Measuring to improve qualityJune 29, 2011

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This presentation will:Provide an overview of the provider profile

and pay-for-performance (P4P) process

Invite discussion on proposed measures and the P4P process for BHRS

Outline next steps after today

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What is a Provider ProfileData-oriented report to measure change at the

System and the Provider level

Intended to profile a Provider in our network on their performance on key quality measures

Include contextual data on who (e.g. demographic information) and how (e.g. length of stay) were served by said Provider

Iterative process: may include new measures each year and or higher targets

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What makes good performance measures?

Central to our Shared Mission

Important & Meaningful

Feasible to Capture

Accurate and Representative

Leads to Improved Performance

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What is Pay-for-PerformanceA payment model rewards providers for

meeting certain performance measures for quality and efficiency

Providers under this arrangement are usually rewarded for meeting pre-established targets for delivery of healthcare services

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How is Philadelphia affected by P4P?

HealthChoices Contract with State

PA Department of Public Welfare pay-for-performance So far, focused on inpatient psychiatric

hospitalizationReceived pay for 2008 performance 2009 performance probably will not as

our Inpatient Outcomes did not keep up with other Counties

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Purpose of Pay for Performance

Focus attention on desired quality processes & outcomes

Shared FocusWhat are the things DBH can do to improve

and what are things Providers can do?Develop Shared Clarity about the direction we

want to go

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Timeline (abbreviated) of development of provider profile• 2007 – Series of meetings with providers to

introduce concept & start discussion• 2008 – Preliminary data tabulations; internal

sharing of results• 2009 – Baseline reports on Inpatient

Psychiatric Services (April) and Children’s Residential Treatment (Dec)

• 2010 - 2nd series on IP & RTF; baseline report on D & A Residential Rehabilitation Services

• 2011 – Repeat others and Baseline for:• BHRS, TCM, CIRC, Host Homes

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Who gets a report?In-network providers

Providers serving at least 20 youthsIndividualized reportsNeed to discuss dose within the year before

expected improvement

Providers with fewer than 20 dischargesAll CBH providers combined report orLetter of Intent for Continuous Quality

Improvement? Similar to the OTIP process? Or Expanded Chart

Reviews?9

Types of Information in the Profiles• Quantitative Outcomes– Inpatient/CRC Visits/RTF rates, Follow-up rates,

AMA rates, etc. • Contextual– Length of Stay– Cost Summaries– Avg Units per Child per Level of Care

• Contractual Oversight– Compliance and Credentialing

• Qualitative Measures (being piloted)– Agency and Individual Service Reviews (chart

audits)10

All reports have:• Measures that compare to national and/or state

standards or to local norms

• Thresholds for assessing good, adequate and poor performance (green, yellow and red) based on national and/or state standards or local norms

• Comparison to overall CBH statistics

• Blinded comparisons to other providers

• Multi-year trends for selected (not all) measures

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How to use the reportsProvide you with comparison benchmarks

System as a whole and other providersRaise questions about care, expectations, and

generate research about differences Generate discussion about system wide

challengesHelp to determine P4P measuresFacilitate providers sharing information about

practices with each other after receiving reportsInform the credentialing process

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Purpose of Pay for Performance

Focus attention on desired quality processes & outcomes

Shared FocusWhat are the things DBH can do to improve

and what are things Providers can do?Develop Shared Clarity about the direction

we want to go?

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P4P MethodologyCriteria for being in P4P Pool each Year

◦ In Network Providers◦ Adequate sample size for measuring said

provider◦ Top 2/3 of Aggregated Scores

Unless all are meeting national standards then possibly consider all as qualifying

Scores/weights for each Measure used in P4P◦ Weighting for specific measure and to

population served – details available from CQI

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2011 performance pay will be based on 2010 FY data for BHRS• Measures from profiles used in all levels of

care P4P• Continuity of Care• Readmission or alternately Not Readmission• Compliance

• Measures used in some levels of care (not all)

• AMA• Quality of Care Concerns

• Measures not used include Complaints

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Sample of what CEO’s Received regarding D&A Residential Rehab P4P Scores

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Performance Dollars are:Proportional to Volume Served Proportional to Weighted Scores

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2010 Performance PayBased on their weights/scores (which are

based on how well they did in certain measures from the profiles), and how much services they had provided in 2009some providers received performance paysome providers did not receive performance

pay

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Profiles reported on 5 domains

System TransformationAccess and Service UtilizationQuality of CareCustomer ServiceContract Status

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1. System TransformationSuggestions for measure includes:

Peer Culture Development

Family Involvement

Recovery/Resilience Training

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2. Access and UtilizationWhat are we counting

Those servedUnits per Child per Level of careLength of Stay

Are membera having timely access?Do we have enough system capacity?Under and over utilization?

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Utilization measures

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3. Quality of CareMeasures in the section of CBH Provider

Profiles that focus on:SafetyClinical effectivenessConsumer-centered

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Measures in Quality of Care• How do we know that our members received

quality care? – Members are doing better

• How measured?– Not returning to same or higher level of care –

recidivism– Engagement in continuity of care – follow-up

care in a lower level of care– Provider closed to admissions

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Quality of Care (cont’d)Few DIRECT measures of quality of careWe need to assess for indicators of quality

care:◦ Documentation of specific desirable

(operationally defined) activities or events in client records (e.g. family meetings)

◦ Lack of undesirable events in client records or data sets (e.g. serious incidents, AMAs, restraints)

◦ Individual assessment tools (e.g. recovery tools, community participation scales).

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Comparison of Providers to CBH System as a whole

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Comparison to other providers – Adult Inpatient recidivism

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One example measure of Significant Incident

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Types of severe incidents

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4. Customer ServiceComplaints

“an issue, dispute, or objection presented by or on behalf of a member regarding a participating health care provider, or the coverage, operations or management policies of a managed care plan”

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Complaints: what we report• First-level complaints

– Number of complaints per provider– Type of complaint• E.g., consumer rights, treatment concerns

– Rate per 1000 authorized units of service

• Blinded comparison across providers– How rate per 1000 authorizations compare to

other providers in same level of care

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5. Contract StatusRate Increase HistoryProvider VolumeCompliance Status and Audit RateCredentialing HistoryRefusal to Admit (proposed)Failure to Notify CBH of Closure (proposed)

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Measurements to be reported by the categoriesPopulation/diagnostic cohorts

ASD, ID or otherSpecific Level of Care Groupings

STSCARESchool-based Wrap-aroundNon-school based Wrap-aroundGroup TSSMobile TherapyFamily Services

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Breakout Group 1: Clinical Review of Agency Infrastructure and Chart Reviews

• A break-out group to review and discuss• Proposed Self Audits and Cross-Validation

• What to do for small volume providers?• Letter of Intent: Plan for Quality Improvement

Processes regarding Practice Guidelines and measures that are included in the reports.• Similar to OTIP along with quantitative

measures..weigh quantitative measures less for these

• Additional chart reviews34

Breakout Group 2: Access and Delivery of ServiceAverage number of days between auth and

date of first claim for new auths that yearPaid to Auth Ratios to demonstrate delivery

of serviceBy 6-digit level of care

Staffing Ratio based upon census submissionLength of time between date of completion of

evaluation and date of submission to CBH Avg Number of Units per youth per level of

care35

Breakout Group 3: Transitioning from BHRS to high intensity services or failure to transition

% of (non ASD, non ID) youth receiving greater than 3 years of BHRS

% of (non ASD, non ID) youth >= 14 receiving BHRS

% of Children admitted to Inpatient, and CRC respectively Control for minimum dose: or two measures

those with higher auth/paid ratio’s and those with lower auth/paid ratio

Or Control by length of time with provider36

Breakout Group 3: Successful Completion, Transition to Family or Lower Levels of Care, positive Outcome% Transitioned to Family Level of Care

Family Based ServicesFamily Focused Behavioral HealthPHICAPSFFTOthers?

% Transitioned to any Outpatient Treatment% Listed as Successful Completion on Discharge

Summaries% of Children with Improvement in School

Attendance37

Breakout Group 4: (3 topics) Support of Evidenced Informed Evaluations, Interpretation of Quality, and Compliance

% Completion and Data Submission of ASEBA at Baseline and Follow-up

% Submission of Census% Submission of Discharge Summaries

Rate of Quality of Care ConcernsError Rates on Compliance

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Report Back by Groups

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Next StepsSummary to the WebsiteData and profile developmentDistribution of ReportsRecommendations for Pay for PerformancePay for Performance Weights and OutcomesPay Increase before 01/01/2012 for those

deemed as receiving P4P

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