Pay-for-performance as a Quality Driver The Quality Colloquium August 21, 2006 Francois de Brantes National Coordinator, Bridges To Excellence

Goals for today Understanding P4P Lessons from the field Understanding the value of measures

From upstream to mainstream No one called this P4P five years ago There are more than 100 programs currently CMS is hungry for more There’s a right way of doing it

The Bridges To Excellence way: use standard performance measures; provide physicians with clearly defined costs and benefits which helps them determine the value of participating; use independent third party organizations to measure the performance of the physicians; bring together lots of payers and purchasers to make rewards meaningful to physicians; encourage physicians to adopt better systems of care, including health information technology, to systematically improve the delivery of care.

Results from the field – the UK Average physician gross income increased by $40K Performance is good in many areas, but the targets were probably too low Gaming is easy to spot – 1% of practices excluded more than 15% of their patients from the performance measures, claiming some exception – but not endemic Socio-demographic factors have a limited impact on performance

Despite the high scores there is still significant variation NEJM, 7-27-2006

Results from the field – NY Multi-Specialty Physician owned and managed 1 of 3 prominent primary care groups in the region with 30 practice sites Started the BTE recognition process in 1Q2003, first recognition 2Q2005 11 Physician Office Link recognized practices (65 physicians) now, working on more Over $400,000 in rewards from BTE alone

Community Care Physicians results The Improvements: Identified for the 1st time their top three chronic conditions Created standards, protocols and programs to manage their patients within and across practices Launched 4 diabetes care improvement programs Population tracking and follow up, DM and case managers Developed Diabetic registry Conducted process audit Provided benchmarking data Developed interventions and implement Re-measured

Community Care Physicians results The Impact: Implemented EMR system – rolling on a practice every two weeks, with wireless access in all practice sites More than 40,000 patients now receive care at practices that have demonstrated improvement Systems mapped to evidenced based care guidelines Diabetics saw an average 1.5% decrease in A1c levels Savings in reduced staff, transcription, materials, overtime “If you want to effect clinical outcomes in patients you first have to make sure your structure and process are in place. This is an opportunity to utilize quality improvement strategies to enhance on going practice development.” Robert Fortini, PNP Clinical Operations Manager, Community Care Physicians

Not all measures are worth the same NEJM, 7-27-2006

The distribution of impact is Pareto-like High clinical value * high cost effectiveness Towers Perrin 2006

These 19 measures are the most valuable Towers Perrin 2006

www.bridgestoexcellence.org Francois.deBrantes@bridgestoexcellence.org