Case Studies in Quality Based Purchasing - PowerPoint PPT Presentation

Case Studies in Quality Based Purchasing

Meredith Rosenthal, Ph.D.

Acknowledgement: Financial support for this work was provided by the Agency for Healthcare Research and Quality.

• 4 case studies of QBP implementation
• Pay-for-performance and public reporting of quality information
• Cases selected to inform new entrants
• Lessons learned in implementation
• Key questions/issues for discussion

• Business and health coalition with multi-stakeholder involvement (150,000 lives)
• Quality measurement and reporting initiative for primary care and hospitals preceded pay-for-performance
• Primary care pay-for-performance extended to all practices in the state
• Hospital pay-for-performance pilot

• Funding: willing (not all) employers and health plans contributed to a fixed bonus pool ($400,000)
• Measures:
• Office system survey developed to assess capacity for patient management
• Administrative measures for appropriate screening, medication, prevention
• Practice-reported data for chronic care management and intermediate health outcomes (e.g., blood pressure control)
• Bonuses determined based on overall scores and number of patients

• Collaboration critical to successful launch: Coalition provided the ground for productive give and take between payers and providers; 14-member physician steering committee had substantial role in measure selection
• Leverage outside expertise: MHMC used a national expert to help develop useable report card; local academic resources also tapped; experts brought resources, legitimacy

• Prepaid health services plan in NY State serving 55,000 Medicaid and SCHIP enrollees
• Began pay-for-performance in 1999 with state payment rate increase using existing quality data from internal quality review; payments depend on ranking – everyone gets something
• Added specific programs using better data for preventive care, SSI needs assessment, diabetes care; payments are for every patient whose care meets guidelines (e.g. $300 for well-managed patient with diabetes)

• Phase in the program: use existing data, start small, garner interest/support; tackle harder (more meaningful) goals later
• Communicate frequently with providers: educate about program, provide assistance with tools for improvement (i.e., don’t assume building a technically nice program is enough)

• Department of Aging
• On-line tool for consumers and families to make quality-based choices
• Structure, measures of quality collecte by CMS, resident and family experiences
• Funding: initially through civil penalty pool; then fees assessed facilities annually
• State subsequently legislated nursing home pay-for-performance based on same measure sets

• Talk (listen) to consumers first!
• Seize the moment: market factors led to facilities being eager to undertake effort
• Collaborate with providers: facilities helped make way for legislation, working together increased trust, willingness to accept standards

• Statewide business coalition
• Hospital report card
• Collaboration with Colorado Hospital Association
• AHRQ IQI measures populate report card; Colorado Hospital Association statewide discharge data were used

• Identify a few champions: to gain the backing of the hospital association, support from within was built
• Rely on well-established measures: for provider acceptance, validated measure sets are best; AHRQ provides software to compute risk-adjusted quality measures
• Engage local employers: it is not obvious to all employers that they have a role to play in quality improvement

• Where is there most to gain from collaboration within a market (across payers, stakeholders)?
• Should public reporting come first? Or last?
• How do you build a case for transparency with providers?
• Where is the low-hanging fruit in this market: existing data? problems with known solutions (local models?)? Major quality deficits? Quality deficits that could result in total cost savings if fixed?
• What message works to convince employers, other purchasers that investment in quality based purchasing is worthwhile?
• Are there good (cheap? systematic?) ways of learning what information consumers want (and how they want it)?
• Is there a sustainable business model for collecting and publicly reporting quality and cost data?
• Is the need for collaboration and alignment of performance measurement and payment compatible with health plan competitive strategies?
• How can free-riding be minimized (some payers contribute to QBP efforts but others just reap the benefits)?