1. Pay for Performance- California Style Jack Rodnick, MD Conference on Practice Improvement Denver, Colorado November 10, 2006

2. What I’ll cover: P4P history and structure P4P history and structure Performance measures The inflow of funds The medical group (Brown and Toland) The outflow of funds The outflow of funds How the group and our practice performed Impact and Problems Impact and Problems

3. P4P goal To significantly improve individual physician and group performance in the delivery of quality of health care and patient experience through financial reward and public recognition.

4. Calif. P4P history and Structure 7 plans and other stakeholders formed Integrated Healthcare Association (IHA) in 1996 and started P4P initiative in 2001 7 plans and other stakeholders formed Integrated Healthcare Association (IHA) in 1996 and started P4P initiative in 2001 Aetna, Blue Cross, Blue Shield, Cigna, HealthNet, & Pacificare (now part of United Health) are the main participating plans Aetna, Blue Cross, Blue Shield, Cigna, HealthNet, & Pacificare (now part of United Health) are the main participating plans IHA makes the rules and recommends payments from the plans to medical groups IHA makes the rules and recommends payments from the plans to medical groups NCQA oversees data collection NCQA oversees data collection New $ from health plans New $ from health plans IHA funded by grants, drug co. and stakeholders IHA funded by grants, drug co. and stakeholders Started payments in 2004 (using 2003 data)

5. P4P structure Largest P4P initiative in the US ~200 Calif. med groups participating with over 35,000 physicians and 6 million commercial HMO enrollees ~200 Calif. med groups participating with over 35,000 physicians and 6 million commercial HMO enrollees For 2005 and 2006 pay/results weighed 50% clinical, 30% patient experience/satisfaction and 20% IT measures 10% bonus if med. group gives clinical/patient experience feedback to indiv. MD 10% bonus if med. group gives clinical/patient experience feedback to indiv. MD

6. Clinical Measures (50%) Data from Commercial HMO members only Clinical criteria chosen from HEDIS measures Clinical criteria chosen from HEDIS measures All plans use same patient eligibility and clinical criteria (defined by IHA and NCQA) Data is claims based (no chart audits) from each plan and aggregated for each group (for 5 of 6 plans) Currently 10 clinical measures (many more sub-measures when broken down by age and other variables) – 4 preventive, 1 acute and 5 chronic care

7. 2005 Clinical Measures Breast Ca screen (% women age 52-69 getting mammogram in past 2 yrs) Cervical Ca screen (% of women age 21- 64 with a uterus getting a pap smear in past 3 yrs.) Chlamydia screen (% women age 16-25 who have ever had pap or are on BCPs that had Chlamydia test in past yr.)

8. 2005 Clinical Measures Childhood immunizations (% of kids that receive 4 DPT, 4 PCV, 3 IPV, 3 Hep B, one MMR and one VZV by second birthday) Appropriate Rx of URIs in kids (% of 3m- 18yr olds with dx of URI who were not given antibiotics within 3d of visit)

9. 2005 Clinical Measures Chol. screen/level in those with DM and/or post MI or CABG or PTCA (% of those who have LDL-C measured in past yr. and % <130) Diabetes care (% of those with DM who have had a HgbA1c past yr. and % with HgbA1c <9.0 ) Use of appropriate Asthma meds (% of those who get 2 or more albuterol canisters in one yr. or have ER visit for asthma, who are on inhaled corticosteroid, cromoyln or leukotriene inhibs)

10. Future Clinical Measures In future may add measures on: Nephropathy monitoring in diabetics* Nephropathy monitoring in diabetics* Asthmatics using too much albuterol* Asthmatics using too much albuterol* Colorectal Ca screen* Colorectal Ca screen* Counseling obese pts Counseling obese pts Follow up after starting SSRIs Follow up after starting SSRIs Flu vaccine in 50-64 yr. olds Flu vaccine in 50-64 yr. olds Prenatal and postpartum care Prenatal and postpartum care * = to be added for 2006 (Medicare patients will be included in some measures in 2006)

11. Patient Experience Measures (30%) From a patient survey (PAS) randomly sent to 900 patients per group, giving about 375 useable responses 46 questions, grouped by: How easy it is to get an appointment with both primaries and specialists (timely access) How easy it is to get an appointment with both primaries and specialists (timely access) Doctor-patient communication Doctor-patient communication Co-ordination of care Co-ordination of care Quality of specialty care Quality of specialty care Overall rating of doctor Overall rating of doctor Key question: Would you recommend the doctor to family and friends?

12. Patient Experience Measures 27 Medical groups gathered PAS data at the individual physician level BTMG sent 100 PAS questionnaires to patients who saw each of 535 physicians who saw over 100 B&T pts in past yr. (yielding about 35 good replies per MD) Group gets 10% bonus if give indiv. physician feedback

13. IT measures (20%) Evaluated thru interviews and documentation 1) Have electronic data set at group level for population management (have patient clinical data sets from visits, lab, X-ray reports or prescriptions and can make queries, reports, registries, etc.). 2) Have tools to support decision making at the point of care (at least 50% of primaries have EMRs, do e-prescribing, get preventive care reminders, get e-lab results, or can a access notes of other physicians).

14. Future IT measures Future IT measures Will add “system-ness” Monitor access to PCPs and specialists Monitor access to PCPs and specialists Monitor effectiveness of DM support Monitor effectiveness of DM support

15. Data flow

16. Public score card

17. P4P payments to Med. Groups Plans pay on relative performance to other groups, after meeting thresholds. most thresholds at 50-80 th percentile of medical groups Each health plan determines their own reward methodology and payment amount to comply with anti-trust regulations. Thresholds and amounts vary (i.e. HN pays 3 cents pmpm if meet 85th percentile of breast Ca screen, Cigna pays 7 cents pmpm if meet 90th percentile)

18. P4P payments Each plan pays physician group separately Range: $.05 to 1.59 pmpm per group per plan Pacificare contributes less per enrollee HealthNet decreasing their contribution $37.4 million paid to all Calif. Med groups in 2004, about $52 million total paid out in 2005 and similar amount in 2006 Range: none to a total of $4.50 pmpm per group

19. Brown and Toland Medical Group (BTMG) Started in 1993 by the physicians from Calif. Pacific Medical Center (CPMC) and UCSF IPA structure (with separate service organization) and physician governed All doctors practice and most patients work/live in San Francisco. Currently has capitated (HMO) contracts for most (excluding inpatient) care from 6 plans: Aetna, Blue Cross, Blue Shield, Cigna, HealthNet, & Pacificare (United Health) Aetna, Blue Cross, Blue Shield, Cigna, HealthNet, & Pacificare (United Health)

20. BTMG 400 primary care and 1100 specialty care physicians (but only 550 MDs see >100 B&T pts/yr) contract with BTMG 180,000 commercial HMO patients and 12,000 Medicare (Seniority Plus and Secure Horizons) HMO patients 40,000 PPO members 70-80% patient care activity done by CPMC affiliated physicians (all in private practice), 20- 30% by UCSF faculty. UC Family Med practice part of UCSF Medical group UC Family Med practice part of UCSF Medical group 12 part-time FPs with 22,000 visits/yr 12 part-time FPs with 22,000 visits/yr B&T patients make up about 50% of visits B&T patients make up about 50% of visits

21. P4P payments BTMG received about $2.3 million in 2005 for 2004 performance (1% of revenue) $1.06 pmpm Estimate BTMG will receive about $2.5 million in 2006 for 2005 performance Range per plan from $0.25 to $4.14pmpm Range per plan from $0.25 to $4.14pmpm Totals a little less than 3% of physician capitation, a little over 1% of total revenue Totals a little less than 3% of physician capitation, a little over 1% of total revenue

22. What BTMG did with P4P funds BTMG did not change capitation (to primaries or specialist contact cap) or other payment rates. 45% paid as “Quality bonus” to those MDs with> 100 B&T patients based on pt. satisfaction scores of each doc (and for PCPs the % of diabetics with A1c 100 B&T patients based on pt. satisfaction scores of each doc (and for PCPs the % of diabetics with A1c <9). 45% paid as “Surplus distribution” based on # of visits of B&T patients (and for PCPs also weighted to those with fewer ER visits/100 pts and fewer specialty referrals/100 pts).

23. P4P payments to UCSF Family Medicine Our FM practice with ~ 6,000 B&T capitated pts. received about $17,000 as quality bonus in 2005 and $23,000 as “surplus distribution” ~ 4% of our B&T revenue or $.50 pmpm ~ 4% of our B&T revenue or $.50 pmpm I “guesstiamte” that we were average on efficiency, diabetes control and patient satisfaction measures compared to other SF primary care practices. Except for the dept. chairman and practice leaders, the other practicing FPs (10) were unaware of either payment. It went to help the practice “bottom-line”.

24. BTMG Clinical Performance BTMG scored well (above most payment thresholds) in: Most childhood immunization rates Most childhood immunization rates Persistent Asthma medication use in adults Persistent Asthma medication use in adults Diabetes A1c screening rate Diabetes A1c screening rate LDL-C screening rate LDL-C screening rate

25. BTMG Performance BTMG scored above average, but not above threshold of many plans for payment in: Persistent Asthma meds in kids Persistent Asthma meds in kids % Diabetics in good control % Diabetics in good control Mammography rate Mammography rate Chlamydia screening rate Chlamydia screening rate BTMG scored average in Patient Satisfaction: BTMG scored average in Patient Satisfaction: Doc-patient communication Doc-patient communication Access to care Access to care Specialty care Specialty care Care co-ordination Care co-ordination

26. BTMG Performance Gaps We estimate improved P4P clinical performance would generate up to $250,000 (if rules stay the same): $50,000 if increase Chlamydia testing $50,000 if increase Chlamydia testing $40,000 if increase VZV vaccinations $40,000 if increase VZV vaccinations $25,000 if increase MMR vaccinations $25,000 if increase MMR vaccinations $20,000 if increase mammograms $20,000 if increase mammograms $20,000 if fewer diabetics in poor control $20,000 if fewer diabetics in poor control Is the investment worth it?

27. BTMG Performance Gaps BTMG estimates we could increase P4P revenue by $4-600,000 through improved patient satisfaction: $250,000 if more timely access $250,000 if more timely access $150,000 if better doc-pt communication $150,000 if better doc-pt communication $150,000 if pt. ratings of specialist care improved $150,000 if pt. ratings of specialist care improved How to do it?

28. But…. There is grade inflation – most groups are improving From 2003 to ‘04, most groups improved their clinical scores by 3-5% From 2003 to ‘04, most groups improved their clinical scores by 3-5% Over 50% of groups improved patient satisfaction scores Over 50% of groups improved patient satisfaction scores Those receiving rewards for IT went from 1/3 to 1/2 of all participating groups Those receiving rewards for IT went from 1/3 to 1/2 of all participating groups Note: those groups receiving full IT credit score much better on clinical measures Note: those groups receiving full IT credit score much better on clinical measures Improvement likely multi-factorial Plans can change payment amounts, methodology or thresholds at anytime Should payment be for improvement or meeting a threshold or relative to other groups?

29. US v. UK Large groups Black box 10 indicators No exclusions Data gathered at group Uses utilization/cost $ Use pt. satisfaction data 1-3% of practice income Practice & indiv. doc Data easily accessed 146 indicators Doc can exclude pts. Data gathered at practice No cost considerations No pt. satisfaction data 20% % of practice income

30. Summary Positive points: Likely more funds came to BTMG than group spent on admin of project, data collection, etc. Likely more funds came to BTMG than group spent on admin of project, data collection, etc. BTMG, analyzing poor results in patient satisfaction area, initiated a program to try to improve doc-pt communication and will work on access and co-ordination. BTMG, analyzing poor results in patient satisfaction area, initiated a program to try to improve doc-pt communication and will work on access and co-ordination. BTMG, in paying out funds, added efficiency of practice (i.e. cost) criteria for PCPs. BTMG, in paying out funds, added efficiency of practice (i.e. cost) criteria for PCPs. P4P, by being there, may have encouraged ongoing IT initiatives. P4P, by being there, may have encouraged ongoing IT initiatives. When (or if) P4P gets serious, we’re ready. When (or if) P4P gets serious, we’re ready.

31. Summary Problem areas: Problem areas: Large majority of physicians not aware of specific measures by which they are being judged, funds flow or how “bonus” calculated. Large majority of physicians not aware of specific measures by which they are being judged, funds flow or how “bonus” calculated. Parts of program not transparent at plan or group level. Parts of program not transparent at plan or group level. Most measurements at group, not individual, level. Most measurements at group, not individual, level. Up to 2 yr gap between clinical performance measurements and pay received Up to 2 yr gap between clinical performance measurements and pay received Clinical measures not relevant to many pts. and/or docs. Clinical measures not relevant to many pts. and/or docs.

32. Conclusions Overall a good first step, showing it can be done Overall a good first step, showing it can be done Very complicated with so many payers, each with different and varying payments. Is the goal quality improvement or cost control? No one knows if it’s really works. No one knows if it’s really works. P4P may have more impact if rewards increase, lag time decreases, develop better measures, use risk adjustment, and give more feedback at indiv. MD level. It’s not going away, but it’s not the salvation of primary care.