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Performance Data Reporting: Impact on Primary Care Practices. Philip D. Sloane, MD, MPH, Jacquie Halladay, MD, MPH, Sally Stearns, PhD, Thomas Wroth, MD, MPH, Paul Bray, MA, Lynn Spragens, MBA, & Sheryl Zimmerman, PhD

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Performance data reporting impact on primary care practices

Performance Data Reporting: Impact on Primary Care Practices

Philip D. Sloane, MD, MPH,

Jacquie Halladay, MD, MPH, Sally Stearns, PhD,

Thomas Wroth, MD, MPH, Paul Bray, MA,

Lynn Spragens, MBA, & Sheryl Zimmerman, PhD

From the North Carolina Network Consortium and the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill

Funded by the US Agency for HealthCare Research and Quality (AHRQ)


Disclosure
Disclosure Practices

  • I have no relationships to disclose, and

  • I will not discuss off label or investigational use in my presentation


Background
Background Practices

  • 2006 AHRQ publication: barriers and challenges to collecting and reporting healthcare data

  • Barriers Identified:

    • Data system inefficiencies of data systems

    • Variation in indicators

    • Technological barriers

    • Competing priorities

    • Economic pressures

    • Organizational and cultural issues.


Objectives
Objectives Practices

  • Detail the costs of implementation and maintenance of performance data reporting

  • Gather information on how practices successfully overcome challenges to data reporting.


Programs evaluated
Programs Evaluated Practices

  • Physician Quality Reporting Initiative (PQRI)

  • Bridges to Excellence

  • Improving Performance in Practice (IPIP)

  • Community Care of North Carolina (CCNC)


PQRI Practices

  • Medicare’s reporting program.

  • 74 quality measures (practices can choose).

  • “G” codes are added to billing submissions.

  • Must have 80% of cases reported on three quality measures.

  • Incentive payment of < 1.5% of Medicare allowable.


Bridges to excellence
Bridges to Excellence Practices

  • Started in 2006 as a three-year pilot program by BC/BS.

  • Incentive: $$, based on achieving quality thresholds and # of patients with BCBS insurance.

  • Two programs studied:

    • Diabetes Care: HbA1c, BP, LDL, Eye exams, Foot exams, Nephropathy assessments, smoking status/cessation.

    • Physician Office Connections: Office systems and processes such as electronic prescribing, referral tracking, performance reporting (9 items total).


Improving performance in practice ipip
Improving Performance in Practice (IPIP) Practices

  • State-based, nationally led QI initiative

  • Pilots in CO and NC.

  • Uses quality improvement coaches (QICs) who go into physicians’ offices and work with the practice on improvement efforts, including:

    • Data system assistance

    • Decision support and protocol development

    • Office team involvement in quality improvement and measurement


Community care of north carolina ccnc
Community Care of North Carolina (CCNC) Practices

  • Statewide system of 14 regional Medicaid care networks

    • Each has a program director, medical director, steering committee, case managers

  • Attention to chronic diseases (mainly diabetes and asthma)

  • Guideline dissemination & case management

  • Yearly statewide audits and reports with comparison data to local practices



Quality data reporting programs represented
Quality Data Reporting Programs Represented Participation

Of the 8 practices in the COMP project, 4 participated in PQRI, 3 in IPIP, 2 in BTE-Diabetes, 1 in BTE- PPC, 1 in a chronic disease collaborative


Conditions evaluated
Conditions Evaluated Participation


Medical data systems
Medical Data Systems Participation


Study methodology
Study Methodology Participation

  • Intensive site visits by economist, QI specialist & qualitative researcher

  • Meticulous detailing of costs (see next slide)

  • Interviews with:

    • quality champion,

    • care providers,

    • other practice staff

  • Quantitative and qualitative analyses


Cost categories 1

Total Resource Costs Participation

  • Costs to Practice

  • Total rather than marginal costs

  • Cost to QI program

  • In-practice only

Cost Categories - 1


Cost categories 2
Cost Categories - 2 Participation

Total Practice Costs

Staff Time:

Measure-Specific

(eye exam referrals, HbA1c)

Supplies, Equipment,

Application Fees

Staff Time:

Non-measure Specific

(data entry, meetings)

Cost Categories - 2


Cost phases

Total Practice Costs Participation

Start-Up Phase

Maintenance Phase

Cost Phases





Average practice program costs per fte of ccnc ipip and pqri
Average Practice & Program Costs per FTE of CCNC*, IPIP**, and PQRI***

Maintenance Phase * 6 practices ** 3 practices *** 4 practices


Estimated costs and reimbursement for participation in b to e diabetes
Estimated Costs and Reimbursement for Participation in B to E Diabetes

Estimates are per provider FTE


Estimated costs and reimbursement for participation in b to e medical home
Estimated Costs and Reimbursement for Participation in B to E Medical Home

Estimates are per provider FTE


Lessons from qualitative interviews
Lessons from Qualitative Interviews E Medical Home

  • Methods:

    • Interviews with practice champion

    • Group interviews with practice staff

    • Medical director joined for lunch

    • Dedicated note taker present; case reports generated; research team reviewed for themes and lessons


Motivation to participate is a key to success
Motivation to Participate is a Key to Success E Medical Home

  • “Pay for performance seems inevitable, and we wanted to prepare our practice for it”

  • “If we are providing quality of care, we want to separate ourselves out and be recognized”


Leadership is crucial to getting started
Leadership is Crucial to Getting Started E Medical Home

  • Leaders with quality improvement experience and an interest in participation; staff who then get motivated

  • “The providers set the tone and empower the staff”


Three major logistical challenges
Three Major Logistical Challenges E Medical Home

  • Staff time and effort

    • "The clinicians and staff are being driven to a frazzle”

  • IT challenges

    • “I’m sure that the EHR vendor could develop a query to do this, if we paid them enough”

  • Difficulties changing physician behavior

    • “Once you start to measure quality, the first thing the providers do is question the measures”


Going through hoops to achieve data consistency
Going Through Hoops to Achieve Data Consistency E Medical Home

  • One practice had to train the physicians to record “feet” instead of “extremity”

  • Another had to create a report on smoking cessation counseling three times before it was in an acceptable format


Involving the team
Involving the Team E Medical Home

  • Practices reported difficulty finding enough time to review and act on quality data reports

  • “(The practice manager) presents the data in a fun way…she puts time into preparing it for you, in charts, so that we have clarity”

  • "Initially providers are burdened by a new reporting activity. But after a while it takes less effort because they figure out how to give it to nursing"


Perceived effects on productivity finances
Perceived Effects on Productivity & Finances E Medical Home

  • Slowed down productivity initially, but overall productivity increase over time

  • Positive: "Good income for good medicine"

  • Negative: “They are taking money out of my pocket"


Catalyst E Medical Home

Practice Precondi-

tions

Infrastructure Development

Sustainability

Program Initiation

Program Maturation

Infrastructure Development

1. Medical director support

2. Administrator support

3. Data entry & reporting resources

4. Staff meeting times

Preconditions

1. Exposure to QI

2. Leader with QI experience

3. Focus on quality > income

Sustainability

1. Tangible constructive change

2. Financial benefit

3. Enhanced practice reputation

4. Strategic partnerships that foster culture of quality

Catalysts

1. Committed leader or mandate

2. Collaborative atmosphere

3. Outside encouragement

Theoretical Model: Factors Involved in Developing and Maintaining Quality Assessment, Improvement, and Reporting in a Primary Care

External and Internal Barriers and Facilitators


Image
Image E Medical Home


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