1. New York State Demonstration Grant Pay for Performance The New York Quality Alliance Performance & Measurement to Drive Quality of Care NY Chapter of the American College of Physicians and the Physician Alliance

2. Presentation Outline Health Care Quality: The Case for Change Health Care Quality: The Case for Change Pay for Performance as a Driver for Change Pay for Performance as a Driver for Change New York State Department of Health Demonstration Projects New York State Department of Health Demonstration Projects New York Quality Alliance (NYQA) New York Quality Alliance (NYQA) Physician Alliance (PA) Physician Alliance (PA) Chartered Value Exchanges: The Next Wave Chartered Value Exchanges: The Next Wave

3. Learning Objectives The physician will understand the extent of concerns about the quality, cost & availability of health care services in the US. The physician will understand the extent of concerns about the quality, cost & availability of health care services in the US. The physician will become familiar with national organizations addressing health care quality and learn about standards for development and use of performance (quality) measures; The physician will understand the potential benefits and limitations of performance measurement and pay-for- performance programs. The physician will become familiar with national organizations addressing health care quality and learn about standards for development and use of performance (quality) measures; The physician will understand the potential benefits and limitations of performance measurement and pay-for- performance programs. The physician will learn about the New York State Department of Health P4P projects and be able to define the terms New York Quality Alliance (NYQA) and the Physician Alliance (PA). The physician will learn about the New York State Department of Health P4P projects and be able to define the terms New York Quality Alliance (NYQA) and the Physician Alliance (PA). The physician will understand Chartered Value Exchanges and the four cornerstones of value driven health care. The physician will understand Chartered Value Exchanges and the four cornerstones of value driven health care. The physician will understand the specifics regarding the NYQA/PA and their role within the NYDOH Grant. The physician will understand the specifics regarding the NYQA/PA and their role within the NYDOH Grant. The physician will be educated regarding the 10 HEIDIS measures that will be utilized in the NYSDOH P4P Grant including their specifications. The physician will be educated regarding the 10 HEIDIS measures that will be utilized in the NYSDOH P4P Grant including their specifications. The physicians will be provided information regarding best practice guidelines for the selected measures including, where available, tools to facilitate provision of efficient effective care, complete documentation and accurate billing. The physicians will be provided information regarding best practice guidelines for the selected measures including, where available, tools to facilitate provision of efficient effective care, complete documentation and accurate billing.

4. The Need to Change

5. Why The Status Quo is Not Acceptable Costs continue to rise Costs continue to rise Over 47 million citizens are without insurance Over 47 million citizens are without insurance No clear association between spending and quality No clear association between spending and quality Perception that current payment methodologies are misaligned- pay the same for care regardless of the quality of care provided. Pay for Performance (performance based reimbursement) programs are designed to align incentives Perception that current payment methodologies are misaligned- pay the same for care regardless of the quality of care provided. Pay for Performance (performance based reimbursement) programs are designed to align incentives

6. The Needs Of The Uninsured Are Not Being Met Declines in health insurance coverage have been recorded in all but four years since 1994. 1994: 36.5 million nonelderly individuals were uninsured 2006: 46.5 million nonelderly individuals were uninsured In spite of substantial growth of the Medicaid population 83% of uninsured are from working families Additional cost of the uninsured: over $100 billion annually Worse health outcomes for the uninsured 25% increase in mortality Cancer diagnosed in later stages Use of ER for routine care Sources: Agency for Healthcare Quality and Research; American College of Physicians, Employee Benefit Research Institute

7. Source: CMS 2005: 16.0% 1929=4%

8. Source: Congressional Budget Office report, The Long-Term Outlook for Health Care Spending, Nov. 13, 2007

9. Health care outstrips inflation Source: Kaiser Family Foundation (2005)

12. Average 54.9% Source: McGlynn, et. al., The quality of health care delivered to adults in the United States, N Engl J Med 2003; 348:2635-45

13. National Health Care Spending 2005 $2 trillion ($6,697 per capita) Growth higher than inflation for decades 6.9% increase from 2004 16.0% of GDP Highest in the world Other developed countries: 8-12% 7 th largest economy in the world Medicare $408 billion Medicaid $291 billion Figures in actual dollars. Data from CMS

14. The Future Health Care spending in 2016 –$4.1 trillion –20% of GDP –Annual rate of increase 6.5-7.0% Estimate based on projection of current trends –Assumes: optimistic economic projections conservative spending projections no change in fundamental structure of the system Medicare will grow 7.5-9.0% annually Unknown cost of new technologies and standards of practice –Implantable defibrillators –Apo-A1 Milano –64-slice CT scanners for cardiac disease Data from CMS reported in Poisal, JA. et. al., Health Spending Projections Through 2015, Health Affairs web exclusive Feb 21, 2007

15. The Value Equation Are we currently getting value? –Medicare spending: 50% in the last year of life –Many studies: more Medicare spending does not prolong life, improve quality of life or result in higher quality of care –US ranks low vs. other countries in commonly accepted measures of health care quality and efficiency The New Vision

16. The Future is Here Clearly, the focus of the health care debate is moving toward demanding efficient and effective care and only paying when such care is provided. Quality measurement is embraced as fundamental to quality improvement and increasingly Pay for Performance is being investigated and implemented in multiple forms.

17. The Field of Quality Measurement & Reporting is Getting Crowded National Committee for Quality Assurance (NCQA) -- Founded 1990 to ensure quality of care to health plan members, develops Health Effectiveness Data Information Set (HEDIS) measures -- www.ncqa.org New York Quality Assurance Reporting Requirements (QARR) –NYS Department of Health (NYSDOH) collects QARR measures from all NY managed care plans health plans, based on HEDIS since 1996 –www.nyhealth.gov/health_care/managed_care/reports/ National Quality Forum (NQF) -- Created in 1999 to develop a national strategy for health care quality measurement and reporting. -- A not-for-profit, public-private, membership organization with broad participation from all sectors of the health care system including consumers -- www.qualityforum.org/about/www.qualityforum.org/about/

18. Quality Measurement & Reporting Institute of Medicine Reports –To Err is Human, 2000; www.iom.edu/?id=12735 –Crossing the Quality Chasm, 2001; www.iom.edu/?id=12736www.iom.edu/?id=12736 AMA Physician Consortium for Performance Improvement -- Established 2000 to develop performance measures for physicians from evidence-based clinical guidelines for select clinical conditions -- Broad representation from the “house of medicine” with AHRQ and the Center for Medicaid and Medicare Services (CMS) -- www.ama-assn.org/ama/pub/category/2946.html Hospital Quality Alliance (HQA) –Established 2002 to make information about hospital performance accessible to the public and to encouraging efforts to improve quality –www.hospitalqualityalliance.org; www.HospitalCompare.hhs.govwww.hospitalqualityalliance.orgwww.HospitalCompare.hhs.gov

19. Quality Measurement & Reporting AQA Alliance In 2004 medical specialty societies, insurance plans and the Agency for Healthcare Research and Quality (AHRQ), joined to determine how to most effectively and efficiently improve performance measurement, data aggregation, and reporting in the ambulatory care setting Originally known as the Ambulatory Care Quality Alliance www.aqaalliance.org/ Quality Alliance Steering Committee (QASC) Established in 2006 to develop an overall framework for the effective use of standard health care quality and cost measures nationwide www.brookings.edu/projects/qasc.aspx

20. Quality Measurement & Reporting Value Driven Health Care Initiative –Established 2006 by executive order –Four cornerstones: interoperable health information technology; measure and publish quality information; measure and publish price information; promote quality and efficiency of care. –Certified Value Exchanges (CVE): local and regional multi-stakeholder collaborative organizations working to improve quality and value in health care by measuring the performance of local health care providers and reporting these findings publicly. –NYQA designated one of 14 nationally recognized CVEs –www.hhs.gov/valuedriven/index.html –64-slice CT scanners for cardiac disease

21. Pay For Performance

22. Pay-for-performance programs are growing, but there is little evidence on their effectiveness or of their potential unintended consequences and effects on the patient- physician relationship. Pay-for-performance programs are growing, but there is little evidence on their effectiveness or of their potential unintended consequences and effects on the patient- physician relationship. Pay-for-performance has the potential to help improve the quality of care if it can be aligned with the goals of medical professionalism. Pay-for-performance has the potential to help improve the quality of care if it can be aligned with the goals of medical professionalism. Annals Int Med 2007;146:792-794

23. Pay – For -Performance “It is no longer enough to take good care of the patient in front of you. To improve results, we must find ways to help patients who do not come to the office regularly. Keeping track of all this data requires a whole new set of skills and resources; this is new work, it costs time and money and it has to be compensated.” Dr Janet (Jessie) Sullivan, Chief Medical Officer of Hudson Health Plan)

24. PROFESSIONAL ISSUES Pay-for-performance programs stir debate Ethics Forum. Nov. 6, 2006.

25. Examples of P4P Initiatives CMS CMS Hospital Core Measures Hospital Core Measures PQRI PQRI Ambulatory “Core Measures” Ambulatory “Core Measures” NY State NY State NYQA Grant and other similar pilots NYQA Grant and other similar pilots Commercial and Medicaid Health Plans in NY Commercial and Medicaid Health Plans in NY Purchaser/Employer Purchaser/Employer Bridges to Excellence Bridges to Excellence

26. Pay For Performance: Issues To Consider Measures Measures Data collection Data collection Data validation/reconciliation Data validation/reconciliation Reports Reports Impact on care and cost, desired and otherwise Impact on care and cost, desired and otherwise

27. Measures Ideal Measures Valid Valid Evidence based Evidence based Reliable Reliable Identify real differences in provider quality Identify real differences in provider quality Must be risk adjusted Must be risk adjusted Actionable Actionable Measure what is intended Measure what is intended No unintended consequences No unintended consequences Measures should be Feasible Measures should be Feasible

28. Types of Measures Types of Measures Process Process Outcomes Outcomes Structural Structural Data sources Data sources Administrative/claims and billing data Administrative/claims and billing data Medical Record Abstraction Medical Record Abstraction Electronic clinical data: EHR, registries, RHIOS Electronic clinical data: EHR, registries, RHIOS Hybrid combinations Hybrid combinations Data reconciliation Data reconciliation Opportunities to review and correct errors prior to publication Opportunities to review and correct errors prior to publication Discrepancies between data sources Discrepancies between data sources Missing Data Missing Data Transcription and coding errors Transcription and coding errors Measure Collection

29. Attribution issues Attribution issues Whose patient is it? Whose patient is it? Reports for group vs. individual Reports for group vs. individual Small numbers Small numbers Samples too small for valid conclusions Samples too small for valid conclusions Report timeliness Report timeliness Time for claims to be filed and processed Time for claims to be filed and processed Time for abstraction, aggregation, processing data Time for abstraction, aggregation, processing data Report actionable Report actionable Identified vs de-identified data Identified vs de-identified data Current but incomplete vs. complete but out-of-date Current but incomplete vs. complete but out-of-date Reports

30. Potential Benefits System Reduce costs and improve quality Reduce costs and improve quality underuse, overuse, misuse underuse, overuse, misusePhysician Economic Economic Quality of Care Quality of Care Preparing for the Future Preparing for the Future

31. Ethical Concerns Inequitable impact Inequitable impact Inefficient use of resources and tendency to focus on efficiency (cost) not other facets of quality Inefficient use of resources and tendency to focus on efficiency (cost) not other facets of quality Unreliable (therefore unfair) measures Unreliable (therefore unfair) measures Concern that Pay for performance is deprofessionalizing Concern that Pay for performance is deprofessionalizing Matthew Wynia, MD, MPH Institute for Ethics at the American Medical Association

32. Inequitable impact Physician Physician Large practices with HIT will win Large practices with HIT will win Those already doing well will win Those already doing well will win Patient Patient Non-adherent patients will be shunned Non-adherent patients will be shunned Minorities/elderly/immigrants will be shunned Minorities/elderly/immigrants will be shunned

33. P4P Aimed At Hitting Target Performance Level Might Be Counterproductive Quality P4P Target Organizations in this area will get the bonus with no additional work Organizations in this area have little hope of gaining the bonus Organizations in this area have an incentive to improve

34. Will the Vulnerable be Neglected? Some evidence from public reporting… Some evidence from public reporting… Pt transfers to Cleveland Clinic from NY increased 31% after public reporting on CABG, sicker patients more likely to be sent. (Omoigui 1996) Pt transfers to Cleveland Clinic from NY increased 31% after public reporting on CABG, sicker patients more likely to be sent. (Omoigui 1996) 59% of internists in PA say harder to find surgeon for high risk patients after public reporting (Schneider 1996) 59% of internists in PA say harder to find surgeon for high risk patients after public reporting (Schneider 1996) Such programs could also result in the de-selection of patients, “playing to the measures” rather than focusing on the patient as a whole…….. Such programs could also result in the de-selection of patients, “playing to the measures” rather than focusing on the patient as a whole…….. Annals Int Med 2007;146:792-794 Annals Int Med 2007;146:792-794

35. What do physicians say? “Dr. Brook correctly states that the use of physician- specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.” “Dr. Brook correctly states that the use of physician- specific outcome data would radically change how we practice medicine. Based on his system, I would assess each patient's risk. If it differed dramatically from the "sickness" scale that he proposes, I would consider asking the patient to seek care elsewhere.” Stephen Clement, MD, Annals of Intern Med 1994 Stephen Clement, MD, Annals of Intern Med 1994 “If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.” “If my pay depended on A1c values, I have 10-15 patients whom I would have to fire. The poor, unmotivated, obese and noncompliant would all have to find new physicians.” Physician in a 2006 survey on P4P Physician in a 2006 survey on P4P “39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent or questioned the physician’s decision-making.” “39% of physicians in this study were willing to discharge hypothetical patients who were nonadherent or questioned the physician’s decision-making.” Farber et al. JGIM 2007 Farber et al. JGIM 2007

36. Inefficient Use of Resources Documentation (rather than quality) improves Documentation (rather than quality) improves Inappropriate emphasis on what’s measured Inappropriate emphasis on what’s measured Little more $ for lots more work – not enough to offset costs of measurement Little more $ for lots more work – not enough to offset costs of measurement  “ Incentives based on a handful of measures of quality may encourage physicians to focus their efforts on improving quality in the areas targeted by the programs, neglecting other important aspects of care” (Epstein et al. 2004)

37. Unfair Measures: Reliability Importance of data aggregation Importance of data aggregation “The largest participating plan in the IHA program has about 1.4 million members, less than 23% of the entire 6.2 million population. Even a plan of this size using its own data often lacks sufficient sample size to allow for statistical reliability.” (Integrated Healthcare Association, 2006) “The largest participating plan in the IHA program has about 1.4 million members, less than 23% of the entire 6.2 million population. Even a plan of this size using its own data often lacks sufficient sample size to allow for statistical reliability.” (Integrated Healthcare Association, 2006)

38. Unfair Measures: Data Reliability Assigning responsibility (attribution) Assigning responsibility (attribution) Medicare beneficiaries see a median of 2 PCPs and 5 specialists working in 4 different practices per year Medicare beneficiaries see a median of 2 PCPs and 5 specialists working in 4 different practices per year 35% of patients’ visits are with their assigned physicians 35% of patients’ visits are with their assigned physicians 33% change PCP each year 33% change PCP each year A PCP’s “assigned” patients are only ~39% of the Medicare patients they see A PCP’s “assigned” patients are only ~39% of the Medicare patients they see (Pham et al. 2007)

39. Unfair Measures: Data Reliability Not enough patients per practice for reliable results year to year Not enough patients per practice for reliable results year to year Among 232 PCPs, 4% of the variance of their diabetic patients’ outcomes was attributable to physician practice patterns Among 232 PCPs, 4% of the variance of their diabetic patients’ outcomes was attributable to physician practice patterns Reliability of measures never better than 0.40 Reliability of measures never better than 0.40 Would need >100 diabetic patients to get reliability of 0.80 Would need >100 diabetic patients to get reliability of 0.80 Outliers could dramatically improve performance by dropping 1-3 patients Outliers could dramatically improve performance by dropping 1-3 patients Hofer 1999

40. Impact on the Profession of Medicine Doctors shouldn’t be motivated by greed… Doctors shouldn’t be motivated by greed… “…P4P programs insinuate that the existing moral and social incentives for providing excellent care are not sufficient – that financial incentives will succeed where the clinician’s professional character failed.” (Satin, 2006)i.e., If they work… it would be embarrassing. “…P4P programs insinuate that the existing moral and social incentives for providing excellent care are not sufficient – that financial incentives will succeed where the clinician’s professional character failed.” (Satin, 2006)i.e., If they work… it would be embarrassing. “Increasing external incentives reduces internal motivation… [so the worst problem with P4P would be] “if you ended up with a system where… doctors only did anything because they were paid for it and had lost their professional ethos.” Martin Rowland, NHS (Health Affairs interview, Sept 2006) “Increasing external incentives reduces internal motivation… [so the worst problem with P4P would be] “if you ended up with a system where… doctors only did anything because they were paid for it and had lost their professional ethos.” Martin Rowland, NHS (Health Affairs interview, Sept 2006)

41. A Possible Path to Take New York State Department of Health Demonstration Grant

42. New York State Demonstration P4P Grant The legislative intent of the demonstration project is to promote the development of pay-for performance programs, involving multiple payers that achieve increased quality and cost effectiveness. The legislation extended authority to the Commissioner of Health to: The legislation extended authority to the Commissioner of Health to: A. Convene a workgroup to delineate the ambulatory and inpatient measures of performance to be used in the demonstration programs; B. Oversee a grant program which will provide funding to purchaser and provider coalitions to establish regional pay-for- performance programs

43. The NYS DOH Commissioner’s Workgroup convened in July 2005. The workgroup consisted of representatives from managed care plans, hospitals, statewide and regional provider associations, payers, labor unions, and consumers. The NYS DOH Commissioner’s Workgroup convened in July 2005. The workgroup consisted of representatives from managed care plans, hospitals, statewide and regional provider associations, payers, labor unions, and consumers. Charged with seeking consensus on the inpatient and ambulatory measures to be included in the pay-for-performance demonstrations, the workgroup met on four occasions between July and December 2005. Charged with seeking consensus on the inpatient and ambulatory measures to be included in the pay-for-performance demonstrations, the workgroup met on four occasions between July and December 2005. In May 2006 DOH issued a RFP making $9.5 million available to support demonstration projects for a period of two years. In May 2006 DOH issued a RFP making $9.5 million available to support demonstration projects for a period of two years. The workgroup agreed to begin with administrative data, but acknowledged that this was just a first step and over the long run administrative data needed to be replaced with outcome data. The workgroup agreed to begin with administrative data, but acknowledged that this was just a first step and over the long run administrative data needed to be replaced with outcome data. The Process

44. To study and test incentive programs, including performance-based payments to physicians, hospitals and clinics that provide high-quality care to their patients. To study and test incentive programs, including performance-based payments to physicians, hospitals and clinics that provide high-quality care to their patients. The state funding will pay project costs and help fund rewards to providers. The state funding will pay project costs and help fund rewards to providers. Participating health plans will select the incentive structure they use, but typical incentives include bonuses or increases in reimbursement rates provided to physicians, hospitals and clinics based on their performance meeting various measures of quality. Participating health plans will select the incentive structure they use, but typical incentives include bonuses or increases in reimbursement rates provided to physicians, hospitals and clinics based on their performance meeting various measures of quality. Elements of The Demonstration Grant

45. The projects are part of the State Health Department’s efforts to encourage providers and insurers to work collaboratively to improve the quality of care that is delivered in New York State. The projects are part of the State Health Department’s efforts to encourage providers and insurers to work collaboratively to improve the quality of care that is delivered in New York State. State Health Commissioner Richard F. Daines, M.D. said: “Evidence-based care that improves patients’ ability to live healthier, productive lives is crucial to reforming our health care system and reducing health care costs. This is an area where the public and private sectors can work together to foster change.” State Health Commissioner Richard F. Daines, M.D. said: “Evidence-based care that improves patients’ ability to live healthier, productive lives is crucial to reforming our health care system and reducing health care costs. This is an area where the public and private sectors can work together to foster change.”

46. 1. Independent Health Association Inc. (Buffalo) 2. Taconic Health Information Network and Community Regional (THINC RHIO) in Hudson Valley Region) 3. Montefiore Medical Center (Bronx) 4. *New York Health Plan Association (NYHPA) This project is a statewide collaboration involving 12 health plans – Aetna, Affinity, CDPHP, Elderplan, GHI HMO, HealthNet, HealthNow, HIP, Hudson Health Plan, Independent Health Association, MVP, and Oxford. HPA will partner with physician, business and consumer groups, Capital District hospitals and RHIOs. This project is a statewide collaboration involving 12 health plans – Aetna, Affinity, CDPHP, Elderplan, GHI HMO, HealthNet, HealthNow, HIP, Hudson Health Plan, Independent Health Association, MVP, and Oxford. HPA will partner with physician, business and consumer groups, Capital District hospitals and RHIOs. The Four State Demonstration Projects

47. New York Health Plan Association (NYHPA) Demonstration Grant

48. NYHPA Demonstration Grant Overview Goal Goal Collaborators Collaborators Structure Structure Clinical Measures Clinical Measures Data Collection/Management/Validation Data Collection/Management/Validation Timelines Timelines Physician Reports Physician Reports Incentives Incentives

49. NYHPA Demonstration Grant Goals Project is to promote patient safety and quality of care through the development of pay-for- performance programs in New York State. Project is to promote patient safety and quality of care through the development of pay-for- performance programs in New York State. A two year demonstration Project. A two year demonstration Project. Brings all the stakeholders together Patients, Physicians and Health Plans, and consumer advocates. Brings all the stakeholders together Patients, Physicians and Health Plans, and consumer advocates. Develop policies and procedures for long lasting P4P programs in New York. Develop policies and procedures for long lasting P4P programs in New York. Develop a mechanism to have ongoing Dialogue with the Health Plans Develop a mechanism to have ongoing Dialogue with the Health Plans

50. Grant Elements  The New York State Health Plan Association through the grant has created the New York Quality Alliance (NYQA), which is a multi-stakeholder collaborative partnership that will guide the adoption and use of evidence based measures to: measure, report and drive improvements.  The reports generated under the guidance of NYQA will be used in pay for performance programs initiated by the Health Plans so that physicians will be financially rewarded that have good patient outcomes.

51. Grant Elements  Standardized set of measures for all participating Health Plans, so a physician collects one data set.  Establish one set of goals to reach a financial incentive (Because of anti-trust concerns, the amount of the financial incentives for each indicator will be established by the individual health plan.)  Data Collection will be administrative billing data.  Subcontract with NYACP to educate physicians regarding the Demonstration Grant and to support development of and staff the Physician Alliance

52. Clinical Measures The project will use tested and familiar HEDIS®/QARR measures; to simplify data collection only administrative (claims) data will be used. Preventive Care Domain (women’s services) Breast Care Screening Breast Care Screening Chlamydia Screening Chlamydia Screening Cervical Cancer Cervical Cancer Heart Disease Domain Persistence of Beta-blocker therapy post MI Persistence of Beta-blocker therapy post MI Diabetes Domain HbA1C Testing HbA1C Testing Lipid Measurement Lipid Measurement Urine Protein Screening Urine Protein Screening Eye Exam in Diabetics Eye Exam in Diabetics Appropriate Antibiotic Use (pediatric) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Testing for Children with Pharyngitis Appropriate Testing for Children with Pharyngitis

53. Time Line For NYDOH Grant 2007 will be the baseline year –a baseline report will be distributed toward the end of 2008. (Don’t wait until then to start!) 2007 will be the baseline year –a baseline report will be distributed toward the end of 2008. (Don’t wait until then to start!) 2008 will be the measurement year. That’s now, the clock is ticking. 2008 will be the measurement year. That’s now, the clock is ticking. The data collection will consist of health plan administrative data that will be supplemented with an adjusted medical record factor, such as the hybrid claims adjustment factor utilized by the Massachusetts's Health Quality Partner ( MHQP). The data collection will consist of health plan administrative data that will be supplemented with an adjusted medical record factor, such as the hybrid claims adjustment factor utilized by the Massachusetts's Health Quality Partner ( MHQP).

54. Grant Incentives Grant funding is available due to matching funds being provided by payers participating in the demonstration project and the DOH. Grant funding is available due to matching funds being provided by payers participating in the demonstration project and the DOH. The Health Plans have committed $8,740,968 in potential incentives. The Health Plans have committed $8,740,968 in potential incentives. The NYS Department of Health have awarded $1,379,278 in matching incentives. The NYS Department of Health have awarded $1,379,278 in matching incentives.

55. Grant Incentives All Plans will collect data on all 10 measures All plans will utilize the same report for determining performance payment The determination for achieving payment will vary from plan to plan

56. Bonus Payments Health plan specific payments are within the control of the plans due to ANTITRUST concerns

57. New York Quality Alliance multi-stakeholder collaborative partnership created within the Grant that will guide the adoption and use of evidence based measures to:  Measure  Report  Drive improvements.

58. NYQA Collaborators PROVIDER GROUPS NY Chapter of the American College of Physicians NY Chapter of the American College of Physicians NYS Academy of Family Physicians NYS Academy of Family Physicians Medical Society of the State of NY Medical Society of the State of NY NY Medical Group Mgmt. Association NY Medical Group Mgmt. Association Hudson Headwaters Health Network Hudson Headwaters Health Network Institute for Urban Family Health Institute for Urban Family Health Community Health Care Association of NYS Community Health Care Association of NYS CONSUMER GROUPS American Heart Association American Heart Association Niagara Health Quality Coalition Niagara Health Quality Coalition NY Diabetes Coalition NY Diabetes Coalition Center for Medical Consumers Center for Medical Consumers BUSINESS Business Council of NYS New York Business Group on Health HEALTH PLANS Aetna Affinity Health Plan CDPHP Elderplan GHI HMO Health Net HealthNow NY HIP of New York Hudson Health Plan Independent Health MVP Health Care Oxford Health Plans

59. NYQA Work Group Structure and Function A work in progress Workgroups Governance Governance Data Management Data Management Project Evaluation Project Evaluation Operations Operations Legal Legal Physician Alliance

60. NYQA Structure and Function Governance Workgroup Develop general operating rules for the NYQA Develop general operating rules for the NYQA Synthesize the materials and produce general operating principles until a formal structure is in place Synthesize the materials and produce general operating principles until a formal structure is in place Develop a mission statement and framework to allow the project to meet the grant deliverables and ensure an open and transparent process Develop a mission statement and framework to allow the project to meet the grant deliverables and ensure an open and transparent process Development of a permanent structure (i.e. bylaws, tax status) that will enable to NYQA to continue beyond the DOH grant funded component Development of a permanent structure (i.e. bylaws, tax status) that will enable to NYQA to continue beyond the DOH grant funded component

61. NYQA Structure and Function Data Management Workgroup Review the responses to the Request for Information from potential data mangers and assist in the selection of a NYQA project vendor Review the responses to the Request for Information from potential data mangers and assist in the selection of a NYQA project vendor Responsible for issues related to the data inputs and outputs as well as issues related to performance benchmarking, inpatient measurement and reporting for the AMI project component and development of a matching funds allocation methodology Responsible for issues related to the data inputs and outputs as well as issues related to performance benchmarking, inpatient measurement and reporting for the AMI project component and development of a matching funds allocation methodology

62. NYQA Structure and Function Project Evaluation Workgroup Develop the questions to be addressed to the project evaluator. Develop the questions to be addressed to the project evaluator. Develop the desired framework for the project evaluation and will work to define the deliverables from the evaluator that will form the contract. Develop the desired framework for the project evaluation and will work to define the deliverables from the evaluator that will form the contract. Monitor the evaluation progress and assist with the ongoing evaluation data collection and analysis. Monitor the evaluation progress and assist with the ongoing evaluation data collection and analysis.

63. NYQA Structure and Function Operations Workgroup Responsible for vetting project component issues, not addressed by the other workgroups that will need to be addressed by the voting members of the NYQA Responsible for vetting project component issues, not addressed by the other workgroups that will need to be addressed by the voting members of the NYQA Legal Workgroup Develop standard Business Associate Agreements and Data Use Agreements. Develop standard Business Associate Agreements and Data Use Agreements.

64. NYQA Physician Alliance Structure and Membership Structure and Membership Formed in 2007, the Physician Alliance, spearheaded by the New York Chapter of the American College of Physicians consists of a diverse geographically dispersed group of primary care physician organizations across New York State. Formed in 2007, the Physician Alliance, spearheaded by the New York Chapter of the American College of Physicians consists of a diverse geographically dispersed group of primary care physician organizations across New York State. The Alliance membership is composed of nine physician representatives from the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, New York Chapter American College of Physicians (Internal Medicine), the New York Chapter of the American Academy of Family Physicians and the Medical Society of the State of New York. The Alliance membership is composed of nine physician representatives from the American College of Obstetrics and Gynecology, the American Academy of Pediatrics, New York Chapter American College of Physicians (Internal Medicine), the New York Chapter of the American Academy of Family Physicians and the Medical Society of the State of New York.

65. NYQA Physician Alliance Goals of Physician Alliance Goals of Physician Alliance Short term, the PA is committed to working jointly with the NYQA to develop fair and reasonable practices of data collection and scoring standards for the P4P demonstration project, funded by New York State over the next two years. Short term, the PA is committed to working jointly with the NYQA to develop fair and reasonable practices of data collection and scoring standards for the P4P demonstration project, funded by New York State over the next two years. The long range goal of the PA will be to work with the NYQA and other entities to develop fair, reasonable and SUSTAINABLE policies and procedures for quality improvement truly impact patient care and safety in a cost effective fashion. The long range goal of the PA will be to work with the NYQA and other entities to develop fair, reasonable and SUSTAINABLE policies and procedures for quality improvement truly impact patient care and safety in a cost effective fashion.

66. NYQA Physician Alliance Responsibilities of Physician Alliance Responsibilities of Physician Alliance Define and promote the use of nationally recognized best practices for the 10 selected clinical measures adopted from the National Committee for Quality Assurance Health Plan Employer Data and Information Set (NCQA/ HEDIS®) that the health plans have all agreed upon to measure and report Define and promote the use of nationally recognized best practices for the 10 selected clinical measures adopted from the National Committee for Quality Assurance Health Plan Employer Data and Information Set (NCQA/ HEDIS®) that the health plans have all agreed upon to measure and report

67. NYQA Physician Alliance Responsibilities (CONTINUED) Responsibilities (CONTINUED) Develop the core curriculum for NYQA and with NYACP provide education for Primary care physicians. Develop the core curriculum for NYQA and with NYACP provide education for Primary care physicians. The core curriculum will include the description of the P4P Grant, NYQA and the PA, best practice materials and administrative specifications. The training will involve web-based materials, performance improvement tools and checklists that will allow practices the ability to evaluate themselves. The educational materials will be available on the web, CD and in traditional lectures modalities. The core curriculum will include the description of the P4P Grant, NYQA and the PA, best practice materials and administrative specifications. The training will involve web-based materials, performance improvement tools and checklists that will allow practices the ability to evaluate themselves. The educational materials will be available on the web, CD and in traditional lectures modalities.

68. NYQA Physician Alliance Responsibilities (CONTINUED Responsibilities (CONTINUED Represent clinicians interest in the development of the data collection methodology, measurement benchmarking, measurement reports and project evaluation; Represent clinicians interest in the development of the data collection methodology, measurement benchmarking, measurement reports and project evaluation; Provide input to the NYQA on proposed data collection methodology and aggregation standards; Provide input to the NYQA on proposed data collection methodology and aggregation standards; Provide input to the NYQA on the “adjustment factor” to be employed for selected HEDIS measures; Provide input to the NYQA on the “adjustment factor” to be employed for selected HEDIS measures; Identify process improvement activities, develop checklists to facilitate implementation of best practices and develop corrective action plans to assist clinicians with measurement improvement; Identify process improvement activities, develop checklists to facilitate implementation of best practices and develop corrective action plans to assist clinicians with measurement improvement;

69. NYQA Physician Alliance ■ Responsibilities (CONTINUED Work with the NYQA to develop fair, reasonable and sustainable policies and procedures for quality improvement designed to impact patient care and safety in a cost efficient fashion. Education to Improve coding/compliance so that the correct information can be obtained form billing data. Development of tools to document compliance Conduct 30 total presentations (10 hospital Grand Rounds and 20 conferences, meetings or other educational events).

70. Clinical Measures The project will use tested and familiar HEDIS®/QARR measures; to simplify data collection only administrative (claims) data will be used. Preventive Care Domain (women’s services) Breast Care Screening Breast Care Screening Chlamydia Screening Chlamydia Screening Cervical Cancer Cervical Cancer Heart Disease Domain Persistence of Beta-blocker therapy post MI Persistence of Beta-blocker therapy post MI Diabetes Domain HbA1C Testing HbA1C Testing Lipid Measurement Lipid Measurement Urine Protein Screening Urine Protein Screening Eye Exam in Diabetics Eye Exam in Diabetics Appropriate Antibiotic Use (pediatric) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Treatment for Children with Upper Respiratory Infection (URI) Appropriate Testing for Children with Pharyngitis Appropriate Testing for Children with Pharyngitis

71. Preventive Health ( Indicators for Women) Chlamydia screening Women 16–25 years as of December 31 of the measurement year who were identified as being sexually active and had at least one Chlamydia test Chlamydia screening Women 16–25 years as of December 31 of the measurement year who were identified as being sexually active and had at least one Chlamydia test Cervical Cancer Women 21–64 years of age who received one or more Pap tests to screen for cervical cancer as of December 31 of the measurement year. Cervical Cancer Women 21–64 years of age who received one or more Pap tests to screen for cervical cancer as of December 31 of the measurement year. Breast Care Screening Women 42–69 years as of December 31 of the measurement year who have had a mammogram to screen for breast cancer during the measurement year and the year prior to the measurement year Breast Care Screening Women 42–69 years as of December 31 of the measurement year who have had a mammogram to screen for breast cancer during the measurement year and the year prior to the measurement year

72. Indicators for Heart Disease Persistence of Beta-blocker Therapy After a Heart Attack Persistence of Beta-blocker Therapy After a Heart Attack The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction and who received persistent beta-blocker treatment for six months (180 days) after discharge as evidenced by pharmacy claims data (prescriptions filled.)

73. Indicators for Diabetes HbA1C Testing One A1C test as of December 31st of the reporting year evidenced by CPT code 83036 or 83037; or CPT Category II Code 3044F, 3045F, 3046F or 3047F; or LOINC code 4548-4, 4549-2 or 17856-6. HbA1C Testing One A1C test as of December 31st of the reporting year evidenced by CPT code 83036 or 83037; or CPT Category II Code 3044F, 3045F, 3046F or 3047F; or LOINC code 4548-4, 4549-2 or 17856-6. Lipid Measurement One LDL-C test as of December 31st of the reporting year as evidenced by CPT codes 80061,83700, 83701, 83704, 83716 0r 83721; or, CPT Category II code 3084F, 3049F or 3050F; or, LOINC 2089-1,12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1 or 39469-2. Lipid Measurement One LDL-C test as of December 31st of the reporting year as evidenced by CPT codes 80061,83700, 83701, 83704, 83716 0r 83721; or, CPT Category II code 3084F, 3049F or 3050F; or, LOINC 2089-1,12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1 or 39469-2. Nephropathy Screening One nephropathy (microalbumin) test as of December 31st of the reporting year as evidenced by listed CPT, CPT Cat II, or LOINC codes; or, evidence of nephropathy indicated by a positive macroalbumin test confirmed by automated laboratory result data; or evidence of ACE inhibitor/ARB treatment or treatment for nephropathy indicated by listed CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG codes. Nephropathy Screening One nephropathy (microalbumin) test as of December 31st of the reporting year as evidenced by listed CPT, CPT Cat II, or LOINC codes; or, evidence of nephropathy indicated by a positive macroalbumin test confirmed by automated laboratory result data; or evidence of ACE inhibitor/ARB treatment or treatment for nephropathy indicated by listed CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG codes. Eye Exam in Diabetics A retinal or dilated eye exam by an eye care professional as of December 31st of the reporting year or a negative retinal exam by an eye care professional in the prior year. Eye Exam in Diabetics A retinal or dilated eye exam by an eye care professional as of December 31st of the reporting year or a negative retinal exam by an eye care professional in the prior year. (For members aged 18-75 identified with diabetes based on an encounter during the measurement year with either ICD-9 diagnosis codes: 250.xx, 357.2, 362.0x, 366.41, 648.0x; or DRG 294,295)

74. Indicators for Children  Appropriate Treatment for Children with Upper Respiratory Infection (URI) The percentage of children 3 months – 18 years of age who had an encounter with a diagnosis of acute upper respiratory infection (ICD9-CM code 460 or 465) and who were not dispensed an antibiotic for the episode. Children with a listed competing diagnosis or who received antibiotics in the prior 30 days are excluded. Appropriate Testing for Children with Pharyngitis Percentage of children 2-18 years of age who had an encounter with only a diagnosis of pharyngitis (ICD-9-CM codes 462, 463 or 034.0), who were dispensed an antibiotic and who received a group A streptococcus test for the episode evidenced by listed CPT or LOINC codes. Children who received antibiotics in the prior 30 days are excluded. Appropriate Testing for Children with Pharyngitis Percentage of children 2-18 years of age who had an encounter with only a diagnosis of pharyngitis (ICD-9-CM codes 462, 463 or 034.0), who were dispensed an antibiotic and who received a group A streptococcus test for the episode evidenced by listed CPT or LOINC codes. Children who received antibiotics in the prior 30 days are excluded.

75. Data Collection, Management and Validation A Data Manager (vendor) will aggregate and analyze the participating health plan claims and lab information and create measurement reports. The data from all NYS P4P Demonstration projects will be forwarded to IPRO for analysis. A Data Manager (vendor) will aggregate and analyze the participating health plan claims and lab information and create measurement reports. The data from all NYS P4P Demonstration projects will be forwarded to IPRO for analysis. Public Reporting is not a component of this demonstration project Public Reporting is not a component of this demonstration project The Physician Alliance will be involved in all aspects of data collection, management and appeals process. The Physician Alliance will be involved in all aspects of data collection, management and appeals process.

76. How to Succeed with Performance Measures #1 Designate an office “Quality Manager,” #1 Designate an office “Quality Manager,” --someone to be responsible for performance measurement # 2 Bill all services provided # 2 Bill all services provided #3 Code accurately and completely #3 Code accurately and completely -- review encounter forms to be sure that codes used will count. -- verify with your billing company that correct codes are billed. #4 Request current “actionable” reports from plans and review baseline NYQA report #4 Request current “actionable” reports from plans and review baseline NYQA report -- to improve coding and billing practice -- to identify practice patterns not consistent with measured standards -- to identify patients who need to be called in for care #5 For future success, reinvest bonus money #5 For future success, reinvest bonus money -- to strengthen skills and resources related to data management: -- consider implementation of a registry or an electronic health record with a registry function..

77. Participating Health Plans PlanContact Methodology for award Hudson Health PlanMarlene Ripa (914)372-xxxx or your Hudson Health Plan Provider relations representative TBD—will coordinate with existing p4P programs and with THINC RHIO project

78. Summary The status quo is not sustainable: cost, quality, access The status quo is not sustainable: cost, quality, access Performance (Quality) Measurement is increasingly seen nationally and locally as a cornerstone of building a better health care delivery system Performance (Quality) Measurement is increasingly seen nationally and locally as a cornerstone of building a better health care delivery system Pay-for-performance programs have been embraced by CMS and health plans and are increasingly common Pay-for-performance programs have been embraced by CMS and health plans and are increasingly common The “House of Medicine” is already extensively present on the national scene; The Physicians Alliance of the NYQA gives New York physicians a voice and a vote in how measures are implemented locally The “House of Medicine” is already extensively present on the national scene; The Physicians Alliance of the NYQA gives New York physicians a voice and a vote in how measures are implemented locally To survive and thrive learn to manage data as well as you manage patients. To survive and thrive learn to manage data as well as you manage patients.

79. Why Should Physicians Be Involved? You have physician representation on the project and input. You have physician representation on the project and input. Physicians will be working with the Health plans to adopt FAIR and REASONABLE principles for P4P. Physicians will be working with the Health plans to adopt FAIR and REASONABLE principles for P4P. Get in on the Ground Floor and Help shape the future! Get in on the Ground Floor and Help shape the future! Next steps for physicians. Next steps for physicians. Physician participation and support is critical. Physician participation and support is critical.

80. Value Exchanges  NYQA has been designated a Certified Value Exchange

81. Value Exchanges Multi-stakeholder collaborative organizations that are working to improve quality and value in health care by measuring the performance of local health care providers and reporting these findings publicly. Multi-stakeholder collaborative organizations that are working to improve quality and value in health care by measuring the performance of local health care providers and reporting these findings publicly. The plan would be to bring the local collaboratives into a nation-wide system, and the collaboratives would use nationally-recognized standards to measure and improve quality of care in their local areas. The plan would be to bring the local collaboratives into a nation-wide system, and the collaboratives would use nationally-recognized standards to measure and improve quality of care in their local areas. The chartered collaboratives would be called Value Exchanges The chartered collaboratives would be called Value Exchanges

82. Value Exchanges The Exchanges could also pioneer new quality improvement strategies and share results through the Learning Network. The Exchanges could also pioneer new quality improvement strategies and share results through the Learning Network. The new system would be administered by HHS' Agency for Healthcare Research and Quality (AHRQ). AHRQ Director Carolyn M. Clancy, M.D., said providers would lead in the development of standards. The new system would be administered by HHS' Agency for Healthcare Research and Quality (AHRQ). AHRQ Director Carolyn M. Clancy, M.D., said providers would lead in the development of standards. Advance the four cornerstones of Value-Driven Health Care. Advance the four cornerstones of Value-Driven Health Care.

83. Four Cornerstones of Value-Driven Health Care Interoperable Health Information Technology (Health IT Standards): Interoperable Health Information Technology (Health IT Standards): Interoperable Health Information Technology Interoperable Health Information Technology Interoperable health information technology has the potential to create greater efficiency in health care delivery. Interoperable health information technology has the potential to create greater efficiency in health care delivery. develop standards that enable health information systems to communicate and exchange data quickly and securely to protect patient privacy. develop standards that enable health information systems to communicate and exchange data quickly and securely to protect patient privacy. all health care systems and products should meet these standards as they are acquired or upgraded. all health care systems and products should meet these standards as they are acquired or upgraded.

84. Four Cornerstones of Value-Driven Health Care Measure and Publish Quality Information (Quality Standards): Measure and Publish Quality Information (Quality Standards): Measure and Publish Quality Information Measure and Publish Quality Information To make confident decisions about their health care providers and treatment options, consumers need quality of care information. To make confident decisions about their health care providers and treatment options, consumers need quality of care information. Similarly, this information is important to providers who are interested in improving the quality of care they deliver. Similarly, this information is important to providers who are interested in improving the quality of care they deliver. Quality measurement should be based on measures that are developed through consensus-based processes involving all stakeholders, such as the processes used by the AQA (multi- stakeholder group focused on physician quality measurement) and the Hospital Quality Alliance. Quality measurement should be based on measures that are developed through consensus-based processes involving all stakeholders, such as the processes used by the AQA (multi- stakeholder group focused on physician quality measurement) and the Hospital Quality Alliance.

85. Four Cornerstones of Value-Driven Health Care Measure and Publish Price Information (Price Standards): Measure and Publish Price Information (Price Standards): Measure and Publish Price Information Measure and Publish Price Information To make confident decisions about their health care providers and treatment options, consumers also need price information. To make confident decisions about their health care providers and treatment options, consumers also need price information. Efforts are underway to develop uniform approaches to measuring and reporting price information for the benefit of consumers. Efforts are underway to develop uniform approaches to measuring and reporting price information for the benefit of consumers. In addition, strategies are being developed to measure the overall cost of services for common episodes of care and the treatment of common chronic diseases. In addition, strategies are being developed to measure the overall cost of services for common episodes of care and the treatment of common chronic diseases.

86. Four Cornerstones of Value-Driven Health Care Promote Quality and Efficiency of Care (Incentives): Promote Quality and Efficiency of Care (Incentives): Promote Quality and Efficiency of Care Promote Quality and Efficiency of Care All parties - providers, patients, insurance plans, and payers - should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively-priced health care. All parties - providers, patients, insurance plans, and payers - should participate in arrangements that reward both those who offer and those who purchase high-quality, competitively-priced health care. Such arrangements may include implementation of pay-for- performance methods of reimbursement for providers or the offering of consumer-directed health plan products, such as account-based plans for enrollees in employer-sponsored health benefit plans. Such arrangements may include implementation of pay-for- performance methods of reimbursement for providers or the offering of consumer-directed health plan products, such as account-based plans for enrollees in employer-sponsored health benefit plans.

87. Value Exchanges Participation as a Chartered Value Exchange offers several benefits. Participation as a Chartered Value Exchange offers several benefits. Members can join their peers in a nationwide Learning Network sponsored by the Agency for Healthcare Research and Quality (AHRQ). Often called communities of practice, Members can join their peers in a nationwide Learning Network sponsored by the Agency for Healthcare Research and Quality (AHRQ). Often called communities of practice, A Learning Network provides peer-to-peer learning experiences through facilitated meetings, both face to face and on the Web. The network also features tools, access to experts, and an ongoing private Web-based knowledge management system. A Learning Network provides peer-to-peer learning experiences through facilitated meetings, both face to face and on the Web. The network also features tools, access to experts, and an ongoing private Web-based knowledge management system.

88. Value Exchanges The Learning Network allows members to: Share their experiences. Share their experiences. Identify promising practices. Identify promising practices. Point out gaps where innovation is needed. Point out gaps where innovation is needed. Raise issues for national consensus-building organizations Raise issues for national consensus-building organizations Provide an on-the-ground perspective to participate in setting national priorities for improvement. Provide an on-the-ground perspective to participate in setting national priorities for improvement. Chartered Value Exchanges will have access to summary Medicare provider performance results, which can be combined with similarly calculated private-sector results to produce and publish all-payer performance results. Chartered Value Exchanges will have access to summary Medicare provider performance results, which can be combined with similarly calculated private-sector results to produce and publish all-payer performance results.