Medicare’s Physician Performance Agenda: Understanding Next Steps and Shaping the Future Course Debra Ness Co-Chair, Consumer-Purchaser Disclosure Project President, National Partnership for Women & Families Peter V. Lee Co-Chair, Consumer-Purchaser Disclosure Project CEO, Pacific Business Group on Health Overview and Key Issues Based on Invitational Working Session February 28, 2007

2 © Consumer-Purchaser Disclosure Project, 2007 Agenda For Meeting Welcome and Introductions –Debra Ness, Disclosure Project and NPWF Overview of Physician Measurement: Opportunities and Obstacles –Peter Lee, Disclosure Project and PBGH Shaping Medicare’s Physician Quality Reporting Initiative –Herb Kuhn, Acting Deputy Administrator for CMS –Tom Valuck, MD, Director of Special Program Office of Value- Based Purchasing for CMS Building for the Future: Moving to Administrative Sources and Electronic Health Records –Marc Overhage, MD, Indiana Health Information Exchange –David Bates, MD, Partners HealthCare System Advancing Medicare’s Physician Quality Reporting Initiative

3 © Consumer-Purchaser Disclosure Project, 2007 CMS’ Physician Quality Reporting Initiative (PQRI): Why Care? Foundation for providing information to consumers, physicians and to inform payment Directionally correct, but imperfect: will need a strong, united consumer/purchaser voice to offset physicians’ criticisms Key opportunity to shape near-term ( ) physician performance transparency Real money at play: $300 million estimated payout for 2007 PQRI program; $1.35 billion set aside for 2008

4 © Consumer-Purchaser Disclosure Project, 2007 Cost Pressures: Health Care/Earnings Disconnect

5 © Consumer-Purchaser Disclosure Project, 2007 Quality Shortfalls: Getting it Right 50% of the Time Adults receive about half of recommended care 54.9% = Overall care 54.9% = Preventive care 53.5% = Acute care 56.1% = Chronic care Not Getting the Right Care at the Right Time Source: McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp

6 © Consumer-Purchaser Disclosure Project, 2007 Each Point on This Graph Represents a Physician Which Ones Would You Prefer to See? Rattray MC, Andrianos J, Stam DT. Used with the permission of The Regence Group, Copyright All rights reserved. For full presentation on Efficiency Performance Measurement given at Electronic Data Discussion Forum, go to:

7 © Consumer-Purchaser Disclosure Project, 2007 Physician Information: Basics: Specialty Board Certification Hours/Contact Performance: Disease management Preventive Care Patient Experience Reporting Issues: Transparency of “Target Rate” Almost all look “above average” Combines practice site and individual physician results Physician Performance Information … The “Good”

8 © Consumer-Purchaser Disclosure Project, 2007 Physician Performance Information … The “Bad”

9 © Consumer-Purchaser Disclosure Project, 2007 Physician Performance Information … The “Ugly”

10 © Consumer-Purchaser Disclosure Project, 2007 PQRI is part of the “deal” between the AMA and Congress to fix the SGR

11 © Consumer-Purchaser Disclosure Project, 2007 What is PQRI? Prevented 5% cut in 2007 Medicare physician payment Allows for up to 1.5% bonus on all Medicare billings for eligible professionals Providers must report on at least 3 measures (or all if less than 3 available) for bonus out of total of 74 measures Confidential performance reports provided to participants For complete information go to:

12 © Consumer-Purchaser Disclosure Project, 2007 General Questions for Consideration How does PQRI relate to other existing initiatives (e.g., AQA and NQF measures, BQI’s, health plans, etc.)? How will performance results be shared and with whom? What are the next steps for moving physician performance transparency forward? What physician measures can be generated from claims? electronic health records?

13 © Consumer-Purchaser Disclosure Project, 2007 Future Directions from a Consumer and Purchaser Perspective Support more robust performance measures Required public disclosure Move from “pay to report” to “pay for performance” Move BEYOND pay-for-performance to broader payment reform ENGAGE – comments to CMS for PQRI; discuss with policymakers and key stakeholders

14 © Consumer-Purchaser Disclosure Project, 2007 Potential Consumer and Purchaser Input on 2008 and Beyond Expanded measures –Address full spectrum of care (safe, timely, effective, efficient, equitable, patient- centered) –Competency vs. standards of care –Cross-cutting measures that apply to all providers –Provide important information to consumers and purchasers Measure selection –Establishing criteria for provider self-selection –Increasing the number of measures required by CMS Measure collection –Move beyond claims to other electronic data (e.g., lab, pharmacy, EHR) –Providers need to be equipped to include CPT-II codes and g-codes on claims –Not all measures have developed CPT-II or g-codes Public reporting of provider-specific results Incentives –Link meaningful and significant payment to performance (move beyond reporting) –Increase the portion of funds allocated to performance-based payment over time to reach a substantial portion of Medicare payment

15 © Consumer-Purchaser Disclosure Project, 2007 The Consumer-Purchaser Disclosure Project is a coalition more than 50 of the nation’s leading consumer, labor, and employer organizations that are working to advance publicly reported, nationally standardized measures of clinical quality, efficiency, equity, and patient centeredness for health plans, hospitals, medical groups, physicians, other providers, and treatments. The Disclosure Project is supported by financial and in-kind support of participating organizations and by financial support from the Robert Wood Johnson Foundation. Previous Discussion Forums are available at: Using Electronic Data to Assess Physician Quality and Efficiency – September 29, 2006 Provider Payments: How They Work, Implications for Cost & Quality, and Creating a Consumer/Purchaser Policy Agenda – July 26, 2006 Cost/Price Transparency – May 25, 2006 About the Disclosure Project