new york state demonstration grant pay for performance the new york quality alliance performance...

New York State New York State Demonstration GrantDemonstration Grant

Pay for Performance

The New York Quality The New York Quality AllianceAlliance

Performance & Measurement to Drive Quality of Care

NY Chapter of the American College of Physicians and the Physician Alliance

Presentation OutlinePresentation Outline

Health Care Quality: The Case for ChangeHealth Care Quality: The Case for Change Pay for Performance as a Driver for Pay for Performance as a Driver for

ChangeChange New York State Department of Health New York State Department of Health

Demonstration ProjectsDemonstration Projects New York Quality Alliance (NYQA)New York Quality Alliance (NYQA) Physician Alliance (PA)Physician Alliance (PA)

Chartered Value Exchanges: The Next Chartered Value Exchanges: The Next WaveWave

Learning ObjectivesLearning Objectives The physician will understand the extent of concerns about the quality, cost & The physician will understand the extent of concerns about the quality, cost &

availability of health care services in the US.availability of health care services in the US.

The physician will become familiar with national organizations addressing health The physician will become familiar with national organizations addressing health care quality and learn about standards for development and use of performance care quality and learn about standards for development and use of performance (quality) measures; The physician will understand the potential benefits and (quality) measures; The physician will understand the potential benefits and limitations of performance measurement and pay-for-performance programs.limitations of performance measurement and pay-for-performance programs.

The physician will learn about the New York State Department of Health P4P 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 projects and be able to define the terms New York Quality Alliance (NYQA) and the Physician Alliance (PA).the Physician Alliance (PA).

The physician will understand Chartered Value Exchanges and the four The physician will understand Chartered Value Exchanges and the four cornerstones of value driven health care. cornerstones of value driven health care.

The physician will understand the specifics regarding the NYQA/PA and their The physician will understand the specifics regarding the NYQA/PA and their role within the NYDOH Grant.role within the NYDOH Grant.

The physician will be educated regarding the 10 HEIDIS measures that will be The physician will be educated regarding the 10 HEIDIS measures that will be utilized in the NYSDOH P4P Grant including their specifications. utilized in the NYSDOH P4P Grant including their specifications.

The physicians will be provided information regarding best practice guidelines for The physicians will be provided information regarding best practice guidelines for the selected measures including, where available, tools to facilitate provision of the selected measures including, where available, tools to facilitate provision of efficient effective care, complete documentation and accurate billing. efficient effective care, complete documentation and accurate billing.

The Need to Change

Why The Status Quo is Not Why The Status Quo is Not AcceptableAcceptable

Costs continue to riseCosts continue to rise Over 47 million citizens are without Over 47 million citizens are without

insurance insurance No clear association between spending and No clear association between spending and

qualityquality Perception that current payment Perception that current payment

methodologies are misaligned- methodologies are misaligned- pay the pay the same for care regardless of the quality of same for care regardless of the quality of care provided.care provided. Pay for Performance Pay for Performance (performance based reimbursement) (performance based reimbursement) programs are designed to align incentives programs are designed to align incentives

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

US Health Care Spending, % of GDP

4

6

8

10

12

14

16

18

1960 1970 1980 1990 2000

Source: CMS

2005: 16.0%

1929=4%

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

Health care outstrips inflation

Source: Kaiser Family Foundation (2005)

Percentage of Patients Receiving Recommended (Evidence-Based) Care

0% 20% 40% 60% 80% 100%

Breast Cancer

Low Back Pain

CAD

CHF

COPD

Diabetes

Pneumonia

Atrial Fibrillation

Hip Fracture

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

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

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

• 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

The New Vision

Cost

QualityValue

The Future is HereThe Future is Here

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

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/

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


• 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


• 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 Certified Value Exchanges (CVE): local and regional multi-stakeholder collaborative organizations working to multi-stakeholder collaborative organizations working to improve quality and value in health care by measuring improve quality and value in health care by measuring the performance of local health care providers and the performance of local health care providers and reporting these findings publicly.reporting these findings publicly.

– NYQA designated one of 14 nationally recognized CVEsNYQA designated one of 14 nationally recognized CVEs– www.hhs.gov/valuedriven/index.html– 64-slice CT scanners for cardiac disease

Pay For Performance

Pay For Performance Pay For Performance

Pay-for-performance programs are growing, but Pay-for-performance programs are growing, but there is little evidence on their effectiveness or there is little evidence on their effectiveness or of their potential unintended consequences and of their potential unintended consequences and effects on the patient-physician relationship. effects on the patient-physician relationship.

Pay-for-performance has the potential to help Pay-for-performance has the potential to help improve the quality of care if it can be aligned improve the quality of care if it can be aligned with the goals of medical professionalism.with the goals of medical professionalism.

Annals Int Med 2007;146:792-794Annals Int Med 2007;146:792-794

Pay – For -PerformancePay – For -Performance

““It is no longer enough to take good care of It is no longer enough to take good care of the patient in front of you. To improve the patient in front of you. To improve results, we must find ways to help patients results, we must find ways to help patients who do not come to the office regularly. who do not come to the office regularly. Keeping track of all this data requires a Keeping track of all this data requires a whole new set of skills and resources; this is whole new set of skills and resources; this is new work, it costs time and money and it new work, it costs time and money and it has to be compensatedhas to be compensated.” .”

Dr Janet (Jessie) Sullivan, Chief Medical Officer of Hudson Health Plan)Dr Janet (Jessie) Sullivan, Chief Medical Officer of Hudson Health Plan)

PROFESSIONAL ISSUESPay-for-performance programs stir debate

Ethics Forum. Nov. 6, 2006.

Examples of P4P InitiativesExamples of P4P Initiatives

CMSCMS Hospital Core MeasuresHospital Core Measures PQRIPQRI Ambulatory “Core Measures”Ambulatory “Core Measures”

NY StateNY State NYQA Grant and other similar pilotsNYQA Grant and other similar pilots Commercial and Medicaid Health Plans in Commercial and Medicaid Health Plans in

NYNY Purchaser/EmployerPurchaser/Employer

Bridges to ExcellenceBridges to Excellence

Pay For Performance: Issues Pay For Performance: Issues To ConsiderTo Consider

MeasuresMeasures Data collectionData collection Data validation/reconciliationData validation/reconciliation ReportsReports Impact on care and cost, Impact on care and cost,

desired and otherwisedesired and otherwise

MeasuresMeasures

Ideal MeasuresIdeal Measures ValidValid

Evidence basedEvidence based ReliableReliable

Identify real differences in provider qualityIdentify real differences in provider quality Must be risk adjustedMust be risk adjusted Actionable Actionable

Measure what is intendedMeasure what is intended No unintended consequencesNo unintended consequences Measures should be FeasibleMeasures should be Feasible

Types of MeasuresTypes of Measures ProcessProcess OutcomesOutcomes StructuralStructural

Data sourcesData sources Administrative/claims and billing dataAdministrative/claims and billing data Medical Record AbstractionMedical Record Abstraction Electronic clinical data: EHR, registries, RHIOSElectronic clinical data: EHR, registries, RHIOS Hybrid combinationsHybrid combinations

Data reconciliationData reconciliation Opportunities to review and correct errors prior to Opportunities to review and correct errors prior to

publicationpublication Discrepancies between data sourcesDiscrepancies between data sources Missing Data Missing Data Transcription and coding errorsTranscription and coding errors

Measure CollectionMeasure Collection

Attribution issuesAttribution issues Whose patient is it?Whose patient is it? Reports for group vs. individualReports for group vs. individual

Small numbersSmall numbers Samples too small for valid conclusionsSamples too small for valid conclusions

Report timelinessReport timeliness Time for claims to be filed and processedTime for claims to be filed and processed Time for abstraction, aggregation, processing Time for abstraction, aggregation, processing

datadata Report actionableReport actionable

Identified vs de-identified dataIdentified vs de-identified data Current but incomplete vs. complete but out-of-Current but incomplete vs. complete but out-of-

datedate

ReportsReports

Potential BenefitsPotential Benefits

SystemSystem Reduce costs and improve Reduce costs and improve

qualityquality underuse, overuse, misuseunderuse, overuse, misuse

PhysicianPhysician EconomicEconomic Quality of CareQuality of Care Preparing for the FuturePreparing for the Future

Ethical ConcernsEthical Concerns

Inequitable impactInequitable impact

Inefficient use of resources and tendency Inefficient use of resources and tendency to focus on efficiency (cost) not other to focus on efficiency (cost) not other facets of qualityfacets of quality

Unreliable (therefore unfair) measuresUnreliable (therefore unfair) measures

Concern that Pay for performance is Concern that Pay for performance is deprofessionalizingdeprofessionalizing

Matthew Wynia, MD, MPHMatthew Wynia, MD, MPHInstitute for Ethics at the American Medical AssociationInstitute for Ethics at the American Medical Association

Inequitable impactInequitable impact PhysicianPhysician

Large practices with HIT will winLarge practices with HIT will win

Those already doing well will winThose already doing well will win

PatientPatient Non-adherent patients will be shunnedNon-adherent patients will be shunned

Minorities/elderly/immigrants will be Minorities/elderly/immigrants will be shunnedshunned

P4P Aimed At Hitting Target P4P Aimed At Hitting Target Performance Level Might Be Performance Level Might Be

CounterproductiveCounterproductive

Quality

P4P Target

Organizations in this area will get the bonus with noadditional work

Organizations in this area have little hope of gainingthe bonus

Organizations in this area have an incentive to improve

Will the Vulnerable be Neglected?Will the Vulnerable be Neglected?

Some evidence from public reporting… Some evidence from public reporting… Pt transfers to Cleveland Clinic from NY increased Pt transfers to Cleveland Clinic from NY increased

31% after public reporting on CABG, sicker 31% after public reporting on CABG, sicker patients more likely to be sent. (Omoigui 1996)patients more likely to be sent. (Omoigui 1996)

59% of internists in PA say harder to find surgeon 59% of internists in PA say harder to find surgeon for high risk patients after public reporting for high risk patients after public reporting (Schneider 1996)(Schneider 1996)

Such programs could also result in the de-Such programs could also result in the de-selection of patients, “playing to the selection of patients, “playing to the measures” rather than focusing on the patient measures” rather than focusing on the patient as a whole…….. as a whole……..

Annals Int Med 2007;146:792-794Annals Int Med 2007;146:792-794

What do physicians say?What do physicians say? ““Dr. Brook correctly states that the use of physician-Dr. Brook correctly states that the use of physician-

specific outcome data would radically change how we specific outcome data would radically change how we practice medicine. Based on his system, I would assess practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.”asking the patient to seek care elsewhere.”

Stephen Clement, MD, Annals of Intern Med 1994Stephen Clement, MD, Annals of Intern Med 1994

““If my pay depended on A1c values, I have 10-15 If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to unmotivated, obese and noncompliant would all have to find new physicians.”find new physicians.”

Physician in a 2006 survey on P4PPhysician in a 2006 survey on P4P

““39% of physicians in this study were willing to 39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent discharge hypothetical patients who were nonadherent or questioned the physician’s decision-making.”or questioned the physician’s decision-making.”

Farber et al. JGIM 2007Farber et al. JGIM 2007

Inefficient Use of Inefficient Use of ResourcesResources

Documentation (rather than quality) Documentation (rather than quality) improvesimproves

Inappropriate emphasis on what’s Inappropriate emphasis on what’s measured measured

Little more $ for lots more work – not enough Little more $ for lots more work – not enough to offset costs of measurementto offset costs of measurement

“ “ Incentives based on a handful of measures Incentives based on a handful of measures of quality may encourage physicians to focus of quality may encourage physicians to focus their efforts on improving quality in the areas their efforts on improving quality in the areas targeted by the programs, neglecting other targeted by the programs, neglecting other important aspects of care” important aspects of care” (Epstein et al. 2004)(Epstein et al. 2004)

Unfair Measures: ReliabilityUnfair Measures: Reliability

Importance of data aggregationImportance of data aggregation

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

Unfair Measures: Data Unfair Measures: Data ReliabilityReliability

Assigning responsibility (attribution)Assigning responsibility (attribution)

Medicare beneficiaries see a median of 2 Medicare beneficiaries see a median of 2 PCPs and 5 specialists working in 4 PCPs and 5 specialists working in 4 different practices per yeardifferent practices per year

35% of patients’ visits are with their 35% of patients’ visits are with their assigned physiciansassigned physicians

33% change PCP each year33% change PCP each year A PCP’s “assigned” patients are only ~39% A PCP’s “assigned” patients are only ~39%

of the Medicare patients they seeof the Medicare patients they see(Pham et al. 2007)(Pham et al. 2007)

Unfair Measures: Data Unfair Measures: Data ReliabilityReliability

Not enough patients per practice for Not enough patients per practice for reliable results year to yearreliable results year to year Among 232 PCPs, 4% of the variance of Among 232 PCPs, 4% of the variance of

their diabetic patients’ outcomes was their diabetic patients’ outcomes was attributable to physician practice patternsattributable to physician practice patterns

Reliability of measures never better than Reliability of measures never better than 0.400.40

Would need >100 diabetic patients to get Would need >100 diabetic patients to get reliability of 0.80reliability of 0.80

Outliers could dramatically improve Outliers could dramatically improve performance by dropping 1-3 patientsperformance by dropping 1-3 patients

Hofer 1999Hofer 1999

Impact on the Profession of Impact on the Profession of MedicineMedicine

Doctors shouldn’t be motivated by greed…Doctors shouldn’t be motivated by greed… “…“…P4P programs insinuate that the existing P4P programs insinuate that the existing

moral and social incentives for providing moral and social incentives for providing excellent care are not sufficient – that financial excellent care are not sufficient – that financial incentives will succeed where the clinician’s incentives will succeed where the clinician’s professional character failed.” (Satin, professional character failed.” (Satin, 2006)i2006)i.e., .e., If they work… it would be If they work… it would be embarrassing.embarrassing.

““Increasing external incentives reduces Increasing external incentives reduces internal motivationinternal motivation… [so the worst problem … [so the worst problem with P4P would be] “if you ended up with a with P4P would be] “if you ended up with a system where… doctors only did anything system where… doctors only did anything because they were paid for it and had lost their because they were paid for it and had lost their professional ethos.” Martin Rowland, NHS professional ethos.” Martin Rowland, NHS (Health Affairs interview, Sept 2006)(Health Affairs interview, Sept 2006)

A Possible Path to TakeA Possible Path to Take

New York State New York State Department of Department of

Health Health Demonstration Demonstration

GrantGrant

New York State New York State Demonstration P4P Grant Demonstration P4P Grant

The The legislative intent of the legislative intent of the demonstration projectdemonstration project is to promote the is to promote the development of pay-for performance development of pay-for performance programs, involving multiple payers that programs, involving multiple payers that achieve increased quality and cost achieve increased quality and cost effectiveness.effectiveness.The legislation extended authority to the The legislation extended authority to the Commissioner of Health to: Commissioner of Health to:

A. Convene a workgroup to delineate the A. Convene a workgroup to delineate the ambulatory and inpatient measures of performance to ambulatory and inpatient measures of performance to be used in the demonstration programs; be used in the demonstration programs;

B. Oversee a grant program which will provide B. Oversee a grant program which will provide funding to purchaser and provider coalitions to funding to purchaser and provider coalitions to establish regional pay-for-performance programsestablish regional pay-for-performance programs

The NYS DOH Commissioner’s Workgroup convened in The NYS DOH Commissioner’s Workgroup convened in July 2005 . The workgroup consisted of representatives July 2005 . The workgroup consisted of representatives from managed care plans, hospitals, statewide and from managed care plans, hospitals, statewide and regional provider associations, payers, labor unions, and regional provider associations, payers, labor unions, and consumers. consumers.

Charged with seeking consensus on the inpatient and Charged with seeking consensus on the inpatient and ambulatory measures to be included in the pay-for-ambulatory measures to be included in the pay-for-performance demonstrations, the workgroup met on performance demonstrations, the workgroup met on four occasions between July and December 2005. four occasions between July and December 2005.

In May 2006 DOH issued a RFP making $9.5 million In May 2006 DOH issued a RFP making $9.5 million available to support demonstration projects for a period available to support demonstration projects for a period of two years.of two years.

The workgroup agreed to begin with administrative The workgroup agreed to begin with administrative data, but acknowledged that this was just a first step data, but acknowledged that this was just a first step and over the long run administrative data needed to be and over the long run administrative data needed to be replaced with outcome data. replaced with outcome data.

The Process

To study and test incentive programs, including To study and test incentive programs, including performance-based payments to physicians, performance-based payments to physicians, hospitals and clinics that provide high-quality hospitals and clinics that provide high-quality care to their patients. care to their patients.

The state funding will pay project costs and help The state funding will pay project costs and help fund rewards to providers. fund rewards to providers.

Participating health plans will select the Participating health plans will select the incentive structure they use, but typical incentive structure they use, but typical incentives include bonuses or increases in incentives include bonuses or increases in reimbursement rates provided to physicians, reimbursement rates provided to physicians, hospitals and clinics based on their performance hospitals and clinics based on their performance meeting various measures of quality. meeting various measures of quality.

Elements of The Demonstration Grant

The projects are part of the State Health The projects are part of the State Health Department’s efforts to encourage providers and Department’s efforts to encourage providers and insurers to work collaboratively to improve the insurers to work collaboratively to improve the quality of care that is delivered in New York quality of care that is delivered in New York State. State.

State Health Commissioner Richard F. Daines, State Health Commissioner Richard F. Daines, M.D. said: “Evidence-based care that improves M.D. said: “Evidence-based care that improves patients’ ability to live healthier, productive lives patients’ ability to live healthier, productive lives is crucial to reforming our health care system and is crucial to reforming our health care system and reducing health care costs. This is an area where reducing health care costs. This is an area where the public and private sectors can work together the public and private sectors can work together to foster change.”to foster change.”

1.1. Independent Health Association Inc. (Buffalo)Independent Health Association Inc. (Buffalo)

2.2. Taconic Health Information Network and Taconic Health Information Network and Community Regional Community Regional (THINC RHIO) in Hudson Valley Region)(THINC RHIO) in Hudson Valley Region)

3.3. Montefiore Medical Center (Bronx) Montefiore Medical Center (Bronx)

4.4. *New York Health Plan Association (NYHPA) *New York Health Plan Association (NYHPA) This project is a statewide collaboration involving 12 This project is a statewide collaboration involving 12

health plans – Aetna, Affinity, CDPHP, Elderplan, GHI health plans – Aetna, Affinity, CDPHP, Elderplan, GHI HMO, HealthNet, HealthNow, HIP, Hudson Health Plan, HMO, HealthNet, HealthNow, HIP, Hudson Health Plan, Independent Health Association, MVP, and Oxford. HPA Independent Health Association, MVP, and Oxford. HPA will partner with physician, business and consumer will partner with physician, business and consumer groups, Capital District hospitals and RHIOs .groups, Capital District hospitals and RHIOs .

The Four State The Four State Demonstration ProjectsDemonstration Projects

New York Health Plan New York Health Plan Association (NYHPA) Association (NYHPA) Demonstration GrantDemonstration Grant

NYHPA Demonstration NYHPA Demonstration Grant OverviewGrant Overview

GoalGoal CollaboratorsCollaborators StructureStructure Clinical MeasuresClinical Measures Data Collection/Management/ValidationData Collection/Management/Validation Timelines Timelines Physician ReportsPhysician Reports IncentivesIncentives

NYHPA Demonstration NYHPA Demonstration Grant GoalsGrant Goals

Project is to promote patient safety and quality Project is to promote patient safety and quality of care through the development of pay-for-of care through the development of pay-for-performance programs in New York State. performance programs in New York State.

A two year demonstration Project.A two year demonstration Project.

Brings all the stakeholders together Patients, Brings all the stakeholders together Patients, Physicians and Health Plans, and consumer Physicians and Health Plans, and consumer advocates.advocates.

Develop policies and procedures for long Develop policies and procedures for long lasting P4P programs in New York.lasting P4P programs in New York.

Develop a mechanism to have ongoing Develop a mechanism to have ongoing Dialogue with the Health PlansDialogue with the Health Plans

Grant ElementsGrant Elements

The New York State Health Plan Association The New York State Health Plan Association through the grant has created the New York through the grant has created the New York Quality Alliance (NYQA), which is a multi-Quality Alliance (NYQA), which is a multi-stakeholder collaborative partnership that will stakeholder collaborative partnership that will guide the adoption and use of evidence based guide the adoption and use of evidence based measures to: measures to: measure, report and drive measure, report and drive improvements.improvements.

The reports generated under the guidance of The reports generated under the guidance of NYQA will be used in pay for performance NYQA will be used in pay for performance programs initiated by the Health Plans so that programs initiated by the Health Plans so that physicians will be financially rewarded that have physicians will be financially rewarded that have good patient outcomes.good patient outcomes.

Grant ElementsGrant Elements Standardized set of measures for all participating Standardized set of measures for all participating

Health Plans, so a physician collects one data set.Health Plans, so a physician collects one data set.

Establish one set of goals to reach a financial Establish one set of goals to reach a financial incentive (Because of anti-trust concerns, the incentive (Because of anti-trust concerns, the amount of the financial incentives for each amount of the financial incentives for each indicator will be established by the individual indicator will be established by the individual health plan.)health plan.)

Data Collection will be administrative billing data.Data Collection will be administrative billing data.

Subcontract with NYACP to educate physicians Subcontract with NYACP to educate physicians regarding the Demonstration Grant and to support regarding the Demonstration Grant and to support development of and staff the Physician Alliancedevelopment of and staff the Physician Alliance

Clinical MeasuresClinical Measures

The project will use tested and familiar The project will use tested and familiar HEDIS®/QARR measures; to simplify data HEDIS®/QARR measures; to simplify data collection only administrative (claims) data will be collection only administrative (claims) data will be used. used.

Preventive Care Domain (women’s services)Preventive Care Domain (women’s services) Breast Care Screening Breast Care Screening Chlamydia Screening Chlamydia Screening Cervical Cancer Cervical Cancer

Heart Disease DomainHeart Disease Domain Persistence of Beta-blocker therapy post MIPersistence of Beta-blocker therapy post MI

Diabetes DomainDiabetes Domain HbA1C Testing HbA1C Testing Lipid Measurement Lipid Measurement Urine Protein Screening Urine Protein Screening Eye Exam in Diabetics Eye Exam in Diabetics

Appropriate Antibiotic Use (pediatric)Appropriate Antibiotic Use (pediatric) Appropriate Treatment for Children with Upper Respiratory Infection Appropriate Treatment for Children with Upper Respiratory Infection

(URI)(URI) Appropriate Testing for Children with PharyngitisAppropriate Testing for Children with Pharyngitis

Time Line For NYDOH Time Line For NYDOH GrantGrant

2007 will be the baseline year –a baseline 2007 will be the baseline year –a baseline report will be distributed toward the end of report will be distributed toward the end of 2008. (Don’t wait until then to start!)2008. (Don’t wait until then to start!)

2008 will be the measurement year. That’s 2008 will be the measurement year. That’s now, the clock is ticking.now, the clock is ticking.

The data collection will consist of health The data collection will consist of health plan administrative data that will be plan administrative data that will be supplemented with an adjusted medical supplemented with an adjusted medical record factor, such as the hybrid claims record factor, such as the hybrid claims adjustment factor utilized by the adjustment factor utilized by the Massachusetts's Health Quality Partner Massachusetts's Health Quality Partner ( MHQP). ( MHQP).

Grant Grant IncentivesIncentives

Grant funding is available due to Grant funding is available due to matching funds being provided by payers matching funds being provided by payers participating in the demonstration project participating in the demonstration project and the DOH.and the DOH.

The Health Plans have committed $8,740,968 The Health Plans have committed $8,740,968 in potential incentives.in potential incentives.

The NYS Department of Health have awarded The NYS Department of Health have awarded $1,379,278 in matching incentives. $1,379,278 in matching incentives.

Grant Incentives

All Plans will collect data on all 10 measures

All plans will utilize the same report for determining performance payment

The determination for achieving payment will vary from plan to plan

Bonus PaymentsBonus Payments

Health plan specific payments are Health plan specific payments are within the control of the plans due to within the control of the plans due to

ANTITRUST ANTITRUST concernsconcerns

New York Quality Alliance

multi-stakeholder collaborative multi-stakeholder collaborative partnership created within the Grant partnership created within the Grant that will guide the adoption and use of that will guide the adoption and use of evidence based measures to: evidence based measures to: MeasureMeasureReportReportDrive improvementsDrive improvements. .

NYQA CollaboratorsNYQA Collaborators

PROVIDER GROUPSPROVIDER GROUPS

NY Chapter of the American NY Chapter of the American College of PhysiciansCollege of Physicians

NYS Academy of Family NYS Academy of Family PhysiciansPhysicians

Medical Society of the State of NYMedical Society of the State of NY NY Medical Group Mgmt. NY Medical Group Mgmt.

AssociationAssociation Hudson Headwaters Health Hudson Headwaters Health

NetworkNetwork Institute for Urban Family HealthInstitute for Urban Family Health Community Health Care Community Health Care

Association of NYSAssociation of NYS

CONSUMER GROUPSCONSUMER GROUPS

American Heart AssociationAmerican Heart Association Niagara Health Quality CoalitionNiagara Health Quality Coalition NY Diabetes CoalitionNY Diabetes Coalition Center for Medical ConsumersCenter for Medical Consumers

BUSINESSBUSINESS

Business Council of NYSBusiness Council of NYS New York Business Group on New York Business Group on

HealthHealth

HEALTH PLANSHEALTH PLANS

AetnaAetna Affinity Health PlanAffinity Health Plan CDPHPCDPHP ElderplanElderplan GHI HMOGHI HMO Health NetHealth Net HealthNow NYHealthNow NY HIP of New YorkHIP of New York Hudson Health PlanHudson Health Plan Independent HealthIndependent Health MVP Health CareMVP Health Care Oxford Health PlansOxford Health Plans

NYQA Work Group Structure and NYQA Work Group Structure and FunctionFunction

A work in progressA work in progress

WorkgroupsWorkgroups GovernanceGovernance

Data ManagementData Management

Project EvaluationProject Evaluation

OperationsOperations

LegalLegal

Physician AlliancePhysician Alliance

NYQA Structure and FunctionNYQA Structure and Function

Governance WorkgroupGovernance Workgroup

Develop general operating rules for the NYQADevelop general operating rules for the NYQA Synthesize the materials and produce general Synthesize the materials and produce general

operating principles until a formal structure is in operating principles until a formal structure is in placeplace

Develop a mission statement and framework to Develop a mission statement and framework to allow the project to meet the grant deliverables allow the project to meet the grant deliverables and ensure an open and transparent process and ensure an open and transparent process

Development of a permanent structure (i.e. Development of a permanent structure (i.e. bylaws, tax status) that will enable to NYQA to bylaws, tax status) that will enable to NYQA to continue beyond the DOH grant funded continue beyond the DOH grant funded component component

NYQA Structure and NYQA Structure and FunctionFunction

Data ManagementData Management WorkgroupWorkgroup

Review the responses to the Request for Review the responses to the Request for Information from potential data mangers Information from potential data mangers and assist in the selection of a NYQA and assist in the selection of a NYQA project vendor project vendor

Responsible for issues related to the data Responsible for issues related to the data inputs and outputs as well as issues related inputs and outputs as well as issues related to performance benchmarking, inpatient to performance benchmarking, inpatient measurement and reporting for the AMI measurement and reporting for the AMI project component and development of a project component and development of a matching funds allocation methodology matching funds allocation methodology


Project Evaluation WorkgroupProject Evaluation Workgroup

Develop the questions to be addressed Develop the questions to be addressed to the project evaluator. to the project evaluator.

Develop the desired framework for the Develop the desired framework for the project evaluation and will work to project evaluation and will work to define the deliverables from the define the deliverables from the evaluator that will form the contract.evaluator that will form the contract.

Monitor the evaluation progress and Monitor the evaluation progress and assist with the ongoing evaluation data assist with the ongoing evaluation data collection and analysis.collection and analysis.


Operations WorkgroupOperations Workgroup Responsible for vetting project Responsible for vetting project

component issues, not addressed by component issues, not addressed by the other workgroups that will need to the other workgroups that will need to be addressed by the voting members be addressed by the voting members of the NYQAof the NYQA

Legal WorkgroupLegal Workgroup Develop standard Business Associate Develop standard Business Associate

Agreements and Data Use Agreements and Data Use Agreements.Agreements.

NYQA Physician AllianceNYQA Physician Alliance

Structure and MembershipStructure and Membership Formed in 2007, the Physician Alliance, Formed in 2007, the Physician Alliance,

spearheaded by the New York Chapter of the spearheaded by the New York Chapter of the American College of Physicians consists of a diverse American College of Physicians consists of a diverse geographically dispersed group of primary care geographically dispersed group of primary care physician organizations across New York State. physician organizations across New York State.

The Alliance membership is composed of nine The Alliance membership is composed of nine physician representatives from the American College physician representatives from the American College of Obstetrics and Gynecology, the American of Obstetrics and Gynecology, the American Academy of Pediatrics, New York Chapter American Academy of Pediatrics, New York Chapter American College of Physicians (Internal Medicine), the New College of Physicians (Internal Medicine), the New York Chapter of the American Academy of Family York Chapter of the American Academy of Family Physicians and the Medical Society of the State of Physicians and the Medical Society of the State of New York.New York.

NYQA Physician AllianceNYQA Physician Alliance Goals of Physician AllianceGoals of Physician Alliance

Short term, the PA is committed to working Short term, the PA is committed to working jointly with the NYQA to jointly with the NYQA to develop fair and develop fair and reasonable practices of data collection and reasonable practices of data collection and scoring standards for the P4P scoring standards for the P4P demonstration project, funded by New York demonstration project, funded by New York State over the next two years. State over the next two years.

The long range goal of the PA will be to The long range goal of the PA will be to work with the NYQA and other entities to work with the NYQA and other entities to develop fair, reasonable and develop fair, reasonable and SUSTAINABLE policies and procedures for SUSTAINABLE policies and procedures for quality improvement truly impact patient quality improvement truly impact patient care and safety in a cost effective fashion. care and safety in a cost effective fashion.


Responsibilities of Physician Responsibilities of Physician AllianceAlliance

Define and promote the use of nationally Define and promote the use of nationally recognized best practices for the 10 recognized best practices for the 10 selected clinical measures adopted from selected clinical measures adopted from the National Committee for Quality the National Committee for Quality Assurance Health Plan Employer Data Assurance Health Plan Employer Data and Information Set (NCQA/ HEDIS®) and Information Set (NCQA/ HEDIS®) that the health plans have all agreed that the health plans have all agreed upon to measure and reportupon to measure and report

NYQA Physician AllianceNYQA Physician Alliance ResponsibilitiesResponsibilities (CONTINUED)(CONTINUED)

Develop the core curriculum for NYQA Develop the core curriculum for NYQA andand with with NYACP provide education for Primary care NYACP provide education for Primary care physicians.physicians.

The core curriculum will include the The core curriculum will include the description of the P4P Grant, NYQA and the description of the P4P Grant, NYQA and the PA, best practice materials and administrative PA, best practice materials and administrative specifications. The training will involve web-specifications. The training will involve web-based materials, performance improvement based materials, performance improvement tools and checklists that will allow practices tools and checklists that will allow practices the ability to evaluate themselves. The the ability to evaluate themselves. The educational materials will be available on the educational materials will be available on the web, CD and in traditional lectures modalities.web, CD and in traditional lectures modalities.

NYQA Physician AllianceNYQA Physician Alliance Responsibilities Responsibilities (CONTINUED(CONTINUED

Represent clinicians interest in the development of Represent clinicians interest in the development of the data collection methodology, measurement the data collection methodology, measurement benchmarking, measurement reports and project benchmarking, measurement reports and project evaluation; evaluation;

Provide input to the NYQA on proposed data collection Provide input to the NYQA on proposed data collection methodology and aggregation standards;methodology and aggregation standards;

Provide input to the NYQA on the “adjustment factor” to be Provide input to the NYQA on the “adjustment factor” to be employed for selected HEDIS measures; employed for selected HEDIS measures;

Identify process improvement activities, develop Identify process improvement activities, develop checklists to facilitate implementation of best checklists to facilitate implementation of best practices and develop corrective action plans to practices and develop corrective action plans to assist clinicians with measurement improvement; assist clinicians with measurement improvement;


■Responsibilities Responsibilities (CONTINUED(CONTINUED

Work with the NYQA to develop fair, reasonable Work with the NYQA to develop fair, reasonable and sustainable policies and procedures for and sustainable policies and procedures for quality improvement designed to impact patient quality improvement designed to impact patient care and safety in a cost efficient fashion.care and safety in a cost efficient fashion.

Education to Improve coding/compliance so that Education to Improve coding/compliance so that the correct information can be obtained form the correct information can be obtained form billing data.billing data.

Development of tools to document complianceDevelopment of tools to document compliance Conduct 30 total presentations (10 hospital Grand Conduct 30 total presentations (10 hospital Grand

Rounds and 20 conferences, meetings or other Rounds and 20 conferences, meetings or other educational events).educational events).

Clinical MeasuresClinical MeasuresThe project will use tested and familiar The project will use tested and familiar

HEDIS®/QARR measures; to simplify data HEDIS®/QARR measures; to simplify data collection only administrative (claims) data will collection only administrative (claims) data will be used. be used.

Preventive Care Domain (women’s services)Preventive Care Domain (women’s services) Breast Care Screening Breast Care Screening Chlamydia Screening Chlamydia Screening Cervical Cancer Cervical Cancer

Heart Disease Domain Heart Disease Domain Persistence of Beta-blocker therapy post MIPersistence of Beta-blocker therapy post MI

Diabetes DomainDiabetes Domain HbA1C Testing HbA1C Testing Lipid Measurement Lipid Measurement Urine Protein Screening Urine Protein Screening Eye Exam in Diabetics Eye Exam in Diabetics

Appropriate Antibiotic Use (pediatric)Appropriate Antibiotic Use (pediatric) Appropriate Treatment for Children with Upper Respiratory Infection Appropriate Treatment for Children with Upper Respiratory Infection

(URI)(URI) Appropriate Testing for Children with PharyngitisAppropriate Testing for Children with Pharyngitis

Preventive HealthPreventive Health((Indicators for Women)Indicators for Women)

Chlamydia screeningChlamydia screening Women 16–25 years as of December 31 of the Women 16–25 years as of December 31 of the measurement year who were identified as being measurement year who were identified as being sexually active and had at least one Chlamydia test sexually active and had at least one Chlamydia test

Cervical CancerCervical Cancer Women 21–64 years of age who received one or more Women 21–64 years of age who received one or more Pap tests to screen for cervical cancer as of December Pap tests to screen for cervical cancer as of December 31 of the measurement year.31 of the measurement year.

Breast Care ScreeningBreast Care Screening Women 42–69 years as of December 31 of the Women 42–69 years as of December 31 of the measurement year who have had a mammogram to measurement year who have had a mammogram to screen for breast cancer during the measurement year screen for breast cancer during the measurement year and the year prior to the measurement yearand the year prior to the measurement year

Indicators for Heart Indicators for Heart DiseaseDisease

Persistence of Beta-blocker Therapy After a Persistence of Beta-blocker Therapy After a Heart AttackHeart AttackThe percentage of members 18 years of age and older during the The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial of the measurement year with a diagnosis of acute myocardial infarction and who received persistent beta-blocker treatment for infarction and who received persistent beta-blocker treatment for six months (180 days) after discharge as evidenced by pharmacy six months (180 days) after discharge as evidenced by pharmacy claims data (prescriptions filled.) claims data (prescriptions filled.)

Indicators for Diabetes Indicators for Diabetes

HbA1C TestingHbA1C TestingOne A1C test as of December 31st of the reporting year evidenced by One A1C test as of December 31st of the reporting year evidenced by CPT code 83036 or 83037; or CPT Category II Code 3044F, 3045F, 3046F CPT code 83036 or 83037; or CPT Category II Code 3044F, 3045F, 3046F or 3047F; or LOINC code 4548-4, 4549-2 or 17856-6.or 3047F; or LOINC code 4548-4, 4549-2 or 17856-6.

Lipid MeasurementLipid MeasurementOne LDL-C test as of December 31st of the reporting year as evidenced One LDL-C test as of December 31st of the reporting year as evidenced by CPT codes 80061,83700, 83701, 83704, 83716 0r 83721; or, CPT by CPT codes 80061,83700, 83701, 83704, 83716 0r 83721; or, CPT Category II code 3084F, 3049F or 3050F; Category II code 3084F, 3049F or 3050F; or, LOINC 2089-1,12773-8, 13457-7, 18261-8, or, LOINC 2089-1,12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1 or 39469-2.18262-6, 22748-8, 24331-1 or 39469-2.

Nephropathy ScreeningNephropathy Screening One nephropathyOne nephropathy (microalbumin) (microalbumin) testtest as of December 31st of the as of December 31st of the reporting year as evidenced by listed CPT, CPT Cat II, or LOINC codes; reporting year as evidenced by listed CPT, CPT Cat II, or LOINC codes; or, evidence of nephropathy indicated by a positive macroalbumin test or, evidence of nephropathy indicated by a positive macroalbumin test confirmed by automated laboratory result data; or evidence of ACE confirmed by automated laboratory result data; or evidence of ACE inhibitor/ARB treatment or treatment for nephropathy indicated by listed inhibitor/ARB treatment or treatment for nephropathy indicated by listed CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG codes.CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG codes.

Eye Exam in Diabetics Eye Exam in Diabetics A A retinal or dilated eye exam by an eye care professional as of December retinal or dilated eye exam by an eye care professional as of December 31st of the reporting year or a negative retinal exam by an eye care 31st of the reporting year or a negative retinal exam by an eye care professional in the prior year.professional in the prior year.

(For members aged 18-75 identified with diabetes (For members aged 18-75 identified with diabetes based on an encounter during the measurement year based on an encounter during the measurement year

with either ICD-9 diagnosis codes: 250.xx, 357.2, with either ICD-9 diagnosis codes: 250.xx, 357.2, 362.0x, 366.41, 648.0x; or DRG 294,295)362.0x, 366.41, 648.0x; or DRG 294,295)

Indicators for ChildrenIndicators for Children

Appropriate Treatment for Children with Upper Appropriate Treatment for Children with Upper Respiratory Infection (URI)Respiratory Infection (URI)The percentage of children 3 months – 18 years of age who had The percentage of children 3 months – 18 years of age who had an encounter with a diagnosis of acute upper respiratory infection an encounter with a diagnosis of acute upper respiratory infection (ICD9-CM code 460 or 465) and who were not dispensed an (ICD9-CM code 460 or 465) and who were not dispensed an antibiotic for the episode. Children with a listed competing antibiotic for the episode. Children with a listed competing diagnosis or who received antibiotics in the prior 30 days are diagnosis or who received antibiotics in the prior 30 days are excluded. excluded.

Appropriate Testing for Children with PharyngitisAppropriate Testing for Children with Pharyngitis

Percentage of children 2-18 years of age who had an encounter Percentage of children 2-18 years of age who had an encounter with only a diagnosis of pharyngitis (ICD-9-CM codes 462, 463 or with only a diagnosis of pharyngitis (ICD-9-CM codes 462, 463 or 034.0), who were dispensed an antibiotic and who received a 034.0), who were dispensed an antibiotic and who received a group A streptococcus test for the episode evidenced by listed group A streptococcus test for the episode evidenced by listed CPT or LOINC codes. Children who received antibiotics in the CPT or LOINC codes. Children who received antibiotics in the prior 30 days are excluded. prior 30 days are excluded.

Data Collection, Management Data Collection, Management and Validationand Validation

A Data Manager (vendor) will aggregate A Data Manager (vendor) will aggregate and analyze the participating health plan and analyze the participating health plan claims and lab information and create claims and lab information and create measurement reports. The data from all measurement reports. The data from all NYS P4P Demonstration projects will be NYS P4P Demonstration projects will be forwarded to IPRO for analysis. forwarded to IPRO for analysis.

Public Reporting is not a component of this Public Reporting is not a component of this demonstration project demonstration project

The Physician Alliance will be involved in all The Physician Alliance will be involved in all aspects of data collection, management and aspects of data collection, management and appeals process. appeals process.

How to Succeed with How to Succeed with Performance MeasuresPerformance Measures

#1 Designate an office “Quality Manager,”#1 Designate an office “Quality Manager,” --someone to be responsible for performance measurement--someone to be responsible for performance measurement

##2 Bill all services provided2 Bill all services provided #3 Code accurately and completely#3 Code accurately and completely

-- review encounter forms to be sure that codes used will count. -- review encounter forms to be sure that codes used will count. -- verify with your billing company that correct codes are billed.-- verify with your billing company that correct codes are billed.

#4 Request current “actionable” reports from plans #4 Request current “actionable” reports from plans and review baseline NYQA reportand review baseline NYQA report -- to improve coding and billing practice -- to improve coding and billing practice -- to identify practice patterns not consistent with measured standards -- to identify practice patterns not consistent with measured standards -- to identify patients who need to be called in for care-- to identify patients who need to be called in for care

#5 For future success, reinvest bonus money#5 For future success, reinvest bonus money -- to strengthen skills and resources related to data management: -- to strengthen skills and resources related to data management: -- consider implementation of a registry or an electronic health record -- consider implementation of a registry or an electronic health record with a registry function. . with a registry function. .

Participating Health Plans

Plan Contact Methodology for award

Hudson Health Plan Marlene Ripa (914)372-xxxx or your Hudson Health Plan Provider relations representative

TBD—will coordinate with existing p4P programs and with THINC RHIO project

SummarySummary The status quo is not sustainable: cost, quality, The status quo is not sustainable: cost, quality,

access access Performance (Quality) Measurement is increasingly Performance (Quality) Measurement is increasingly

seen nationally and locally as a cornerstone of seen nationally and locally as a cornerstone of building a better health care delivery systembuilding a better health care delivery system

Pay-for-performance programs have been embraced Pay-for-performance programs have been embraced by CMS and health plans and are increasingly by CMS and health plans and are increasingly common common

The “House of Medicine” is already extensively The “House of Medicine” is already extensively present on the national scene; The Physicians present on the national scene; The Physicians Alliance of the NYQA gives New York physicians a Alliance of the NYQA gives New York physicians a voice and a vote in how measures are implemented voice and a vote in how measures are implemented locally locally

To survive and thrive learn to manage data as well To survive and thrive learn to manage data as well as you manage patients.as you manage patients.

Why Should Physicians Be Why Should Physicians Be Involved?Involved?

You have physician representation on the You have physician representation on the project and input.project and input.

Physicians will be working with the Health Physicians will be working with the Health plans to adopt FAIR and REASONABLE plans to adopt FAIR and REASONABLE principles for P4P.principles for P4P.

Get in on the Ground Floor and Help shape Get in on the Ground Floor and Help shape the future!the future!

Next steps for physicians.Next steps for physicians.

Physician participation and support is critical.Physician participation and support is critical.

Value ExchangesValue Exchanges

NYQA has been designated a NYQA has been designated a Certified Value ExchangeCertified Value Exchange

Value ExchangesValue Exchanges Multi-stakeholder collaborative organizations Multi-stakeholder collaborative organizations

that are working to improve quality and value in that are working to improve quality and value in health care by measuring the performance of health care by measuring the performance of local health care providers and reporting these local health care providers and reporting these findings publicly. findings publicly.

The plan would be to bring the local The plan would be to bring the local collaboratives into a nation-wide system, and the collaboratives into a nation-wide system, and the collaboratives would use nationally-recognized collaboratives would use nationally-recognized standards to measure and improve quality of standards to measure and improve quality of care in their local areas.care in their local areas.

The chartered collaboratives would be called The chartered collaboratives would be called Value ExchangesValue Exchanges

Value ExchangesValue Exchanges The Exchanges could also pioneer new The Exchanges could also pioneer new

quality improvement strategies and share quality improvement strategies and share results through the Learning Network.results through the Learning Network.

The new system would be administered by The new system would be administered by HHS' Agency for Healthcare Research HHS' Agency for Healthcare Research and Quality (AHRQ). AHRQ Director and Quality (AHRQ). AHRQ Director Carolyn M. Clancy, M.D., said providers Carolyn M. Clancy, M.D., said providers would lead in the development of would lead in the development of standards.standards.

Advance the four cornerstones of Value-Advance the four cornerstones of Value-Driven Health Care.Driven Health Care.

Four Cornerstones of Value-Four Cornerstones of Value-Driven Health CareDriven Health Care

Interoperable Health Information Interoperable Health Information Technology (Health IT Standards):Technology (Health IT Standards): Interoperable health information technology has Interoperable health information technology has

the potential to create greater efficiency in the potential to create greater efficiency in health care delivery. health care delivery.

develop standards that enable health develop standards that enable health information systems to communicate and information systems to communicate and exchange data quickly and securely to protect exchange data quickly and securely to protect patient privacy. patient privacy.

all health care systems and products should all health care systems and products should meet these standards as they are acquired or meet these standards as they are acquired or upgraded. upgraded.


Measure and Publish Quality Measure and Publish Quality Information (Quality Standards):Information (Quality Standards): To make confident decisions about their health To make confident decisions about their health

care providers and treatment options, care providers and treatment options, consumers need quality of care information. consumers need quality of care information.

Similarly, this information is important to Similarly, this information is important to providers who are interested in improving the providers who are interested in improving the quality of care they deliver. quality of care they deliver.

Quality measurement should be based on Quality measurement should be based on measures that are developed through measures that are developed through consensus-based processes involving all consensus-based processes involving all stakeholders, such as the processes used by the stakeholders, such as the processes used by the AQA (multi-stakeholder group focused on AQA (multi-stakeholder group focused on physician quality measurement) and the physician quality measurement) and the Hospital Quality Alliance.Hospital Quality Alliance.


Measure and Publish Price Measure and Publish Price Information (Price Standards):Information (Price Standards): To make confident decisions about their health To make confident decisions about their health

care providers and treatment options, care providers and treatment options, consumers also need price information.consumers also need price information.

Efforts are underway to develop uniform Efforts are underway to develop uniform approaches to measuring and reporting price approaches to measuring and reporting price information for the benefit of consumers. information for the benefit of consumers.

In addition, strategies are being developed to In addition, strategies are being developed to measure the overall cost of services for measure the overall cost of services for common episodes of care and the treatment of common episodes of care and the treatment of common chronic diseases. common chronic diseases.


Promote Quality and Efficiency of Care Promote Quality and Efficiency of Care (Incentives):(Incentives): All parties - providers, patients, insurance plans, All parties - providers, patients, insurance plans,

and payers - should participate in arrangements and payers - should participate in arrangements that reward both those who offer and those who that reward both those who offer and those who purchase high-quality, competitively-priced health purchase high-quality, competitively-priced health care. care.

Such arrangements may include implementation of Such arrangements may include implementation of pay-for-performance methods of reimbursement for pay-for-performance methods of reimbursement for providers or the offering of consumer-directed providers or the offering of consumer-directed health plan products, such as account-based plans health plan products, such as account-based plans for enrollees in employer-sponsored health benefit for enrollees in employer-sponsored health benefit plans.plans.

Value ExchangesValue Exchanges

Participation as a Chartered Value Participation as a Chartered Value Exchange offers several benefits. Exchange offers several benefits. Members can join their peers in a nationwide Members can join their peers in a nationwide

Learning Network sponsored by the Agency for Learning Network sponsored by the Agency for Healthcare Research and Quality (AHRQ). Often Healthcare Research and Quality (AHRQ). Often called communities of practice, called communities of practice,

A Learning Network provides peer-to-peer A Learning Network provides peer-to-peer learning experiences through facilitated learning experiences through facilitated meetings, both face to face and on the Web. The meetings, both face to face and on the Web. The network also features tools, access to experts, network also features tools, access to experts, and an ongoing private Web-based knowledge and an ongoing private Web-based knowledge management system.management system.

Value ExchangesValue ExchangesThe Learning Network allows members to:The Learning Network allows members to: Share their experiences. Share their experiences. Identify promising practices. Identify promising practices. Point out gaps where innovation is needed. Point out gaps where innovation is needed. Raise issues for national consensus-building Raise issues for national consensus-building

organizationsorganizations Provide an on-the-ground perspective to Provide an on-the-ground perspective to

participate in setting national priorities for participate in setting national priorities for improvement.improvement.

Chartered Value Exchanges will have access Chartered Value Exchanges will have access to summary Medicare provider performance to summary Medicare provider performance results, which can be combined with similarly results, which can be combined with similarly calculated private-sector results to produce calculated private-sector results to produce and publish all-payer performance results.and publish all-payer performance results.

new york state demonstration grant pay for performance the new york quality alliance performance...

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