ensure sample sizes are adequate to support meaningful data analysis
Rely on meaningful data and analytic techniques
Share and review data with physician or practices prior to public release
Ensure transparency of all quality and cost-effectiveness measure and
methods
8. Identify and consider practice characteristics that may require special
attention in quality and cost-effectiveness monitoring
9. Use uniform reporting formats
10. Minimize unintended harmful consequences of quality and costeffectiveness monitoring and public reporting
11. Be pre-tested before implementation.
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Current initiatives &
discussion
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BORIM & MMS developing credentialing guidelines
TJC requires us to conduct periodic assessments of provider
CMS has developed PQRI to advance MD quality
MHQP advancing provider measurement
PCHI has been evolving its approach to MD measures
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