Philip D. Sloane, MD, MPH, Philip D. Sloane, MD, MPH, Jacquie Halladay, MD, MPH, Sally Stearns, PhD, Jacquie Halladay, MD, MPH, Sally Stearns, PhD,
Thomas Wroth, MD, MPH, Paul Bray, MA, Thomas Wroth, MD, MPH, Paul Bray, MA, Lynn Spragens, MBA, & Sheryl Zimmerman, PhDLynn Spragens, MBA, & Sheryl Zimmerman, PhD
From the North Carolina Network Consortium and the Cecil G. From the North Carolina Network Consortium and the Cecil G. Sheps Center for Health Services Research, University of Sheps Center for Health Services Research, University of
North Carolina at Chapel HillNorth Carolina at Chapel Hill
Funded by the US Agency for HealthCare Research and Funded by the US Agency for HealthCare Research and Quality (AHRQ)Quality (AHRQ)
Performance Data Performance Data Reporting: Impact on Reporting: Impact on
Primary Care PracticesPrimary Care Practices
DisclosureDisclosure
I have no relationships to disclose, andI have no relationships to disclose, and I will not discuss off label or I will not discuss off label or
investigational use in my presentation investigational use in my presentation
BackgroundBackground
2006 AHRQ publication: barriers and challenges 2006 AHRQ publication: barriers and challenges to collecting and reporting healthcare datato collecting and reporting healthcare data
Barriers Identified:Barriers Identified:
Data system inefficiencies of data systemsData system inefficiencies of data systems Variation in indicatorsVariation in indicators Technological barriersTechnological barriers Competing prioritiesCompeting priorities Economic pressuresEconomic pressures Organizational and cultural issues.Organizational and cultural issues.
ObjectivesObjectives
Detail the costs of implementation Detail the costs of implementation and maintenance of performance and maintenance of performance data reportingdata reporting
Gather information on how practices Gather information on how practices successfully overcome challenges to successfully overcome challenges to data reporting.data reporting.
Programs EvaluatedPrograms Evaluated
Physician Quality Reporting Initiative (PQRI)
Bridges to Excellence
Improving Performance in Practice (IPIP)
Community Care of North Carolina (CCNC)
PQRIPQRI
Medicare’s reporting program.Medicare’s reporting program. 74 quality measures (practices can 74 quality measures (practices can
choose).choose). ““G” codes are added to billing G” codes are added to billing
submissions.submissions. Must have 80% of cases reported on three Must have 80% of cases reported on three
quality measures.quality measures. Incentive payment of Incentive payment of < 1.5% of Medicare 1.5% of Medicare
allowable.allowable.
Bridges to ExcellenceBridges to Excellence Started in 2006 as a three-year pilot program by Started in 2006 as a three-year pilot program by
BC/BS.BC/BS.
Incentive: $$, based on achieving quality Incentive: $$, based on achieving quality thresholds and # of patients with BCBS insurance.thresholds and # of patients with BCBS insurance.
Two programs studied:Two programs studied: Diabetes CareDiabetes Care: HbA1c, BP, LDL, Eye exams, Foot : HbA1c, BP, LDL, Eye exams, Foot
exams, Nephropathy assessments, smoking exams, Nephropathy assessments, smoking status/cessation.status/cessation.
Physician Office ConnectionsPhysician Office Connections: Office systems and : Office systems and processes such as electronic prescribing, referral processes such as electronic prescribing, referral tracking, performance reporting (9 items total).tracking, performance reporting (9 items total).
Improving Performance Improving Performance in Practice (IPIP)in Practice (IPIP)
State-based, nationally led QI initiativeState-based, nationally led QI initiative Pilots in CO and NC. Pilots in CO and NC. Uses quality improvement coaches (QICs) Uses quality improvement coaches (QICs)
who go who go intointo physicians’ offices and work with physicians’ offices and work with the practice on improvement efforts, the practice on improvement efforts, including:including: Data system assistanceData system assistance Decision support and protocol developmentDecision support and protocol development Office team involvement in quality improvement Office team involvement in quality improvement
and measurementand measurement
Community Care of Community Care of North Carolina (CCNC)North Carolina (CCNC)
Statewide system of 14 regional Medicaid Statewide system of 14 regional Medicaid care networkscare networks Each has a program director, medical director, steering Each has a program director, medical director, steering
committee, case managerscommittee, case managers
Attention to chronic diseases (mainly Attention to chronic diseases (mainly diabetes and asthma)diabetes and asthma)
Guideline dissemination & case managementGuideline dissemination & case management Yearly statewide audits and reports with Yearly statewide audits and reports with
comparison data to local practicescomparison data to local practices
Eight Practices Selected Eight Practices Selected For Variety and For Variety and
Program ParticipationProgram ParticipationPractice Size by Total Number of Providers (MD's and PA/NP's)
4 3
189
3
8
6
11
112
2 3 3
0
5
10
15
20
25
Pvt-sm Non-P-Med
Non-P-Med
Pvt-sm Teaching Pvt-Lg Pvt-sm Non-P-Med
Nu
mb
er
MD's PA/NP's
Quality Data Quality Data Reporting Programs Reporting Programs
RepresentedRepresented
Of the 8 practices in the COMP project, 4 participated in PQRI, 3 in IPIP, 2 in BTE-Diabetes, 1 in BTE- PPC, 1 in a chronic disease collaborative
Programs
43
21
6
0
1
2
3
4
5
6
7
PQRI IPIP CCNC BTE DM BTE PPC
# o
f p
ract
ices
par
tici
pat
ing
Conditions EvaluatedConditions Evaluated
Disease or Quality Measures
6
32 2
8
0123456789
Diabetes Asthma COPD Falls RiskAssessment
others
# pr
actic
es
Medical Data SystemsMedical Data Systems
Types of Electronic Medical Record Systems
3
2
3
0
1
2
3
Paper record andelectronic registry
EMR w/o populationfunctions
EMR with populationqueries
Nu
mb
er
Study MethodologyStudy Methodology
Intensive site visits by economist, QI Intensive site visits by economist, QI specialist & qualitative researcherspecialist & qualitative researcher
Meticulous detailing of costs (see next slide)Meticulous detailing of costs (see next slide) Interviews with:Interviews with:
quality champion, quality champion, care providers, care providers, other practice staffother practice staff
Quantitative and qualitative analysesQuantitative and qualitative analyses
Cost Categories - 1Cost Categories - 1
Total Resource Costs
Costs to Practice• Total rather than marginal costs
Cost to QI program• In-practice only
Total Practice Costs
Supplies, Equipment, Application Fees
Staff Time:Non-measure Specific
(data entry, meetings)
Staff Time:Measure-Specific
(eye exam referrals, HbA1c)
Cost Categories - 2Cost Categories - 2Cost Categories - 2Cost Categories - 2
Total Practice Costs
Maintenance PhaseStart-Up Phase
Cost PhasesCost Phases
PQRI Implementation PQRI Implementation Costs in Four PracticesCosts in Four Practices
$0
$5,000
$10,000
$15,000
$20,000
$25,000
Total Per FTE
Practice A
Practice B
Practice D
Practice H
PQRI Implementation in PQRI Implementation in Practices A and HPractices A and H
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Total Per FTE
Practice A
Practice H
Cost Per FTE of Cost Per FTE of Implementing CCNC vs IPIPImplementing CCNC vs IPIP
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
CCNC IPIP
Practice B
Practice C
Average Practice & Program Costs Average Practice & Program Costs per FTE of CCNC*, IPIP**, and PQRI***per FTE of CCNC*, IPIP**, and PQRI***
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
CCNC IPIP PQRI
Practice Costs
In-OfficeProgram Costs
Combined
Maintenance Phase * 6 practices ** 3 practices *** 4 practices
Estimated Costs and Reimbursement Estimated Costs and Reimbursement for Participation in B to E Diabetesfor Participation in B to E Diabetes
$0$200$400$600$800
$1,000$1,200$1,400$1,600$1,800
Practice A Practice G
Diabetes Cost
Diabetes Reimb
Estimates are per provider FTE
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Practice A
Diabetes Cost
Diabetes Reimb
Med Home Cost
Med HomeAnnual Reimb
Estimated Costs and Reimbursement Estimated Costs and Reimbursement for Participation in B to E Medical Homefor Participation in B to E Medical Home
Estimates are per provider FTE
Lessons from Lessons from Qualitative InterviewsQualitative Interviews
Methods:Methods: Interviews with practice championInterviews with practice champion Group interviews with practice staffGroup interviews with practice staff Medical director joined for lunchMedical director joined for lunch Dedicated note taker present; case Dedicated note taker present; case
reports generated; research team reports generated; research team reviewed for themes and lessonsreviewed for themes and lessons
Motivation to Participate Motivation to Participate is a Key to Successis a Key to Success
““Pay for performance seems inevitable, Pay for performance seems inevitable, and we wanted to prepare our practice and we wanted to prepare our practice for it” for it”
“ “If we are providing quality of care, we If we are providing quality of care, we want to separate ourselves out and be want to separate ourselves out and be recognized” recognized”
Leadership is Crucial to Leadership is Crucial to Getting StartedGetting Started
Leaders with quality improvement Leaders with quality improvement experience and an interest in experience and an interest in participation; staff who then get participation; staff who then get motivated motivated
“ “The providers set the tone and The providers set the tone and empower the staff”empower the staff”
Three Major Logistical Three Major Logistical ChallengesChallenges
Staff time and effortStaff time and effort "The clinicians and staff are being driven to a "The clinicians and staff are being driven to a
frazzle”frazzle”
IT challengesIT challenges ““I’m sure that the EHR vendor could develop a I’m sure that the EHR vendor could develop a
query to do this, if we paid them enough” query to do this, if we paid them enough”
Difficulties changing physician behaviorDifficulties changing physician behavior ““Once you start to measure quality, the first thing Once you start to measure quality, the first thing
the providers do is question the measures”the providers do is question the measures”
Going Through Hoops to Going Through Hoops to Achieve Data ConsistencyAchieve Data Consistency
One practice had to train the physicians One practice had to train the physicians to record “feet” instead of “extremity” to record “feet” instead of “extremity”
Another had to create a report on Another had to create a report on smoking cessation counseling three smoking cessation counseling three times before it was in an acceptable times before it was in an acceptable formatformat
Involving the TeamInvolving the Team
Practices reported difficulty finding enough Practices reported difficulty finding enough time to review and act on quality data reportstime to review and act on quality data reports
““(The practice manager) presents the data in (The practice manager) presents the data in a fun way…she puts time into preparing it for a fun way…she puts time into preparing it for you, in charts, so that we have clarity” you, in charts, so that we have clarity”
"Initially providers are burdened by a new "Initially providers are burdened by a new reporting activity. But after a while it takes reporting activity. But after a while it takes less effort because they figure out how to less effort because they figure out how to give it to nursing"give it to nursing"
Perceived Effects on Perceived Effects on Productivity & FinancesProductivity & Finances
Slowed down productivity initially, but overall productivity increase over time
Positive:Positive: "Good income for good medicine" "Good income for good medicine" Negative:Negative: “They are taking money out of my “They are taking money out of my
pocket"pocket"
External and Internal Barriers and Facilitators
Infrastructure Development
Practice Precondi-
tions Program Initiation
Program Maturation
Sustainability
Preconditions1. Exposure to QI2. Leader with QI experience3. Focus on quality > income
Infrastructure Development
1. Medical director support2. Administrator support3. Data entry & reporting resources4. Staff meeting times
Sustainability1. Tangible constructive change2. Financial benefit3. Enhanced practice reputation4. Strategic partnerships that foster culture of quality
Catalyst
Catalysts1. Committed leader or mandate2. Collaborative atmosphere3. Outside encouragement
Theoretical Model: Factors Involved in Developing Theoretical Model: Factors Involved in Developing and Maintaining Quality Assessment, Improvement, and Maintaining Quality Assessment, Improvement,
and Reporting in a Primary Careand Reporting in a Primary Care
Image