Barbara Epke, Vice President

1
Pay for Performance A Providers Perspective

• Barbara Epke, Vice President
• LifeBridge Health

Maryland HIMSS April 25, 2008
2
Origins of Pay for Performance
PI

• Not A New Concept Emerged In The 90s Through
  Private Payers And Provider Groups Across The US
• Focus Was Providing Financial Awards And
  Incentives For Achieving A Certain Level Of
  Performance On Established Quality Measures
• Concept Has Grown Programs Are High In Number
  Nationally
• CMS Involvement In Current Initiatives Will
  Further Advance And Secure The Concept
• HSCRC Quality Based Reimbursement Initiatives
  Will Serve To Advance The Concept In Maryland

3
National Snapshot

• Approximately 175 National and Regional Programs
• Medicare National Program and Demonstration
  Projects
• Medicare PQRI (Physician Quality Reporting
  Initiative)
• Medicaid Demonstrations
• Commercial Leapfrogs Hospital Rewards
• Programs Focused on
• Hospitals
• Physicians or Physician Groups
• Health Plans
• Consumers

4
Largest National Programs

• Medicares Hospital Quality Alliance
• Premiers 3-Year Demonstration Project 277
  Participants Nationwide -- Healthcare Quality
  Improvement Demonstration Project (HQID)
• Premier QUEST Second 3-Year Demonstration
  Project Participants of HQID
• Insurers and Large Employers Have Sponsored
  Programs

5
Why Pay for Performance? Why Now?
ERRORS

• IOM report of medical errors of almost 8 years
  ago changed the focus of quality performance
• Subsequent IOM reports focused on the need for
  technology and a more rapid implementation of
  performance improvement
• External drivers CMS, Business, Payers
• Valid measures available
• Rapidly Rising Health Care Costs
• Pace of improvement too slow
• Early evidence of effectiveness
• not clear if effectiveness is due to public
  nature of reporting or payment

6
HSCRC Pay for Performance Concept in MD

• Concept Crafted Via Steering Committee Beginning
  In 2003
• Vision Improved Quality Among All Maryland
  Hospitals To Include IT Development
• Financial Benefit Variety Of Approaches -- DRG
  Payment Update, Bonus, Of Inpatient Payment,
  Tiered Bonus, Variable Cost Sharing, IT And Other
  Incentives
• Non Financial Public Recognition, Public
  Reporting, H/T Technical Support, CME
• Belief That Incentive Is Enough To Drive Behavior
  Change

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And the Hospital Perspective Was

• HSCRC Initiative Sparked Interest in MD Hospitals
• Higher Level Quality in Maryland
• Focus In The Midst of Diverse Public Reporting
  Nationwide
• Assumed Linkage Between the MHCC Hospital Guide
  Public Reporting and HSCRC Initiative
• Primary Interest Was In Being A Part Of The
  Planning, Part Of The Process

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What is the Impact of Initiating P4P on Maryland
Hospital?

• Attainment and Maintenance of Results
• Resources Required to Conduct and Submit Review
  Data
• Technology IT and Automation
• Means and Method of Reporting Information to the
  Public
• Sustaining Results
• Clear Methodology

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Why an HSCRC Program?

• Congruent With HSCRC And Steering Committee
  Mission Align Financial Incentives With Safe,
  Effective, Efficient Quality Healthcare For
  Maryland Citizens
• Marylands Unique Rate-Setting Structure All
  Payers Distinctive Opportunity
• APR-DRGs Provide Risk Adjustment
• MD Hospitals Report Quality Data Now To MHCC
  JCAHO Ability To Piggyback

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Why HSCRC Program (cont)

• HSCRC Has Existing Provider Relationships
• Catalyst To Advance Maryland QI Activities
• Valid Measures Available And National Program
  Guidelines Emerging
• No One Best Program Model Opportunity For
  Innovative Maryland Program

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Differences in National vs. HSCRC Programs in 2004

• HSCRC
• Maryland Focused
• All Payers
• All Acute Hospitals
• HSCRC Mission
• APR DRGs
• Piggyback on Existing Data

• Other Programs
• National/Generic
• Single Payer
• Network Hospitals
• Contractually Driven
• Lack of Risk Adjustment
• New Data Demands

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And So the HSCRC Began the Process of Development

• 2003 Early Draft of Mission/Vision Statement
  for HSCRC Quality Initiative
• Improve The Quality Of Patient Care And
  Efficiency/Effectiveness Of Services By Providing
  Financial Support And Incentives
• 2004 HSCRC Steering Committee Report
• 2005 Initiation Work Group Formed (IWG)
• Academics, Hospitals, Payors, MHCC, DHMH, CPS as
  Contractor
• Focus On Measure Selection, Scoring
• No Discussion Of Payment Policy
• RFP For Consultant Results In Signing On Center
  For Performance Sciences (CPS), Vahe Kazandjian

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Source of Measures, Review of Existing PFP
Programs

• Review of CMS, Leapfrog, Joint Commission,
  Programs and Measures
• MHCC Hospital Guide Indicators
• National Quality Forum Consensus Measures
• AHRQ Inpatient and Prevention Quality
  Indicators, Safety Indicators

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Leapfrog Leaps

• Create A Culture Of Safety
• Procedures/Treatment That May Require Referral
  (Frequency)
• Assurance Of Adequate Level Of Nursing Care
• Intensive Care Staffing By MDs Certified In
  Critical Care Medicine
• Utilization Of CPOE (75 Med Orders)
• Use Of Standardized Abbreviations And Dose
  Designations
• Patient Care Summaries Not Completed From Memory

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JCAHO National Patient Safety Goals

• Patient Identification
• Communication Among Caregivers
• Medication Safety
• Healthcare-Associated Infections
• Reconciliation of Medications
• Patient Falls
• Flu and Pneumonia Immunization
• Surgical Fires
• Patient Involvement
• Pressure Ulcers
• Focused Risk Assessment (Suicide Home Fires)

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Hospitals Involved in the IWG Emphasized

• Transparency and
• NO Black Box Methodology

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And So the HSCRC and IWG Began the Process of
Indicator Choice

• Initial List Was Very Large And Included As
  Options Falls, Patient Perception (HCAHPS), UTIs
  In The ICU
• Outcome Measures Were Sought
• Initial Set Should Be Base For Future Additions
• Measures Should Focus On Areas Needing
  Improvement In Maryland

RESULT OF PROCESS Starter Indicator Set of 19
Measures
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Measures

• AMI -1 Aspirin at arrival
• AMI- 2 Aspirin prescribed at discharge
• AMI- 3 Angiotensin converting enzyme inhibitors
  (ACEI) or angiotensin receptor blockers (ARB) for
  left ventricular systolic dysfunction (LVSD)
• AMI- 4 Adult smoking cessation advice/counseling
• AMI- 5 Beta blocker prescribed at discharge
• AMI 6 Beta blocker at arrival
• PN -2 Pneumococcal vaccination
• PN- 3a Blood cultures performed within 24 hours
  prior to or 24 hours after hospital arrival for
  patients who were transferred or admitted to the
  ICU within 24 hours of hospital arrival
• PN - 3b Blood culture before first antibiotic
  Pneumonia
• PN- 4 Adult smoking cessation advice/counseling

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Measures (cont.)

• PN- 5b Pneumonia patients receive their first
  dose of antibiotics within 8 hours after arrival
  in the hospital
• PN- 7 Influenza vaccination
• HF- 1 Discharge instructions
• HF- 2 Left ventricular systolic dysfunction
  (LVSD) assessment
• HF- 3 ACEI or ARB for LVSD
• HF- 4 Adult smoking cessation advice/counseling
• SIP- 1 Prophylactic antibiotic received within
  one hour prior to surgical incision (by surgery
  type for 8 procedures.)
• SIP- 2 Prophylactic antibiotic selection for
  surgical patients (by surgery type for 8
  procedures.)
• SIP - 3 Prophylactic antibiotics discontinued
  within 24 hours after surgery end time (48 hours
  for CABG) (by surgery type for 8 procedures.)

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HSCRC Timetable for Key Events
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What Has Been in Progress Since Indicator
Selection?

• Center For Performance Sciences Vahe
  Kazandjian And Brandeis-Based Consultant Grant
  Ritter, Ph.D. Presented Methodologies To The IWG
• Appropriateness Model All Or Nothing Scoring,
  No Partial Credit For Indicators In A Disease
  Specific Domain
• Opportunity Model Assigns Partial Credit For
  Indicators In A Disease Specific Domain
• Opportunity Model With Topped Out Measures
  Includes Measures Such As Smoking Which Have
  Topped Out In Maryland

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And the Winner Is

• Opportunity Model Including Topped Out Measures
  For The First Phase Of The Initiative
• The Provider Opinion Of This Choice Is Positive

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Current HSCRC Activity

• Alpha Phase (FY07)
• Tests Subset Of Hospitals Feasibility
• Beta Phase (FY08)
• Statewide Test In Progress
• Hospital Consent For Data Use Needing Improvement
  In Maryland
• Key Dates
• FY 08 Year Baseline Data
• FY 09 Year Measurement Of Attainment/Improvement
  
• FY 10 Year - Payout

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Summary of HSCRC Recommendations

• 19 Indicators
• Include Topped Out Measures, Establish Thresholds
• Equal Weighting Of Indicators And Domains
• Report On Each Domain But Combine Scores Into A
  Single Index
• Opportunity Model
• No Peer Group Model
• Scores For Attainment And Improvement (Whichever
  Is Higher Determines Award)
• Lowest Number Of Patients (Per Indicator Per
  Year) 10
• Key Issues For Hospitals

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And the Provider Response

• Peer Grouping May Matter But Does Not Show As
  Statistically Significant With Starter Set
  Consider In Next Phase
• Attainment Vs. Improvement Is Perhaps The Most
  Key Issue For Hospitals
• Opportunity Model Is Fair

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HSCRC Key Plans

• Creation Of A Subgroup To Check Model Including
  Provider Reps
• Team To Determine Financial Model For Payouts
• Establish An Evaluation Work Group In Spring Of
  08 For Ongoing Evaluation And Research

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Looking to the Future

• Increased Use Of Automation For Indicator
  Selection, Data Gathering
• Inclusion Of Indicators That Focus On
• Outcomes
• Patient Perception
• Prevention/Education
• Infection
• Adverse Events
• Process Indicators ED TAT
• Disease States Diabetes
• Pressure Ulcers
• Falls
• Medication Safety
• Preventable Complications
• Have Been Discussed For Future Use

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Future of Quality-Based Reimbursement

• Focus on Quality and Efficiency
• Transparency on Pricing and Quality Data
• Research Needs Best Models, Impact on Quality
  and Costs and ROI
• Application of P4P to all Care Delivery Sites
• Emphasis on Outcomes, Episodes of Care
• HIT Essential to Efficient Data Collection