rewarding performance: three-year results from california's statewide pay-for-performance...
TRANSCRIPT
Rewarding Performance: Rewarding Performance: Three-Year Results from California's Three-Year Results from California's
Statewide Pay-for-Performance Statewide Pay-for-Performance ExperimentExperiment
Rewarding Performance: Rewarding Performance: Three-Year Results from California's Three-Year Results from California's
Statewide Pay-for-Performance Statewide Pay-for-Performance ExperimentExperiment
Cheryl L. Damberg, PhD, Kristiana Raube, PhD, Stephanie Cheryl L. Damberg, PhD, Kristiana Raube, PhD, Stephanie Teleki, PhD, and Erin dela CruzTeleki, PhD, and Erin dela Cruz
June 5, 2007June 5, 2007
Financial support provided by the California Healthcare FoundationFinancial support provided by the California Healthcare Foundation
Academy Health, 2007
Presentation TopicsPresentation Topics
IHA Pay-for-Performance program designIHA Pay-for-Performance program design
Year-to-year changes in performance scores Year-to-year changes in performance scores
Physician group responses to P4P post 3Physician group responses to P4P post 3rdrd incentive paymentincentive payment
ConclusionsConclusions
Academy Health, 2007
Evaluation of the IHA P4P ProgramEvaluation of the IHA P4P Program
A 5-year evaluation to assess the impact of A 5-year evaluation to assess the impact of the IHA P4P program on:the IHA P4P program on:
Changes in performance over timeChanges in performance over time
Changes in payments and the distribution of Changes in payments and the distribution of payments over timepayments over time
The relationship between structural The relationship between structural characteristics and performance scorescharacteristics and performance scores
Physician group responses to the incentive Physician group responses to the incentive programprogram
Leadership interviews with physician groupsLeadership interviews with physician groups
Academy Health, 2007
IHA P4P ProgramIHA P4P Program A statewide collaborative effort among:A statewide collaborative effort among:
7 major health plans and 225 medical groups7 major health plans and 225 medical groups 12 million commercial HMO and POS enrollees12 million commercial HMO and POS enrollees
Measurement started in 2003 for 1Measurement started in 2003 for 1stst payout in 2004 payout in 2004 33rdrd payout occurred late summer 2006 payout occurred late summer 2006
Design ElementsDesign Elements
Unit of paymentUnit of payment Medical groups (n=225)Medical groups (n=225)
# of measures# of measures 17 (clinical, patient experience, IT capability)17 (clinical, patient experience, IT capability)
Data sourceData source Administrative (plan or medical group self-report)Administrative (plan or medical group self-report)
Min of 3.25 encounters PMPYMin of 3.25 encounters PMPY
Earning potentialEarning potential Avg. bonus of 2-3% of cap (~$2.50 per member Avg. bonus of 2-3% of cap (~$2.50 per member per month)per month)
Scoring methodScoring method Most plans use relative rankingsMost plans use relative rankings
TransparencyTransparency Full transparencyFull transparency
Academy Health, 2007
Performance Measures Performance Measures MY Year 2005, Payout 2006MY Year 2005, Payout 2006
ClinicalClinical Asthma managementAsthma management Childhood immunization (MMR, VZV)Childhood immunization (MMR, VZV) Cancer screening (breast, cervical)Cancer screening (breast, cervical) Diabetes (HbA1c measure and control)Diabetes (HbA1c measure and control) LDL (screening and control: 03 cardiac; 04 cardiac and LDL (screening and control: 03 cardiac; 04 cardiac and
diabetic)diabetic)
Patient ExperiencePatient Experience Timely access to careTimely access to care Doctor-patient interaction/communicationDoctor-patient interaction/communication Specialty careSpecialty care Overall ratings of careOverall ratings of care
IT CapabilityIT Capability Integrate clinical electronic dataIntegrate clinical electronic data for population management for population management
Clinical decision making Clinical decision making support at point of caresupport at point of care through through electronic toolselectronic tools
Academy Health, 2007
Weighting of Measures in Payout FormulaWeighting of Measures in Payout Formula
Payout YearPayout Year 20042004 20052005 20062006 20072007
Clinical MeasuresClinical Measures 50%50% 40%40% 50%50% 50%50%
Patient Experience with CarePatient Experience with Care 40%40% 40%40% 30%30% 30%30%
IT Capabilities (add systemness IT Capabilities (add systemness measures in 2007)measures in 2007) 10%10% 20%20% 20%20% 20%20%
TotalTotal 100%100% 100%100% 100%100% 100%100%
Individual physician Feedback program Individual physician Feedback program ((optional add on bonusoptional add on bonus)) xx xx
Year-to-year improvement Year-to-year improvement ((optional optional in 06; begins 07 for all plansin 06; begins 07 for all plans)) xx
Academy Health, 2007
$55.0
$89.5
$144.6
$53.7$37.4
$83.4
$82.0
$119.5$137.1
$0.0
$40.0
$80.0
$120.0
$160.0
2004 2005 2006
Millions of Dollars
IHA Payouts Non-IHA Payouts Total Payouts
Changes in Payouts: 2004-2006Changes in Payouts: 2004-2006
∆∆=47% increase in IHA portion=47% increase in IHA portion
Academy Health, 2007
Total Payments to Physician Organizations*Total Payments to Physician Organizations*2004 vs. 2005 2004 vs. 2005
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
$0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000
2004
20
05
* Note: Truncated to groups receiving less than $2 million
Academy Health, 2007
3-Year Performance Changes3-Year Performance Changes
2003 (2004 payout) to 2003 (2004 payout) to
2005 (2006 payout) 2005 (2006 payout)
Academy Health, 2007
Modest Changes in Patient Experience ScoresModest Changes in Patient Experience Scores
MeasureMeasure 20032003 20042004 Mean Mean DifferenceDifference
Rating of Health CareRating of Health Care 70.0%70.0% 71.4%71.4% 1.4%1.4%****
Rating of Doctor Rating of Doctor 80.0%80.0% 80.7%80.7% 0.5%0.5%
Rating of Specialist Rating of Specialist 71.0%71.0% 71.9%71.9% 0.8%0.8%
Doctor CommunicationDoctor Communication 85.6%85.6% 87.0%87.0% 1.3%1.3%******
Timely Care and AccessTimely Care and Access 69.5%69.5% 70.2%70.2% 1.4%1.4%******
No Problem Seeing SpecialistNo Problem Seeing Specialist 59.5%59.5% 61.3%61.3% 2.2%2.2%******
Statistically significant at *** p<.001 ** p < .01; * p < .05
Academy Health, 2007
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005
Measurement Year
Mea
n S
core
Overall Mean
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Asthma: All AgesAsthma: All Ages
Reduction of 5.6% points in variationReduction of 5.6% points in variation
21% point gain in 21% point gain in performanceperformance
Academy Health, 2007
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005
Measurement Year
Me
an
Sc
ore
Overall Mean
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Breast Cancer ScreeningBreast Cancer Screening
Reduction of 2.3% points in variationReduction of 2.3% points in variation
3.5% point gain in 3.5% point gain in performanceperformance
Academy Health, 2007
HbA1c ScreeningHbA1c Screening
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005
Measurement Year
Mea
n S
core
Overall Mean
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Reduction of 19.8% points in variationReduction of 19.8% points in variation
7.7% point gain in 7.7% point gain in performanceperformance
Academy Health, 2007
Diabetes HbA1c Screening: 2004 vs. 2005Diabetes HbA1c Screening: 2004 vs. 2005
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
2004
20
05
Academy Health, 2007
Breast Cancer Screening: 2004 vs 2005Breast Cancer Screening: 2004 vs 2005
0
10
20
30
40
50
60
70
80
90
100
0 20 40 60 80 100
2004
2005
Academy Health, 2007
IT adoption increases each yearIT adoption increases each year
0
10
20
30
40
50
60
70
80
90
100
Patient Registry Actionable Reports HEDIS Results
Number of Groups Measurement Year 2003
Measurement Year 2004
Measurement Year 2005
By 2005, 33-44% of Groups and 68-76% of By 2005, 33-44% of Groups and 68-76% of Patients Had Data Integration TechnologyPatients Had Data Integration Technology
Academy Health, 2007
More IT Functions are AdoptedMore IT Functions are Adopted
0
10
20
30
40
50
60
70
80
90
ElectronicPrescribing
ElectronicCheck of
PrescriptionInteraction
ElectronicRetrieval ofLab Results
ElectronicAccess of
Clinical Notes
ElectronicRetrieval of
PatientReminders
AccessingClinicalFindings
ElectronicMessaging
Number of Groups
Measurement Year 2003 Measurement Year 2004 Measurement Year 2005
By 2005, 1-39% of Groups; 20-64% of By 2005, 1-39% of Groups; 20-64% of Patients had Point of Care TechnologyPatients had Point of Care Technology
Academy Health, 2007
Physician Organization Responses to Physician Organization Responses to
Pay for Performance:Pay for Performance:
Findings from Leadership InterviewsFindings from Leadership Interviews
Academy Health, 2007
Physician Organization Responses to the Physician Organization Responses to the Incentive ProgramIncentive Program
Second round of interviews with physician Second round of interviews with physician leadership (3 years into program)leadership (3 years into program)
Study population: 35 physician organizations Study population: 35 physician organizations (POs) out of a universe of 225 in CA ((POs) out of a universe of 225 in CA (n=29 n=29 completed to datecompleted to date))
Cross section of groupsCross section of groups High, medium, and low performing PosHigh, medium, and low performing Pos
Reflects the spectrum of “winners and Reflects the spectrum of “winners and losers”losers”
Large and small POsLarge and small POs Reflects resource constraintsReflects resource constraints
Rural and urban POs Rural and urban POs
Academy Health, 2007
Support Quality Focus, but Face ConstraintsSupport Quality Focus, but Face Constraints
• Most said the organization provides Most said the organization provides support to addressing quality support to addressing quality Mean score = 4.0 (1 to 5 scale, with 5 = a lot of support)Mean score = 4.0 (1 to 5 scale, with 5 = a lot of support)
• Biggest constraints to improving quality:Biggest constraints to improving quality: Technology challenges, such as lack of EMRTechnology challenges, such as lack of EMR
Changing physician behaviorChanging physician behavior
Data issues, such as data integration, missing Data issues, such as data integration, missing information, etc.information, etc.
• POs feel they are moderately successful in POs feel they are moderately successful in monitoring their quality performancemonitoring their quality performance
Mean score=3.7 ( 1-5 scale, with 5 = very successful)Mean score=3.7 ( 1-5 scale, with 5 = very successful)
Academy Health, 2007
Is the Current Incentive Level of 1-2% of Is the Current Incentive Level of 1-2% of Capitation Right?Capitation Right?
Among those earning incentives, the amount was 2% Among those earning incentives, the amount was 2% or less as a percentage of total capitation paymentsor less as a percentage of total capitation payments
Mixed results on +/- ROIMixed results on +/- ROI
Widespread support for increasing incentivesWidespread support for increasing incentives to 5- to 5-10% of capitation payments (26 out of 29 POs 10% of capitation payments (26 out of 29 POs agreed)agreed)
This level would increase attention, provide a positive ROI This level would increase attention, provide a positive ROI and defray set-up costsand defray set-up costs
Some POs noted current levels have gotten their attention Some POs noted current levels have gotten their attention and urged them to make changesand urged them to make changes
Academy Health, 2007
Most POs Believe P4P Affects Organizational Most POs Believe P4P Affects Organizational and Physician Behaviorand Physician Behavior
• Increased organizational accountability for qualityIncreased organizational accountability for quality
New project managers, quality support, and medical New project managers, quality support, and medical directors directors
• Improvements in data collection, including IT adoptionImprovements in data collection, including IT adoption IT and data support staffIT and data support staff
Data mining capabilitiesData mining capabilities
EMRs, hardware, software, and web interfacesEMRs, hardware, software, and web interfaces
• Physicians are more directly managing patients and Physicians are more directly managing patients and working with administration to improve qualityworking with administration to improve quality
Bonuses tied to qualityBonuses tied to quality
Outreach to physicians; clinical and patient satisfaction Outreach to physicians; clinical and patient satisfaction guideline reviewguideline review
Academy Health, 2007
ConclusionsConclusions Modest positive changes occurring for most Modest positive changes occurring for most
measuresmeasures Combination of quality improvements and improvements in Combination of quality improvements and improvements in
data capturedata capture
Data capture continues to challenge small groups and some Data capture continues to challenge small groups and some IPAsIPAs
Challenges of how to improve patient experienceChallenges of how to improve patient experience
Performance payments have grown slowly over timePerformance payments have grown slowly over time $$ at risk for performance are still a small fraction of total $$ at risk for performance are still a small fraction of total
paymentspayments
Current level of incentives isn’t high enough to really get Current level of incentives isn’t high enough to really get attention of physiciansattention of physicians
Hard to incentivize specialists given absence of Hard to incentivize specialists given absence of measuresmeasures
Academy Health, 2007
Will P4P Solve the Cost and Quality Problems Will P4P Solve the Cost and Quality Problems in the U.S. Health System?in the U.S. Health System?
Improving the Improving the reliability of carereliability of care received from current received from current level of one-sigma to six-sigma?level of one-sigma to six-sigma?
Slowing the growth in healthcare costsSlowing the growth in healthcare costs to the rate of to the rate of growth in the GDP or general level of inflation?growth in the GDP or general level of inflation?
Reducing the number of deaths from medical errorsReducing the number of deaths from medical errors from from estimated rate of >100,000/year to below 5,000/year?estimated rate of >100,000/year to below 5,000/year?
Unlikely in near termUnlikely in near term
Need for other policy levers in conjunction with P4P Need for other policy levers in conjunction with P4P (e.g., broader performance measurement, (e.g., broader performance measurement, transparency, investments in information systems)transparency, investments in information systems)