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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. Overview. 4 case studies of QBP implementation Pay-for-performance and public reporting of quality information

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case studies in quality based purchasing

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
maine health management coalition mhmc
Maine Health Management Coalition (MHMC)
  • 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
mhmc primary care pay for performance
MHMC Primary Care Pay-for-Performance
  • 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
key lessons learned
Key Lessons Learned
  • 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
hudson health plan
Hudson Health Plan
  • 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)
key lessons learned7
Key Lessons Learned
  • 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)
ohio long term care consumer guide
Ohio Long-Term Care Consumer Guide
  • 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
key lessons learned9
Key Lessons Learned
  • 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
colorado business group on health
Colorado Business Group on Health
  • 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
key lessons learned11
Key Lessons Learned
  • 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
questions issues to consider
Questions/Issues to Consider
  • 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)?