1 Does NCQA Diabetes Recognition Impact Prevention Quality Indicator (PQI) Performance? American Public Health Association Joseph A. Stankaitis, MD, MPH Laura Weisbein, PhD Julian Allen, RN, MSN, MBA October 30, 2012

2 American Public Health Association The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose Presenter Disclosures Joseph A. Stankaitis, MD, MPH

3 Healthcare Services Organization Contracted Delivery System with Excellus BlueCross BlueShield to Provide Care in Finger Lakes and Southern Tier Regions for Enrollees in: - Medicaid Managed Care - Family Health Plus - Child Health Plus American Public Health Association Monroe Plan:

4 American Public Health Association NCQA Diabetes Recognition Program (DRP):

5 American Public Health Association Adult Prevention Quality Indicators (PQIs) Quantify Avoidable Events Through High-Quality Outpatient Care: Diabetes Related: Uncontrolled Diabetes Admission Diabetes Long-Term Complication Admission Diabetes Short-Term Complication Admission Lower Extremity Amputation Among Patients with Diabetes Other Conditions (Excluded Low Birth Weight): Adult Asthma Admission Angina Without Procedure Admission Bacterial Pneumonia Admission COPD Admission CHF Admission Dehydration Admission Hypertension Admission Perforated Appendix UTI Admission

6 Study Design: Monroe County (Rochester, NY) Comparison Groups - Physicians with NCQA DRP Recognition > 12 Months (n = 148) - Physicians Without NCQA DRP > 12 Months (n = 413) Compared Rates for 13 PQI Indicators Time Period One Year 2011 American Public Health Association

7 Findings: NCQA DRP Recognized Physicians: Overall PQI Rate 30.4% Lower Diabetes PQI Rate 54.5% Lower Non-Diabetes PQI Rate 20.3% Lower

8 American Public Health Association Pay for Performance ROI: NCQA DRP Recognized Physicians: Receive Diabetes Care Management Fee ($8.50/Diabetic Member/Month) Total Diabetes Care Management Fee Payment to DRP Recognized Physicians: $93,330 (915 Patients) Savings from Avoided PQIs: $188,453 ROI: Savings from Avoided PQIs Diabetes Care Management Fees = 2.02

9 American Public Health Association Conclusions/Implications: Physicians with NCQA DRP Recognition Appeared to Have Lower Rates for Preventable Quality Indicators Might be Due to Practice Improvement Activities Implemented to Achieve the Recognition Could Mean that Only High-Performing Physicians Apply for NCQA DRP Recognition We will be Examining Data from Previous Years to Further Investigate This Point There is a Potential ROI in Rewarding Physicians for Generating Cost Savings for Better care Delivery as Evidenced by Lower Rates of PQIs