Pay for Pay for Performance:Performance:

Choosing MeasuresChoosing Measures

Linda K. SheltonLinda K. Shelton

AVP, Product DevelopmentAVP, Product Development

PFP Boot Camp for Physicians and PFP Boot Camp for Physicians and Physician OrganizationsPhysician Organizations

February 2006February 2006

Overview

• Framework for quality measures• Use of medical evidence to develop

measures• Desirable attributes of measures• Examples of measures used for reports

and rewards

What is the Health CareSystem Supposed to Do?

A value-based health care system

20% of peoplegenerate

80% of costs

A: Move people from right to left—and keep them there

Healthy/Low Risk

At-Risk

HighRisk

ActiveDisease

Health care spending

Early Symptoms

Source: HealthPartners

Using Medical Evidence:Guidelines and Measures

• National, trusted sources – rate evidence and develop guidelines

• Guidelines--indicate what to do, based on the best evidence, to achieve the desired result

• Measures--indicate what result you have achieved (threshold, bands, absolute values)– Indicator – Fully developed measure

• The progression from evidence to fully developed measure is NOT assured

General Types of Measures

• Structure

• Process

• Outcomes

Desirable Attributes of Measures--NCQA

• Relevance• Scientific soundness• Feasibility• Level of specification and sampling required

related to use of measure and level of system measured

Desirable Attributes of Measures—Health Plans

• Based on evidence-based medicine• Target prevalent conditions• Relevant to practice for specialty/region• Focus on improvement opportunities• Communicate effectively to MD and patient

Source: Kathleen Curtin, from Conference on Benchmarking Physician Performance, NCQA/AHRQ, January 11, 2006

N C Q AB oard of D irec tors

fin al overs ig h t

M easu rem en tA d visory P an el

M A P

Tech n icalA d visory G rou p

TA G

F ield Testin gcon trac tu al

in tern al

N C Q A S taffflow of work

m easu re work -u p

P u b licC om m en t

d raftresp on se to com m m en ts

C P Msets p riorit ies

reviews p rop osals

S p ec ia l A d visoryC om m ittees

P h ys ic ianH ealth P lan

ID E A SV ariou s sou rces

An example of weighing the

evidence

Data collectionData collectionDefinition of

Implementation rules

Definition of Implementation

rulesConsensus ProcessConsensus Process Measure

Development

Measure Development

Data transmissionData transmission

VerificationVerification Data AnalysisData Analysis ReportingReporting MaintenanceMaintenance

Standardization needs for benchmarking

Some measures that can rely on administrative data

Chronic Disease• Asthma Med. Mgmt.• Antidep. Med. Mgmt. – Acute Phase• Antidep. Med. Mgmt. – Conti Phase• Follow-up After MH Hosp – 30 day• Follow-up After MH Hosp – 7 day• Beta Blocker After AMI – On Disch.• Beta Blocker After AMI – Persistent• Diabetes: LDL Screening• Diabetes: HbA1c Testing• Diabetes: Nephropathy Screening• ADHD: Initiation Visit• ADHD: Follow-up Visits• Osteoporosis Management Post

Fracture

Prevention• Cervical Cancer Screening• Breast Cancer Screening• Colorectal Cancer Screening• Glaucoma Screening• Chlamydia Screening

Medication monitoring• ACE Inhibitors• Anticonvulsants• Digoxin• Diuretics• Statins

Overuse• Children with Upper Respiratory

Infection• Pharyngitis Testing• Adults with Bronchitis• Imaging for Low Back Pain

NCQA Recognition Programs: Physicians’ data

• What measures included: Structure, process and outcomes of excellent care management

• Where they come from: partnership with leading national health organizations

• Who rewards recognized physicians: many health plans and Bridges to Excellence employers

• Who is recognized: over 3800 physicians nationally

Measures in NCQA Recognition Programs

OU

TC

OM

ES

(C

linic

al)

ST

RU

CT

UR

EP

RO

CE

SS

DPRP

BP controlled

LDL <100 and <130

HbA1c good control high

HbA1c poor control low

HSRP

DPRP: • eye exams• foot exams

• nephropathy testing

HSRP: • lipid profiles• anticoagulants

ALL: • smoking assessment and advice

PPC: • patients in registries • risk factors assessed• use of e-prescribing • patients with EMRs• e-results • reporting across practice

PPC: • electronic systems • test follow-up process• care management processes • patient education & support• e-reminders • case management

Tracking Improvement

Physicians Achieving Diabetes Physician Recognition Show Substantial Improvement In Key Clinical Measures

% of adult patients with

60

18

38

51

25

21

59

37

9

70

49

7

79

37

63

84

53

79

0 20 40 60 80 100

Monitoring for Nephropathy

Lipid Control (<100 mg dl)

Lipid Control (<130 mg dl)

BP < 140/90 mm Hg

Good HbA1c Control (<7.0%)

Poor HbA1c Control* (>9.5%)

200420001997

Diabetes Physician Recognition Program, average performance of applicants, 1997-2003 data.* Lower is better for this measure.

Physician Practice Connections (PPC)

• What it is: recognition for practices that use systematic processes and IT

• What it measures:– Access & communication– Registry functions– Care management– Patient self-management support– E-Prescribing– Test tracking and management– Referral tracking & management– Performance measurement & improvement– Interoperability

Patient – Care Team Interaction

● in person

● by telephone

● by e-mail

The Systematic Practice & PPC Standards

Systematic InputsSystematic Follow-up & Outcomes

2. Patient Tracking & Registries● patient’s demographic &

visit data● patient’s clinical data● population-based

reporting● identifying top conditions

3. Care Management● guidelines or protocols● team roles – internal &

external● pre-visit planning● clinician reminders (decision

support)● PHR and self-monitoring tools

● patient reminders● self-management resources

4. E-prescribing Information● safety (interactions)● efficiency (formulary)

5. Test Results History

6. Referral Results

2. Patient Tracking & Registries ● updated database

3. Care Management● further reminders &

contact● disease management &

case management● referrals to self

management resources● self-management

tools including PHR● updated care plans & goals

4. E-Prescribing, Checks for Safety & Efficiency

5. Test Follow-up across practice

6. Referral Follow-up across practice

7. Performance Measurement, Feedback & Reporting

8. Interoperability

1. Access & Scheduling

● open access

● care coordination

● 24/7 telephone

● web site

Access NCQA & BTE

• NCQA Web site www.ncqa.org• Diabetes Physician Recognition Program page

www.ncqa.org/dprp • Heart Stroke Recognition Program page

www.ncqa.org/hsrp• Physician Practice Connections page

www.ncqa.org/ppc • Recognized physicians:

www.ncqa.org/PhysicianQualityReports.htm• NCQA Customer Support (888) 275-7585