1. Quality Measures: Background IOM 1999 “To Err is Human” (Rx related deaths); 2001 “Crossing the Quality Chasm” (“aims for 21 st century”) –gaps in quality of healthcare / disparities –cost of care  quality of care –incentives can change behavior –managed care / single payor experiences pharmacy risk / formulary adherence / restrictions utilization payment adjustments facilitated via electronic medical record (EMR) –“Pay for Performance” (P4P) > 100 private P4P programs in USA

2. California P4P Measures Clinical Domain (50%) (Quality + Efficiency) –HEDIS (Health Plan Employer Data and Information Set) Indicators (years 1 and 2) –Measurement of Control (year 3+) Patient Experience Domain (30%) –Timeliness/Access –Coordination –Overall Rating Information Technology Investment (20%) Bonus Opportunity (10%) –Feedback Provided at Individual Provider Level

3. Clinical Domain Evolution-Examples Earlier Years –Hgb A1C Screening –LDL Screening –Breast Cancer Screening –Cervical Cancer Screening Later Years –HgbA1C Control –LDL Control –Nephropathy Control in Diabetes –Appropriate Treatment of Children with URIs –Chlamydia Screening of Young Women Problem: bad patients (non-compliant, comorbidity etc.) = “bad quality care”

4. P4P in USA: Current and Future Multiple Variations Currently CMS Setting Expectations and Standards –Voluntary Ambulatory Indicators (voluntary for now!!!) –Evidence-Based –Chosen By Consensus –Major Medical Societies Represented Expect All Payers Will Follow All Indicators Will Be Within CMS Universe Driver of Healthcare IT Higher Quality Will Become the Expectation P4P May Yield to Minimum Quality Thresholds P4P Reimbursement May Not Be Upside –Poor Performers =Lower Reimbursement

5. Quality: The Players in the USA Centers for Medicare and Medicaid Services (CMS): www.cms.hhs.gov/quality/pfqi.asp. Physician Focused Quality Initiative (PFQI). Physician Voluntary Reporting System (PVRS). Doctor’s Office Quality (DOQ) project. www.cms.hhs.gov/quality/pfqi.asp American Medical Association (AMA): www.ama- assn.org/ama/pub/category/2946.html. Physician Consortium for Performance Improvement (PCPI). Major source of material for NQF, AQAwww.ama- assn.org/ama/pub/category/2946.html Ambulatory Quality Alliance (AQA): www.ambulatoryqualityalliance.org Started in 2004 by America’s Health Insurance Plans, AAFP, ACP, and Agency for Healthcare Research and Quality (AHRQ). Leader in selecting performance measures for physician practices (26 as of 5/06).www.ambulatoryqualityalliance.org National Committee for Quality Assurance (NCQA): www.ncqa.org A supplier of performance measurements, especially for managed care. Invited ACR et al to participate in back pain measures.www.ncqa.org National Quality Forum (NQF): www.qualityforum.org Non-profit group developing performance measureswww.qualityforum.org

6. It Ain’t Going Away Slide taken from UCSD Quality Council Presentation 4/5/06

7. QUALITY MEASURES “Quality” – a prerequisit for reimbursement Definition of “quality” Action points

8. Quality – a prerequisit for reimbursement Disease Management Programs Certified QM as pre- requisit for re- imbursement by German insurance companies (planned for the near future) –formal QM systems (KTQ®) –outcome-oriented systems (EFQM®)

9. Definition of “Quality” Provide EBM –Document disease severity using „approved“ measures What are these? –Document therapeutic choice Example: Germany –Document efficacy using „approved“ measures What are these? –Participate in registries!!!

10. Document therapeutic choice: the German way

13. ACTIONS “GRAPPA checklist on quality”?