Transcript Document

Pay-for-performance..
Can it deliver?
Dale W. Bratzler, DO, MPH
QIOSC Medical Director
What’s driving policy on
health care?
US Healthcare Spending
Problem #1 - Cost!
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$1.9 trillion
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16% of the gross domestic product
$6,280 for each man, woman, and
child
Medicare and Medicaid - $600 billion
in 2006
US Healthcare Spending
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Five percent of the population accounts for
almost half of total healthcare expenses
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The 15 most expensive health conditions
account for 44 percent of total healthcare
care expenses
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Patients with multiple chronic conditions cost
up to seven times as much as patients with
only one chronic condition
Stanton MW, Rutherford MK. The high concentration of U.S. health care expenditures. Rockville (MD): Agency
for Healthcare Research and Quality; 2005. Research in Action Issue 19. AHRQ Pub. No. 06-0060.
Spending is Unevenly Distributed
97
100
80
Percent of total expenditures
80
64
60
49
40
22
20
3
0
Top 1%
Top 5%
Top 10%
Top 20%
Top 50%
Bottom 50%
Spending is Unevenly Distributed
Percent of Population
Top 1%
Expenses per person
$
> 35,543
Top 5%
> 11,487
Top 10%
> 6,444
Top 20%
> 3,219
Top 50%
664
Bottom 50%
< 664
Conwell LJ, Cohen JW. Statistical Brief #73. March 2005. Agency for Healthcare Research
and Quality, Rockville, MD.
Spending is Unevenly Distributed
Age Distribution of the Top 5%
Percent of total expenditures
40
29
30
20
18
15
10
9
10
19-34
35-44
14
5
0
18 and
under
45-54
Age in years
55-64
65-79
80 and
over
Problem #2 = Variation
Dartmouth Atlas of Healthcare
Wennberg/Fisher et al.
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Evidence-sensitive care
• The easiest one to attack
• Patient preference-sensitive care
• We are beginning to (finally) scratch the
surface
• Supply-sensitive care
• Nobody has any idea what to do about this,
short of legislative mandates and/or rationing
Elyria has three times the rate of
angioplasties of Cleveland, 30 miles
away
www.dartmouthatlas.com
Care of Patients with Chronic
Illness
New Study Shows Need for a Major
Overhaul of How United States
Manages Chronic Illness
“Almost One-Third of Medicare Spending for
Chronically Ill Unnecessary. Improving Care Could
Also Lower Costs”
Care of Patients with Chronic
Illness
"Variation is the result of an
unmanaged supply of resources, limited
evidence about what kind of care really
contributes to the health and longevity
of the chronically ill, and falsely
optimistic assumptions about the
benefits of more aggressive treatment
of people who are severely ill with
medical conditions that must be
managed but can't be cured."
Problem #3 - Performance
RAND Study: Quality of Health Care
Often Not Optimal
Patients’ care often deficient, study says. Proper
treatment given half the time.
On average, doctors provide appropriate health care only half the
time, a landmark study of adults in 12 U.S. metropolitan areas
suggests.
Medical Care
Often Not
Optimal
.Failure to Treat
Patients Fully Spans
Range of What Is
Expected of
Physicians and Nurses
Medical errors corrode
quality of healthcare system
The American healthcare system,
often touted as a cutting-edge
leader in the world, suddenly
finds itself mired in serious
questions about the ability of its
hospitals and doctors to deliver
quality care to millions.
In summary, we found that the quality of
hospital care in the United States varies
widely across different indicators of quality
and that individual hospitals vary in their
performance according to indicators and
conditions.
N Engl J Med 2005;353:265-274.
Quality from the Patient’s Perspective
Hospital Quality Measures, Qtr. 4, 2005
100
83.2
80
Percent
60.2
58.6
57.6
60
39.7
40
20
0
HF
AMI
SCIP Inf
Pneumonia
23 Measures
The “Appropriate Care Measure” reflects the percentage of hospital patients that receive
all indicated care (all-or-none).
Unsustainable cost growth
(questionable returns in healthy lifespan)
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Huge variation in services delivered
(no relationship to outcomes)
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Data demonstrating significant gaps
in delivery of ideal care
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Need to Pay Differently
Calls for Medicare to Provide
Payment for Quality
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IOM report 2002, 2006
• Health Affairs article, former
HCFA administrators, 2003
• MedPAC report 2004
• Private sector efforts
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Bridges to Excellence
Leapfrog Group
Presentation Outline
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Pay-for-performance… does it work
to improve quality?
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Payment incentive models
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The potential for unintended
consequences
Does Pay-for-performance improve
quality?
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Strategies for accelerating quality
improvement:
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Public reporting
Pay-for-performance
Despite limited evidence demonstrating
benefit, P4R and P4P are being widely
advocated
Hospital Public Reporting
4043
4192
0.4% payment incentive
1952
1407
434
August, 2003
February,
2004
May, 2004
October, 2004
Number of Reporting Hospitals
March, 2005
Hospital Public Reporting
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Currently have a very limited set of
measures
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Focus predominantly on processes of
care
Few outcomes measures because of
risk-adjustment challenges
Hospital Public Reporting
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Hospital Quality Alliance
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10 measures recently expanded to 21 (AMI,
HF, Pneumonia, SIP)
New York State CABG mortality
Wisconsin “Quality Counts”
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Generally, quality seems to improve
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Mechanism??
Little data that reporting drives much patient
decision making at this point
Hospital market share largely unaffected
Pay-for-Performance
Much to be learned
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While there are lots of
demonstrations, there is little
evaluative data at this time
Ann Intern Med. 2006;145:265-272.
Does P4P improve the quality of
health care?
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Seventeen studies with control groups
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13 focused on process of care measures
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5 of 6 studies of physician-level financial
incentives linked to improved quality
7 of 9 studies of provider group-level incentives
found partial or positive effects on quality
4 studies suggested unintended consequences
of payment incentives
Petersen LA, et al. Ann Intern Med. 2006;145:265-272.
HQID Hospital Participation
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Voluntary
• Eligibility: Hospitals in Premier Perspective
system as of March 31, 2003
• 278 hospitals started
• Demonstration Project: Pilot test of concept
• Can economic incentives effectively
improve quality of care?
Condition X
Condition X
Condition X
1st Decile
2nd Decile
Top
Performance
Threshold
1st Decile
1st Decile
3rd Decile
2nd Decile
4th Decile
5th Decile
3rd Decile
2nd Decile
3rd Decile
6th Decile
4th Decile
7th Decile
5th Decile
8th Decile
9th Decile
6th Decile
4th Decile
7th Decile
5th Decile
8th Decile
10th Decile
Hospital
9th Decile
6th Decile
Payment
Adjustment
Threshold
7th Decile
10th Decile
Hospital
8th Decile
9th Decile
10th Decile
Year One
Year Two
Year Three
Results show significant
improvement
Composite Quality Score: Quarterly Median Improvement by Focus Area
CMS/Premier Hospital Quality Initiative Demonstration Project Participants
October 1, 2003 - December 31, 2004
Preliminary Results
100%
95%
Composite Quality Score
90%
85%
80%
75%
70%
65%
60%
55%
50%
AMI
CABG
Pneumonia
Heart Falure
Clinical Focus Area
Q4-03
Q1-04
Q2-04
Q3-04
Q4-04
Hip and Knee
CMS/Premier HQI Project
Reduction in Variation
AMI Composite Quallity Score Distribution
Positive trend in both
upper and lower
scores of range
• Reduction in variance
(narrowing of range)
• Median moving
upward
Time Periods:4Q03 - 2Q04
Composite Quality Score
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120
100
80
60
4Q03
1Q04
2Q04
Does P4P reward improvement?
Those that improved the most, received the lowest bonus payments. Those at high
levels of performance to start with reaped most of the rewards.
Rosenthal MB, et al. JAMA. 2005;294:1788-1793.
The “winners”
Condition X
Condition X
Condition X
1st Decile
2nd Decile
Top
Performance
Threshold
1st Decile
1st Decile
3rd Decile
2nd Decile
4th Decile
5th Decile
3rd Decile
2nd Decile
3rd Decile
6th Decile
4th Decile
7th Decile
5th Decile
8th Decile
9th Decile
6th Decile
4th Decile
7th Decile
5th Decile
8th Decile
10th Decile
Hospital
9th Decile
6th Decile
Payment
Adjustment
Threshold
7th Decile
10th Decile
Hospital
8th Decile
9th Decile
10th Decile
Year One
Year Two
Year Three
Cost savings?
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To date, there is little evidence that
pay-for-performance programs
save money
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Many target measures that address
underutilization of care and services
Most do not provide incentives for
efficiency
Little coordination
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At this time, there has been little
coordination between payers
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Multiple different models and
measures even within the same
clinical setting
Payment Incentives
Financial Rewards/Incentives
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Bonus Payments
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Awards for Improvement Projects
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Fee Schedules Based on Performance
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“At-Risk” Contracting
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Cost Differentials for Consumers
P4P Issues
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What to Reward
• Relative quality
• Absolute threshold
• Improvement
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How to Finance Incentives
• Across-the-board reduction to create pool
• Offsetting penalties
• Offsetting savings
• New dollars: ? Source
P4P Issues
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Who to reward?
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Individual practitioners
• Groups of practitioners
• Communities (?!)
Challenges and Pitfalls to P4P
The potential for unintended
consequences….
Challenges to Incentives for
Quality Performance
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Selection of measures/off label use of
measures
Dynamic measurement environment
Measures maintenance
Hospital Burden
Time lags
Validation/Scoring methodology
Need for proof of effectiveness
Unintended consequences
Issues in the Selection of Quality
Measures
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Outcome measures (i.e. mortality) require risk
adjustment
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Disease-specific measures don’t necessarily
reflect overall quality
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Volume may or not be a proxy for quality
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Statistical issues with low volume programs
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Hospital performance versus medical staff
performance
Unintended Consequences
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Direct harm
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Indirect harm
Pneumonia as an example…
Direct Harm
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Antibiotics within 4 hours of hospital
arrival
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Process linked to improved patient
outcomes, however
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Some patients who are ultimately diagnosed
with pneumonia do not have an obvious
diagnosis at the time of arrival
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Potential for inappropriate antibiotic administration to
those who don’t have pneumonia to achieve high
performance rates on the measure
Unintended Consequences
Direct Harm
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Giving a beta blocker to a patient
with contraindications
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Use of VTE prophylaxis in patients
with bleeding risks
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Clinical issues of uncertainty that
are exacerbated by incentives
created by pay-for-performance
Unintended Consequences
Indirect Harm
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Caregivers shift attention to those conditions
that are subject to payment incentives
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e.g., triage pneumonia patients in preference to
abdominal pain patients
Focus on glucose control in a diabetic while
ignoring control of hyperlipidemia
Reallocating resources to excel on measures with
payment incentives
Risk avoidance – turn away high risk patients
Performance in one area does not necessarily
predict performance in another
“playing to the test”
What do we know about P4P?
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Currently resource intensive (data
collection, validation, etc)
A number of issues to be resolved with
regard to incentive structure
Programs are proliferating
The evidence on effectiveness is mixed
Expansion is inevitable
Need to build evaluation into P4P
programs prospectively
What do we know about P4P?
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Hospitals
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Dislike relative thresholds (prefer absolute
thresholds)
? Support for payment based on
improvement
Don’t currently include hospital outpatient
services
How to calculate ROI
Don’t track unintended consequences
Don’t currently align with physician
incentives
Current CMS P4P Demonstrations
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Premier HQID
Physician Group Practice Demonstration
Medicare Care Management Performance
Demonstration
• Medicare Health Care Quality Demonstration
• Chronic Care Improvement Program
• ESRD Disease Management Demonstration
• Disease Management Demonstration for Severely
Chronically Ill Medicare Beneficiaries
• Disease Management Demonstration for Chronically
Ill Dual Eligible Beneficiaries
• Care Management For High Cost Beneficiaries
PVRP
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On October 28, 2005, CMS announced the
Physician Voluntary Reporting Program
(PVRP) to begin on January 3, 2006. The
primary purpose of the PVRP is to provide
a means for physicians to report clinical
data using the claim process. This clinical
and other claims data can be used to
calculate quality measures. Physicians
who participate will receive confidential
feedback, if requested, on their reporting
and performance rates.
The future
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More transparency
• More partnerships and coalitions
• More measures
• Efficiency measures
• Efficiency across providers – Current
demonstration projects
• Mortality measures
• More P4P