Purchasers’ Efforts to Promote Better Information Technology Peter V. Lee Pacific Business Group on Health The Health Information Technology Summit West March 7, 2005 Pacific Business Group on Health, 2005

Measuring Provider Quality and Cost-Efficiency to Improve Value SAVE LIVES, SAVE MONEY Adapted from Regence Blue Shield © Pacific Business Group on Health, 2005 Pacific Business Group on Health, 2005

Putting the Consumer in the Driver’s Seat Pacific Business Group on Health, 2005

PBGH Plan Evaluation Process eValue8 RFP has been implemented in local markets by employer coalitions and national purchasers Standardized health plan performance evaluation and quality improvement process Applicable to HMOs, POS, Medicare+ Choice and PPOs Provides a data repository of benchmarking data for nearly 400 health plans nationally via collaboration with Watson Wyatt

Evaluation Components: New Health IT Module Plan Profile Health Information Technology Consumer Engagement and Support Web-based consumer support tools Provider Management: Incentives and Rewards Accessibility of provider performance information Use and adoption of IT, including electronic medical records, CPOE Primary Prevention and Health Promotion Accessibility of clinical guidelines Integration of Health Risk Appraisal information Chronic Care Management (CAD, Diabetes, Asthma, Depression) Data integration for member identification and targeting Member “push” communications Practitioner support – care reminders Pharmacy Management Data integration Quality and safety Health Info Technology Detail: Plan HIT budget and resource allocation Community collaboration Compliance with data standards Provider support tools Administrative: Eligibility, benefits, claims look-up/processing Clinical: Referral, ordering of diagnostic services Electronic prescribing Member Support tools Provider selection Provider performance information Electronic personal health record Purchaser Support tools Plan administration Cost and utilization reports Incentives for HIT adoption Pay for Performance Performance measurement Ease of plan Web site use (CAHPS) Transaction timeliness and accuracy

NCQA Refreshing Accreditation – Quality Plus PBGH Breakthrough evaluation feedback Major portion of accreditation linked to process measures – many mandated through insurance regulators Current NCQA accreditation places more weight on HEDIS outcomes, but overall, inadequate for differentiating value New accreditation strategy Increase availability of comparable and actionable information among multiple plan types Focus on identifying value and efficiency Recognize effective strategies and tools for consumer engagement Distinguish efforts to measure provider performance and incent improvement Pacific Business Group on Health, 2005

Physician and Hospital Quality About Quality Plus Why? To strengthen NCQA’s position as the leader in health plan evaluation Quality Plus will keep NCQA’s accreditation programs responsive to the evolving needs and desires of employers and consumers What? Quality Plus consists of the following new programs and reports: New Accreditation Content and Reports (new content areas initially will be voluntary) Member Connection Health Improvement Physician and Hospital Quality New modules will incorporate measures of value New Report Chronic Care Report The Chronic Care Report features data from current accreditation surveys and HEDIS submissions Pacific Business Group on Health, 2005

Member Connection Intent: To assess the effectiveness of an organization as infomediary and provider of assistance to consumers WHAT NCQA WILL EVALUATE (working draft) Breadth, usability and quality of information, assistance with: Benefits (copays, deductibles) Pharmacy benefits/functions Health decisions Preparing for MD visit Decision Support Health Plan Mechanics ID cards Changing PCP Claims Handling HOW NCQA WILL EVALUATE CAHPS questions, such as: Ability to find and understand plan information Correct handling of claims HEDIS measures: Call answer timeliness Call abandonment Claims timeliness Performance standards for: Ease of use of website information, eg # of clicks Accuracy of website information Effectiveness of interactions with member services Sources: eValue8, HI Ethics, NCQA Provider Directory Project, requirements of benefits consultants Focus Groups with consumers to inform content Pacific Business Group on Health, 2005

health risks, chronic disease and severe cases Health Improvement Chronic Care Report provides 1st phase of information; To be supplemented by new content Intent: To measure the value of an organization’s management of populations’ health risks, chronic disease and severe cases WHAT WE’LL EVALUATE (working draft) Use of data to stratify risk levels of entire population Preventive and acute-care advice for all members Engagement of patients and practitioners in management of chronic conditions Promotion of self-management Personalized DM for higher utilizers with chronic-conditions Effective case management for complex cases HOW WE’LL EVALUATE HEDIS measures, such as: Comprehensive Diabetes Care Controlling High Blood Pressure Performance standards for: Use of evidence-based content Use of HRAs Functions of case managers Value measures for plans and DM vendors, such as: Appropriate medication management Readmission rates Sources: PBGH; American Healthways/Johns Hopkins paper; Value measures Pacific Business Group on Health, 2005

Physician and Hospital Quality Intent: To measure the effectiveness of an organization in identifying, measuring, rewarding high value providers, and steering consumers to them WHAT WE’LL EVALUATE (working draft) Provider Directories—completeness, usability, accuracy Hospital value information (move towards standardization) Physician value information (move towards standardization) Tools to help members identify value providers Incentives for high value providers Goal: Alignment with Leapfrog; large employer RFPs HOW WE’LL EVALUATE CAHPS questions such as: Ease of use of provider directory Ratings of providers Performance standards for: Quality of information in provider directory New metrics such as: PPSI* progress index, initially PPSI* complete measure in future Use of provider value measures developed by Value MAP Sources: Leapfrog,GE RFP, Provider Directory project *Leapfrog Provider Performance Sensitivity Index Pacific Business Group on Health, 2005

Hospital Choice Tools • Hospital quality linked to treatment choice information • Network, cost and quality information linked to tiered benefit design Member preference-based ranking: • Volume • Mortality • Complications • Length of Stay • Leapfrog • Cost • Patient Experience Pacific Business Group on Health, 2005

Why Pay for Performance? Shifts payment from toxic to performance-based Drives performance transparency & market rewards Promotes quality improvement & IT adoption Pacific Business Group on Health, 2005

California P4P—Key Stakeholder Roles Integrated Health Care Association The “neutral table” for plans, providers and consumers to design and administer program Health Plans Medical Groups Purchasers and Pacific Business Group on Health Early (1999/2000) promoter of pay for performance Representation on IHA program design committees Plan participation built into health plan performance guarantees Public and behind-the-scenes support during critical times Grant-funded technical development State of California Publishes consumer scorecard with results California HealthCare Foundation Funded technical development & program evaluation Pacific Business Group on Health, 2005

Performance Metrics—An Evolving Scorecard Clinical Quality (50% weighting) 10 HEDIS-based measures Reported with Administrative data Patient Experience (30% weighting) 5 measures ( i.e. access, specialty care, MD communication) Collected through common statewide CAHPS-like survey Investment and Adoption of IT (20% weighting) 2 Measures: point of care and population management Collected through web-based survey plus audit Clinical Measures (50% weight) Preventive Care Breast Cancer Screening Cervical Cancer Screening Childhood Immunizations Chlamydia Screening Acute Treatment for Upper Respiratory Infection in Children Chronic Disease Care Appropriate Meds for Persons with Asthma Diabetes: HbA1c Testing and Treatment Cholesterol Management: LDL Testing and Treatment Patient Experience (30% weight) Communication with doctor Care Coordination Specialty care Timely Access to care Overall ratings of care Pacific Business Group on Health, 2005

Information Technology (20% weight) Identify populations of patients needing care – integrates at least two electronic data sets at the patient level – e.g. encounters, lab results, pharmacy, inpatient or ER, radiology Provide physicians clinical decision support – delivers patient clinical information electronically to physician’s office – e.g. lab results, patients due for tests, electronic prescribing

Physician Incentive Bonus “Extra Credit” for instituting a program to measure physician performance on clinical and patient experience; provide regular feedback to those physicians and offer rewards based on performance

P4P First Year Results — Largest Program in Nation: 2004 Estimated $100 million in total paid to California physician groups for quality (includes all products and efficiency, e.g. including use of generics vs. brand) $50 million based on common P4P measures in 2004 Pacific Business Group on Health, 2005

Future Steps for P4P in California Reward year-to-year improvement Dramatically increase in number of clinical metrics (from 12 to 50) Increase in percentage of revenue devoted to performance-based pay Develop efficiency metrics Expand to other product lines: i.e. Medicare, PPO Pacific Business Group on Health, 2005