Alyna Chien MD MS Marshall Chin MD MPH Andrew Davis MD

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Presentation transcript:

PROCEED WITH CAUTION performance incentive programs and racial disparities Alyna Chien MD MS Marshall Chin MD MPH Andrew Davis MD Lawrence Casalino MD PhD University of Chicago Pay-for-Performance Summit Beverly Hilton – February 15, 2007

Outline Background / Evidence Impact on racial disparities Leader perspectives on current programs (or at least not widening them) Recommendations

Performance incentive programs

Performance incentive programs Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes

Performance incentive programs Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes “Pay-for-performance”  cash

Performance incentive programs Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes “Pay-for-performance”  cash “Public reporting”  reputation

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

Desired effect of programs Quality “A rising tide lifts all boats.” JFK Time

Evidence for desired effect Significant Mixed None Fairbrother 1998 * Hibbard 2003 * Hickson 1987 * Kouides 1998 * Norton 1992 Pourat 2005 Beaulieu 2005 Clark 1995 Casalino 2003 McMenamin 2003 Rosenthal 2005 Grady 1997 Hillman 1998 * Hillman 1999 * Shen 2003 6 5 4 *Randomized design Dudley, AHRQ Technical Paper 2004; Peterson, Annals Int Med 2006

Unknown effect on disparities Quality ? Time

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

Quality improvement literature NEUTRAL NARROWING WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking Widens resource gaps / “rich get richer” ● National QI effort to:  hemodialysis dose  anemia management  nutritional status ● Depression ● Multi-state QI effort to:  depression care  depression severity  functional impairment

NEUTRAL NARROWING WIDENING

NEUTRAL NARROWING WIDENING

NEUTRAL NARROWING WIDENING

NEUTRAL NARROWING WIDENING

Unintended consequences

Evidence of desired effect Significant Mixed None Fairbrother 1998 * Hibbard 2003 * Hickson 1987 * Kouides 1998 * Norton 1992 Pourat 2005 Beaulieu 2005 Clark 1995 Casalino 2003 McMenamin 2003 Rosenthal 2005 Grady 1997 Hillman 1998 * Hillman 1999 * Shen 2003 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design Dudley, AHRQ Technical Paper 2004; Peterson, Annals Int Med 2006

Evidence of desired effect Significant Mixed None Fairbrother 1998 * Hibbard 2003 * Hickson 1987 * Kouides 1998 * Norton 1992 Pourat 2005 Beaulieu 2005 Clark 1995 Casalino 2003 McMenamin 2003 Rosenthal 2005 Grady 1997 Hillman 1998 * Hillman 1999 * Shen 2003 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design Dudley, AHRQ Technical Paper 2004; Peterson, Annals Int Med 2006

Evidence of desired effect Significant Mixed None Fairbrother 1998 * Hibbard 2003 * Hickson 1987 * Kouides 1998 * Norton 1992 Pourat 2005 Beaulieu 2005 Clark 1995 Casalino 2003 McMenamin 2003 Rosenthal 2005 Grady 1997 Hillman 1998 * Hillman 1999 * Shen 2003 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design Dudley, AHRQ Technical Paper 2004; Peterson, Annals Int Med 2006

Impact of incentive programs on racial disparities

Systematic review of MEDLINE® 536 “hits”  1 empirical study Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards 1991 New York publicly reported risk-adjusted CABG mortality rates Compared CABG rates Hispanics and African Americans vs Whites Before and after ‘report card’ instituted NY versus 12 comparison states 1966-March 2006 MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically Also evaluated: Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction Surgeon movement Patient transfers out-of-state Werner, Circulation 2005

Systematic review of MEDLINE® 536 “hits”  1 empirical study Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards 1991 New York publicly reported risk-adjusted CABG mortality rates Compared CABG rates Hispanics and African Americans vs Whites Before and after ‘report card’ instituted NY versus 12 comparison states 1966-March 2006 MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically Also evaluated: Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction Surgeon movement Patient transfers out-of-state Werner, Circulation 2005

Systematic review of MEDLINE® 536 “hits”  1 empirical study Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards 1991 New York publicly reported risk-adjusted CABG mortality rates Compared CABG rates Hispanics and African Americans vs Whites Before and after ‘report card’ instituted NY versus 12 comparison states 1966-March 2006 MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically Also evaluated: Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction Surgeon movement Patient transfers out-of-state Werner, Circulation 2005

1991 New York “CABG Report Cards” Werner, Circulation 2005

1991 New York “CABG Report Cards” Werner, Circulation 2005 0.7

1991 New York “CABG Report Cards” Werner, Circulation 2005 3.2 0.7

1991 New York “CABG Report Cards” Werner, Circulation 2005 3.2 0.7 2.7

1991 New York “CABG Report Cards” Werner, Circulation 2005 3.2 5.0 0.7 2.7

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not necessarily have the needs of racial & ethnic groups or disparities in mind Have features that may contribute to widening disparities

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not necessarily have the needs of racial & ethnic groups or disparities in mind Have features that may contribute to widening disparities

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not necessarily have the needs of racial & ethnic groups or disparities in mind Have features that may contribute to widening disparities

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not necessarily have the needs of racial & ethnic groups or disparities in mind Have features that may contribute to widening disparities

Leader Perspectives

Leader Perspectives NARROWING ? Measuring race and/or ethnicity ? Identifies minority sub-groups WIDENING ? Induces cherry-picking ? Widen resource gaps / “rich get richer”

Leader Perspectives NARROWING ? Measuring race and/or ethnicity ? Identifies minority sub-groups WIDENING ? Induces cherry-picking ? Widen resource gaps / “rich get richer”

Leader Perspectives Leaders from: 5 Nationally prominent PIPs 4 State Medicaid PIPs 6 Commercial health plan PIPs 15

Does/will your PIP: 4 / 15 Measure race/ethnicity NARROW DISPARITIES Leaders Responding “YES” Does/will your PIP: Measure race/ethnicity Identify sub-groups in need of more tailored programs 4 / 15

Does/will your PIP: 8 / 15 4 / 15 Measure race/ethnicity NARROW DISPARITIES Leaders Responding “YES” Does/will your PIP: Measure race/ethnicity Identify sub-groups in need of more tailored programs 8 / 15 4 / 15

Does/will your PIP: 8 / 15 4 / 15 Measure race/ethnicity NARROW DISPARITIES Leaders Responding “YES” Does/will your PIP: Measure race/ethnicity Identify sub-groups in need of more tailored programs 8 / 15 4 / 15

Does/will your PIP: 6 / 15 * Induce “cherry-picking” WIDEN DISPARITIES Leaders Responding “NO” Does/will your PIP: Induce “cherry-picking” Widen resource gaps / allow the “rich to get richer” while the “poor get poorer” 6 / 15 *

Does/will your PIP: 6 / 15 * 6 / 15 * Induce “cherry-picking” WIDEN DISPARITIES Leaders Responding “NO” Does/will your PIP: Induce “cherry-picking” Widen resource gaps / allow the “rich to get richer” while the “poor get poorer” 6 / 15 * 6 / 15 * *mainly State Medicaid PIPs

Does/will your PIP: 6 / 15 * 6 / 15 * Induce “cherry-picking” WIDEN DISPARITIES Leaders Responding “NO” Does/will your PIP: Induce “cherry-picking” Widen resource gaps / allow the “rich to get richer” while the “poor get poorer” 6 / 15 * 6 / 15 * *mainly State Medicaid PIPs

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not necessarily have the needs of racial & ethnic groups or disparities in mind Have features that may contribute to widening disparities

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not have disparities in mind Have features that may contribute to widening disparities

Summary Literature: Programs as currently designed: PIPs may not improve quality Quality improvement does not necessarily narrow disparities PIPs may widen racial/ethnic disparities Programs as currently designed: Do not have disparities in mind Have features that may widen disparities

Recommendations

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals #4 Make stratified comparisons ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals #4 Make stratified comparisons #5 Explore “disparity” measures ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency ● Risk adjustment ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals #4 Make stratified comparisons #5 Explore “disparity” measures ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency #6 Consider risk adjustment #7 Reward improvement ● Achievement ● Improvement ● Tournament

Recommendations Context: Payors: Payees: Incentivized Measures: ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: #1 Understand the patient/provider mix #2 Measure race and/or ethnicity #3 Decide “individual” versus “system” ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals #4 Make stratified comparisons #5 Explore “disparity” measures ● Clinical process/outcome ● Clinical access ● Patient satisfaction ● Use of formulary ● Administrative efficiency #6 Consider risk adjustment #7 Reward improvement ● Achievement ● Improvement ● Tournament

5841 S. Maryland Avenue – MC 6082, Chicago IL 60637 http://solvingdisparities.org Alyna T. Chien, MD MS 5841 S. Maryland Avenue – MC 6082, Chicago IL 60637 alyna_chien@yahoo.com 773-702-3874