margaret e. o’kane president, ncqa february 28, 2008 p4p: part of a larger health reform agenda
TRANSCRIPT
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MARGARET E. O’KANEPRESIDENT, NCQA
FEBRUARY 28, 2008
P4P: PART OF A LARGERHEALTH REFORM AGENDA
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2MARGARET E. O’KANEFEBRUARY 28, 2008
ABOUT TODAY’S DISCUSSION
• About NCQA– Physician Recognition Programs
• Trends in Pay for Performance• P4P: Part of a Larger Strategy
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3MARGARET E. O’KANEFEBRUARY 28, 2008
NCQA: A BRIEF INTRODUCTION
• Private, independent non-profit health care quality oversight organization founded in 1990
• Mission: To improve the quality of health care
• Committed to measurement, transparency and accountability
• Unites diverse groups around common goal: improving health care quality
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4MARGARET E. O’KANEFEBRUARY 28, 2008
WHAT DOES NCQA MEASURE?
• HEDIS®
– Cancer screening, diabetes, cardiac care– Measures of effective, appropriate care– HEDIS measure criteria: valid, relevant,
feasible– Specifications vetted by committee of
health care stakeholders, thought leaders– Results are rigorously audited
• CAHPS®
– Access, timeliness, satisfaction– Independently collected
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5MARGARET E. O’KANEFEBRUARY 28, 2008
WHAT DOES NCQA MEASURE?
• Health Plans– HEDIS and CAHPS quality measurement– 2/3 of HMOs in U.S. are NCQA Accredited
•Covering 75% of HMO lives
– Only Accreditation program that scores programs on quality of care
– 2008: NCQA extends many MCO Accreditation requirements to PPOs
• Physicians/physician groups– HEDIS for Physician Measurement– NCQA Physician Recognition programs
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6MARGARET E. O’KANEFEBRUARY 28, 2008
MEASUREMENT LEADS TO IMPROVEMENT
30
40
50
60
70
80
90
100
1999 2000 2001 2002 2003 2004 2005 2006
Beta-BlockersAfter a HeartAttack
LDL Control
ChildhoodImmunizations(Combo 2)
HbA1c control(<9.0)
Hypertension
Denotes measure specification change in 2006
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7MARGARET E. O’KANEFEBRUARY 28, 2008
PHYSICIAN RECOGNITION PROGRAMS
• Identify providers whodeliver superior care
• Measure against evidence-based standards
• Assess care for diabetes, heart/stroke, back pain, care delivery systems
• New PPC-PCMH program serves to identify practices as “medical homes”
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8MARGARET E. O’KANEFEBRUARY 28, 2008
IDENTIFYING PATIENT-CENTERED MEDICAL HOMES
Assessing whether practices provide:• Access and communication• Patient tracking and registry functions• Care management• Patient self-management support• Electronic prescribing• Test tracking• Referral tracking• Performance reporting and improvement• Advanced electronic communications
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9MARGARET E. O’KANEFEBRUARY 28, 2008
RECOGNIZED PHYSICIANS, 2003-2007
1,944
2,974
3,968
5,415
9,818
0 2,000 4,000 6,000 8,000 10,000 12,000
2003
2004
2005
2006
2007
Active Recognitions as of December 31 of each year.
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10MARGARET E. O’KANEFEBRUARY 28, 2008
P4P PROGRAMS GAIN TRACTION
35
85
107
148
160
0 50 100 150 200
2003
2004
2005
2007
2009
Source: MedVantage
*
* estimate
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11MARGARET E. O’KANEFEBRUARY 28, 2008
...BUT THEIR IMPACT ON THE SYSTEMISN’T YET REALIZED
• Penetration is still limited• Often target primary care• Incentives are not strong compared
to underlying payment system• Not a silver bullet!
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12MARGARET E. O’KANEFEBRUARY 28, 2008
A CROSSROADS FOR QUALITY
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13MARGARET E. O’KANEFEBRUARY 28, 2008
98%
73%
59%
43%
25%
11%
87%
12%7%
4%
15%10%
20%24%
5%10%
3%
14%7%
18% 21%
0%
20%
40%
60%
80%
100%
120%
2000 2001 2002 2003 2004 2005 2006 2007
Premiums Wages Inflation
Cu
mu
lati
ve G
row
thWE MUST ADDRESS THE COST
JUGGERNAUT Cumulative Changes in Health Insurance Premiums, Workers’
Earnings and Inflation, 2000-2007
Sources: KFF/HRET 2007 Employer Health Benefits Survey, BLS Consumer Price Index
Average premium for family of 4 = $11,480
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14MARGARET E. O’KANEFEBRUARY 28, 2008
THE WORLD’S SIX LARGEST ECONOMIES
GDP, BILLIONS, 2004
1
2
3
4
5
6
USA: $11,673
USA HEALTH ECONOMY: $1,905
GERMANY: $2,360
JAPAN: $3,788
UNITED KINGDOM: $1,881
FRANCE: $1,838
Sources: OECD Fact Book, 2006 US National Health Expenditures, 2004 (CMS, 8/06)
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15MARGARET E. O’KANEFEBRUARY 28, 2008
STATE ATTEMPTS AT REFORM UNDERMINED BY COST PRESSURE
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16MARGARET E. O’KANEFEBRUARY 28, 2008
TWO STEPS FORWARD, TWO STEPS BACK?
• Missouri• Texas • Tennessee• Maine
McDonough JE, Miller M, Barber C. A Progress Report On State Health Access Reform. Health Affairs 27, no. 2 (2008): w105-w115
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17MARGARET E. O’KANEFEBRUARY 28, 2008
LESSONS FROM CALIFORNIA’S P4P EFFORTS
• Regional variation reflects an uneven playing field– Population adjustments necessary; extends
beyond P4P to capitation strategies– Paying for achievement and improvement a
good start
• Aggregation of physicians does not necessarily equal integration
• Incentives for QI need to be clear• Affordability requires a more
comprehensive strategy
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18MARGARET E. O’KANEFEBRUARY 28, 2008
THE OPPORTUNITY IS HERE
• Rising costs lead to frustration among payers, consumers, providers
• Health care reform is at the top of the national agenda– Access is widely agreed-upon priority
• We have more clarity about the relationship between quality and costs
• Benchmarking has revealed high performers
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19MARGARET E. O’KANEFEBRUARY 28, 2008
P4P NEEDS TO BE PART OF A LARGER STRATEGY
• Comprehensive payment reform• Evidence-based benefit design• Evidence stewardship• Clinically accountable entities • Population health strategy
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20MARGARET E. O’KANEFEBRUARY 28, 2008
1. PAYMENT REFORM: TIE IT TO OUTCOMES
• Bundling of payments (e.g. capitation) desirable to allow integrated systems to gain from their efficiencies
• Performance benchmarking also plays an important role – Facilitates performance comparison– Transparency critical to trust– Allows differential rewarding for superior
care• Pathway out of Medicare Sustainable
Growth Rate
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21MARGARET E. O’KANEFEBRUARY 28, 2008
2. EVIDENCE-BASED BENEFIT DESIGN
• Cover what works• Cover what’s appropriate for this
patient• When in doubt, use coverage with
– Evidence development– Shared decision-making
• Don’t pay for avoidable errorsBenefit design can’t be an obstacle to effective care
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22MARGARET E. O’KANEFEBRUARY 28, 2008
3. EVIDENCE STEWARDSHIP
• We don’t have evidence to support much of the medical care we deliver
Current model:• Investigator-initiated research• Fragmented by specialty, organ
systems• Repetitive trials in some areas, no
evidence in others
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23MARGARET E. O’KANEFEBRUARY 28, 2008
CONFLICTS IN EVIDENCE • Data from ACCORD, ADVANCE trials leave
conflicting messages on tight HbA1c control
• ACCORD – Studied high-risk patients with diabetes– Very strict control targets (<6.0%)– Found excess mortality
• ADVANCE– Found no excess mortality among those with
strict control targets
• Needed: more targeted RCTs and study large population experience through learning networks
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24MARGARET E. O’KANEFEBRUARY 28, 2008
POOR EVIDENCE LEADS TO UNPROVEN TREATMENTS
• Bone marrow transplant/high dose chemotherapy for breast cancer– Deployed based on inadequate evidence– Trials in the 1990s showed conventional
therapy to be more effective– 30,000 women unnecessarily subjected
to ABMT/HDC– 600 died as a result of the treatment
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25MARGARET E. O’KANEFEBRUARY 28, 2008
4. CLINICALLY ACCOUNTABLE ENTITIES
• Medical Home:– Wellness– Complex pediatrics– Geriatrics– Cancer– HIV
• Coordinated group practice• Hospital-centered network• Other integrated, accountable
systems
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26MARGARET E. O’KANEFEBRUARY 28, 2008
ALTERNATIVE DELIVERY SYSTEMS AND ACCOUNTABLE MODELS
MedicalHome
SpecialtyCare
HospitalCare
AccountableClinical Entity
PCP
Specialists
Hospital
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27MARGARET E. O’KANEFEBRUARY 28, 2008
5. POPULATION HEALTH STRATEGY
• We need to treat our collective health as an asset and zealously protect it– Stepped-down accountability in the
delivery system– Issues go beyond health care– Tobacco is a model for non-healthcare
aspects
• Warning signs are there: growing numbers of uninsured, rising obesity rates
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28MARGARET E. O’KANEFEBRUARY 28, 2008
NEXT STEPS
• Affordable, quality universal coverage is the goal– Costs will overwhelm reform programs
that focus solely on access
• Leave room for “buy-up”• Public-private cooperation• Educating the public
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29MARGARET E. O’KANEFEBRUARY 28, 2008
“Where would you rather be than right here, right now?”
--Marv Levy Head Coach, Buffalo Bills (1986-
1997)
IT’S AN EXCITING TIME TO BE IN HEALTH CARE
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30MARGARET E. O’KANEFEBRUARY 28, 2008
DISCUSSION