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Task Force on Performance Assessment, Recognition, Reinforcement and Reward (PAR 3) Pennsylvania Chapter Meeting October 12-14, 2007 Janet Wright MD FACC.

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Presentation on theme: "Task Force on Performance Assessment, Recognition, Reinforcement and Reward (PAR 3) Pennsylvania Chapter Meeting October 12-14, 2007 Janet Wright MD FACC."— Presentation transcript:

1 Task Force on Performance Assessment, Recognition, Reinforcement and Reward (PAR 3) Pennsylvania Chapter Meeting October 12-14, 2007 Janet Wright MD FACC

2 PAR 3 What What Why Why Which Which How How When When Help Help

3 Define Care Standards Clinical Guidelines Define Care Standards Clinical Guidelines Define Data Standards Data Standards Define Data Standards Data Standards Develop Measures Performance Measures Develop Measures Performance Measures Appropriateness AC Appropriateness AC Measure Quality NCDR Measure Quality NCDR Improve Quality Take ACTION, D2B Improve Quality Take ACTION, D2B “… to foster optimal cardiovascular care and disease prevention through professional education, promotion of research, leadership in the development of standards and Guidelines and the formulation of health care policy.” Measurement and Improvement ACC Mission Statement

4 Par3 Goal Excellence in Performance Assessment: ‘beyond’ measurement Assessment: ‘beyond’ measurement Recognition: identification & acknowledgment Recognition: identification & acknowledgment Reinforcement: lower the hurdles, make case Reinforcement: lower the hurdles, make case Reward: heal the healer, restore trust, rational reimbursement Reward: heal the healer, restore trust, rational reimbursement Reporting: what to whom for what purpose Reporting: what to whom for what purpose

5 Performance Measurement Today

6 Par3: Forces at Work “Maturation” of Measurement

7 Par3: Forces at Work Technology Explosion “Maturation” of Measurement

8 Par3: Forces at Work “Maturation” of Measurement Technology Explosion CV Care Successes

9 Par3: Forces at Work “Maturation” of Measurement Rise of the Consumer Technology Explosion CV Care Successes

10 Par3: Forces at Work “Maturation” of Measurement Rise of the Consumer Technology Explosion CV Care Successes $$$$$$$$$$

11 Performance Assessment Attitudes Passive Passive Placid Placid Paranoid Paranoid P-----, uh, Livid P-----, uh, Livid Proactive Proactive Prepared Prepared

12 Par3: Composition Advocacy Quality Strategic Directions Education NCDR Informatics Medical Directors Institute Guidelines Perf Measures Data Stds Board of Governors CCAs Board of Trustees Approp Criteria Practice Administration Reps from SCAI, HRS, HFSA, ASNC Linkages: Physicians Consortium for Performance Improvement, AQA, NQF, NCQA, NBGH

13 What Do We Do? Formulate and recommend strategy Formulate and recommend strategy Monitor activities that may impact patient care and members’ practice Monitor activities that may impact patient care and members’ practice Influence the performance assessment process Influence the performance assessment process Inform and learn from members Inform and learn from members

14 Stat Stat Stat Stat 1. Principles for P4P Programs 2. Principles for Public Reporting on CV Physician Performance 3. Influence 2007 PQRI cardiology measure implementation 4. Educate members and provide toolkit for PQRI implementation

15 Urgent but Challenging Influence payer proposals for cardiologist recognition programs Influence payer proposals for cardiologist recognition programs Monitor the Patient-Centered Medical Home movement Monitor the Patient-Centered Medical Home movement Position: Public Reporting Position: Public Reporting Position: Comparative Effectiveness Position: Comparative Effectiveness What IS a quality cardiologist? What IS a quality cardiologist?

16 July 2007 Retreat Cardiologist Recognition Program: valid, feasible, actionable Cardiologist Recognition Program: valid, feasible, actionable Strategy for implementing PCPI performance measures Strategy for implementing PCPI performance measures Understand and influence efficiency measure development Understand and influence efficiency measure development Track the implementation of the Patient- centered Medical Home Track the implementation of the Patient- centered Medical Home

17 Work Groups CV Specialist Recognition Program CV Specialist Recognition Program PCPI Measures Implementation PCPI Measures Implementation Efficiency Measurement Efficiency Measurement Patient-Centered Medical Home Patient-Centered Medical Home Comparative Effectiveness in Health Care Comparative Effectiveness in Health Care

18 2008 Work Plan Medical Directors’ Institute, Oct Medical Directors’ Institute, Oct Par3 work groups form, November Par3 work groups form, November 2 nd Wednesday Webinars each quarter 2 nd Wednesday Webinars each quarter Quarterly Payer Roundtables Quarterly Payer Roundtables CVRP CVRP Efficiency Efficiency

19 PAR3 Members Kathleen Blake Robert Bonow Ralph Brindis John Brush Joseph Cacchione James Fasules Greg Dehmer Joseph Drozda Kim Eagle Paul Heidenreich Robert Hendel Jerry Kennett Harlan Krumholz Fred Masoudi Joseph Messer Chuck McKay Michael Mirro Michael O’Toole Jim Palazzo Eric Peterson Rita Redberg Andrea Russo Mark Sanz John Schaeffer Sidney Smith John Spertus John Strobeck Henry Ting Michael Valentine Bonnie Weiner Janet Wright Staff: Eileen Hagan, Kathleen Flood, Joel Harder (HRS), Patricia Upchurch (ASNC), Wayne Powell (SCAI)

20 Public Reporting Will enhanced transparency and accountability improve healthcare?

21 Public Reporting Bandwagon Employers: accelerate QI, steerage Employers: accelerate QI, steerage Hospitals: $, competitive advantage Hospitals: $, competitive advantage Health Plans: accelerate QI, tierage Health Plans: accelerate QI, tierage Consumers: “right to know, choose” Consumers: “right to know, choose”

22 Experience to Date Cardiac surgery Cardiac surgery HCFA HCFA NNECSG NNECSG STS STS Pa CABG, NY CSRS, MA Pa CABG, NY CSRS, MA CMS’ Hospital Compare CMS’ Hospital Compare Consumer Web Sites Consumer Web Sites

23 Guidance Mass Medical Society Mass Medical Society AQA Alliance AQA Alliance RAND RAND NCQA NCQA

24 Basic Principles Promote quality improvement Promote quality improvement Develop in partnership with physicians Develop in partnership with physicians Provide the evidence base for program Provide the evidence base for program PMs should be clinically relevant PMs should be clinically relevant Risk- and case mix- adjusted Risk- and case mix- adjusted Monitor for unintended consequences Monitor for unintended consequences

25 Basic Facts Assessment of individual MDs is in its infancy Assessment of individual MDs is in its infancy Claims data do not adequately represent care and cannot serve as the primary assessor of performance Claims data do not adequately represent care and cannot serve as the primary assessor of performance EHRs can provide valuable clinical data EHRs can provide valuable clinical data Poorly designed or executed PR programs can damage reputations, relationships, access to care Poorly designed or executed PR programs can damage reputations, relationships, access to care

26

27 ACC & Comparative Effectiveness Church:: State as CE research::coverage Church:: State as CE research::coverage Complex area requiring specific skill sets Complex area requiring specific skill sets High risk for unintended consequences High risk for unintended consequences Source of practical information for clinicians Source of practical information for clinicians

28 PCMH: result of 2yr policy review Data on rising costs of care, gaps/variations Data on rising costs of care, gaps/variations Need to offer alternatives to the SGR Need to offer alternatives to the SGR P4P limitations & consequences P4P limitations & consequences Workforce trends showing a marked decline in physicians going into general & primary care Workforce trends showing a marked decline in physicians going into general & primary care Increase in patients with chronic diseases Increase in patients with chronic diseases Evidence that care coordinated by a personal physician is associated with better outcomes Evidence that care coordinated by a personal physician is associated with better outcomes Purchasers’ demands for accountability and transparency Purchasers’ demands for accountability and transparency

29 Principles of the Patient-Centered Medical Home Personal physician Personal physician Physician directed medical practice Physician directed medical practice Whole person orientation Whole person orientation Care is coordinated and/or integrated Care is coordinated and/or integrated Quality and safety Quality and safety Enhanced access to care Enhanced access to care Payment to support the PCMH Payment to support the PCMH

30 PCMH Practices… Organize the delivery of care for all patients Organize the delivery of care for all patients Use evidence-based medicine and clinical decision support tools Use evidence-based medicine and clinical decision support tools Coordinate care in partnership with patients and families Coordinate care in partnership with patients and families Provide enhanced and convenient access Provide enhanced and convenient access Identify and measure key quality indicators Identify and measure key quality indicators Use HIT to promote quality, safety & security Use HIT to promote quality, safety & security Provide feedback on performance & accept accountability for process improvement and outcomes Provide feedback on performance & accept accountability for process improvement and outcomes

31 PCMH Practice Facilitates Care… …to sub-specialists through better information sharing, coordinated transitions, and feedback …to sub-specialists through better information sharing, coordinated transitions, and feedback …for tests, procedures and hospitalization …for tests, procedures and hospitalization …by reducing redundant testing …by reducing redundant testing …through the appropriate application of EVM where such guidelines exist …through the appropriate application of EVM where such guidelines exist …via direct collaboration with DM entities or by providing such care support directly …via direct collaboration with DM entities or by providing such care support directly ….with HIT that supports population management, clinical decision support, and health information exchange ….with HIT that supports population management, clinical decision support, and health information exchange

32 PCMH-Not Defined by Specialty Any physician in a recognized practice who has the training and experience to provide first contact, continuous and comprehensive care could be the patient’s “personal physician” Any physician in a recognized practice who has the training and experience to provide first contact, continuous and comprehensive care could be the patient’s “personal physician” In some cases, the most qualified personal physician to take care of the “whole patient” will be a subspecialist or specialist In some cases, the most qualified personal physician to take care of the “whole patient” will be a subspecialist or specialist

33 AARP AARP AAFP AAFP AAP AAP ACP ACP AHQA AHQA AOA AOA Aurum Dx Aurum Dx Bridges to Excellence Bridges to Excellence The Center for Excellence in Primary Care The Center for Excellence in Primary Care The Center for Health Value Innovation The Center for Health Value Innovation CVS Caremark CVS Caremark Disease Management Association of America Disease Management Association of America eHealth Initiative eHealth Initiative The ERISA Industry Committee The ERISA Industry Committee Exelon Corp Exelon Corp Foundation for Informed Medical Decision Making Foundation for Informed Medical Decision Making General Motors General Motors HR Policy Association HR Policy Association IBM IBM McKesson Corporation McKesson Corporation NACHC NACHC Nat’l Business Group on Health Nat’l Business Group on Health Nat’l Business Coalition on Health Nat’l Business Coalition on Health Nat’l Coalition on Health Care Nat’l Coalition on Health Care NCQA NCQA National Retail Foundation National Retail Foundation Pacific Group on Health Pacific Group on Health Partners in Care Partners in Care The Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins The Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Walgreens Health Initiatives Walgreens Health Initiatives Wyeth Wyeth Xerox Xerox

34 Partnership with NCQA AAFP, AAP, ACP, AOA worked with NCQA to revise the 2006 Physician Practice Connections module to align with PCMH AAFP, AAP, ACP, AOA worked with NCQA to revise the 2006 Physician Practice Connections module to align with PCMH Evolving process Evolving process PPC-PCMH to be ready January 2008 PPC-PCMH to be ready January 2008 Current statistics on NCQA Physician recognition programs: Current statistics on NCQA Physician recognition programs: 3,335 PPC Recognized Physicians 3,335 PPC Recognized Physicians 2,873 Diabetes Module 2,873 Diabetes Module 1,092 Heart/Stroke 1,092 Heart/Stroke

35 Proposal: Hybrid Payment Structure Bundled, severity-adjusted, prospective care coordination fee to cover the following: Bundled, severity-adjusted, prospective care coordination fee to cover the following: the physician and non-physician clinical staff work required to manage care outside a face-to-face visit the physician and non-physician clinical staff work required to manage care outside a face-to-face visit the health information technology and system redesign incurred by the practice the health information technology and system redesign incurred by the practice Combined with per visit FFS payment Combined with per visit FFS payment Performance based bonus payments based on evidence based measures of care Performance based bonus payments based on evidence based measures of care Shared savings Shared savings

36 Other Demonstration Projects North Carolina Medicaid demonstration reports considerable savings North Carolina Medicaid demonstration reports considerable savings A Mercer analysis showed that an upfront $10.2 million investment for North Carolina Community Care operations in SFY04 saved $244 million in overall healthcare costs for the state. Similar results were found in 2005 and 2006 A Mercer analysis showed that an upfront $10.2 million investment for North Carolina Community Care operations in SFY04 saved $244 million in overall healthcare costs for the state. Similar results were found in 2005 and 2006 Other potential demonstration projects Other potential demonstration projects Louisiana Louisiana New York New York Rhode Island Rhode Island Wyoming Wyoming Arizona Arizona Washington Washington

37 Key Questions to Explore How much does the PCMH cost? How much does the PCMH cost? How will the PCMH model affect referrals to subspecialty practices? How will the PCMH model affect referrals to subspecialty practices? Under what circumstances would/should subspecialty practices qualify as a PCMH? Under what circumstances would/should subspecialty practices qualify as a PCMH? How do patients transition from one PCMH to another? How do patients transition from one PCMH to another? How and what should information flow to/from the PCMH? How and what should information flow to/from the PCMH? How will the PCMH be funded? How will the PCMH be funded? What will the impact be on the primary care work force? What will the impact be on the primary care work force? What if a subspecialty practice provides some of the services characteristic of a PCMH but not all – or not for all patients? What if a subspecialty practice provides some of the services characteristic of a PCMH but not all – or not for all patients?

38 Opportunities Explore dynamics of primary care/subspecialty care interactions in an environment with medical homes Explore dynamics of primary care/subspecialty care interactions in an environment with medical homes Collaboration with health systems, disease management companies Collaboration with health systems, disease management companies Development of virtual “teams” Development of virtual “teams” Support for small medical offices to facilitate transformation of practices – QIOs, others Support for small medical offices to facilitate transformation of practices – QIOs, others Implementation/testing of information technology & health information exchange Implementation/testing of information technology & health information exchange Research Research

39 Conclusions PCMH concept has garnered considerable attention and support PCMH concept has garnered considerable attention and support Evidence supports the hypothesis that this model can improve health care in the U.S. Evidence supports the hypothesis that this model can improve health care in the U.S. Tests of the PCMH model are being developed Tests of the PCMH model are being developed Uncertain whether model will prove attractive enough to drive more medical students into primary care Uncertain whether model will prove attractive enough to drive more medical students into primary care Reimbursement methodology needs to be defined and tested Reimbursement methodology needs to be defined and tested Critical operational issues need to be explored and described Critical operational issues need to be explored and described

40 PAR3 Take-Aways Measurement is here to stay Measurement is here to stay Your ability to practice will be impacted Your ability to practice will be impacted Your professional society is working with others to influence, analyze, push back Your professional society is working with others to influence, analyze, push back This process is iterative and will only work This process is iterative and will only work -to protect patients and to improve quality- if you are aware, engaged, prepared

41 Medical Directors’ Institute 2007 Partnerships for Transformation: Systematic Assessment, Recognition, and Reporting Identify gaps in performance assessment, recognition, and reporting Develop collaborative recommendations for improvements that can be implemented in ‘09 October 24-25, 2007 in Phoenix


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