1. Purchasers’ Efforts to Promote Better Information Technology
Peter V. Lee
Pacific Business Group on Health
The Health Information Technology Summit West
March 7, 2005
Pacific Business Group on Health, 2005

2. Measuring Provider Quality and Cost-Efficiency to Improve Value
SAVE LIVES, SAVE MONEY
Adapted from Regence Blue Shield
© Pacific Business Group on Health, 2005
Pacific Business Group on Health, 2005

3. Putting the Consumer in the Driver’s Seat
Pacific Business Group on Health, 2005

4. PBGH Plan Evaluation Process
eValue8 RFP has been implemented in local markets by employer coalitions and national purchasers
Standardized health plan performance evaluation and quality improvement process
Applicable to HMOs, POS, Medicare+ Choice and PPOs
Provides a data repository of benchmarking data for nearly 400 health plans nationally via collaboration with Watson Wyatt

5. Evaluation Components: New Health IT Module
Plan Profile
Health Information Technology
Consumer Engagement and Support
Web-based consumer support tools
Provider Management: Incentives and Rewards
Accessibility of provider performance information
Use and adoption of IT, including electronic medical records, CPOE
Primary Prevention and Health Promotion
Accessibility of clinical guidelines
Integration of Health Risk Appraisal information
Chronic Care Management (CAD, Diabetes, Asthma, Depression)
Data integration for member identification and targeting
Member “push” communications
Practitioner support – care reminders
Pharmacy Management
Data integration
Quality and safety
Health Info Technology Detail:
Plan HIT budget and resource allocation
Community collaboration
Compliance with data standards
Provider support tools
Administrative: Eligibility, benefits, claims look-up/processing
Clinical: Referral, ordering of diagnostic services
Electronic prescribing
Member Support tools
Provider selection
Provider performance information
Electronic personal health record
Purchaser Support tools
Plan administration
Cost and utilization reports
Incentives for HIT adoption
Pay for Performance
Performance measurement
Ease of plan Web site use (CAHPS)
Transaction timeliness and accuracy

6. NCQA Refreshing Accreditation – Quality Plus
PBGH Breakthrough evaluation feedback
Major portion of accreditation linked to process measures – many mandated through insurance regulators
Current NCQA accreditation places more weight on HEDIS outcomes, but overall, inadequate for differentiating value
New accreditation strategy
Increase availability of comparable and actionable information among multiple plan types
Focus on identifying value and efficiency
Recognize effective strategies and tools for consumer engagement
Distinguish efforts to measure provider performance and incent improvement
Pacific Business Group on Health, 2005

7. Physician and Hospital Quality
About Quality Plus
Why?
To strengthen NCQA’s position as the leader in health plan evaluation
Quality Plus will keep NCQA’s accreditation programs responsive to the evolving needs and desires of employers and consumers
What?
Quality Plus consists of the following new programs and reports:
New Accreditation Content and Reports (new content areas initially will be voluntary)
Member Connection
Health Improvement
Physician and Hospital Quality
New modules will incorporate measures of value
New Report
Chronic Care Report
The Chronic Care Report features data from current accreditation surveys and HEDIS submissions
Pacific Business Group on Health, 2005

8. Member Connection
Intent: To assess the effectiveness of an organization as infomediary
and provider of assistance to consumers
WHAT NCQA WILL EVALUATE
(working draft)
Breadth, usability and quality of information, assistance with:
Benefits (copays, deductibles)
Pharmacy benefits/functions
Health decisions
Preparing for MD visit
Decision Support
Health Plan Mechanics
ID cards
Changing PCP
Claims Handling
HOW NCQA WILL EVALUATE
CAHPS questions, such as:
Ability to find and understand plan information
Correct handling of claims
HEDIS measures:
Call answer timeliness
Call abandonment
Claims timeliness
Performance standards for:
Ease of use of website information, eg # of clicks
Accuracy of website information
Effectiveness of interactions with member services
Sources: eValue8, HI Ethics, NCQA Provider Directory Project, requirements of benefits consultants
Focus Groups
with consumers
to inform content
Pacific Business Group on Health, 2005

9. health risks, chronic disease and severe cases
Health Improvement
Chronic Care Report
provides 1st phase
of information;
To be supplemented
by new content
Intent: To measure the value of an organization’s management of populations’
health risks, chronic disease and severe cases
WHAT WE’LL EVALUATE
(working draft)
Use of data to stratify risk levels of entire population
Preventive and acute-care advice for all members
Engagement of patients and practitioners in management of chronic conditions
Promotion of self-management
Personalized DM for higher utilizers with chronic-conditions
Effective case management for complex cases
HOW WE’LL EVALUATE
HEDIS measures, such as:
Comprehensive Diabetes Care
Controlling High Blood Pressure
Performance standards for:
Use of evidence-based content
Use of HRAs
Functions of case managers
Value measures for plans and DM vendors, such as:
Appropriate medication management
Readmission rates
Sources: PBGH; American Healthways/Johns Hopkins paper; Value measures
Pacific Business Group on Health, 2005

10. Physician and Hospital Quality
Intent: To measure the effectiveness of an organization in identifying,
measuring, rewarding high value providers, and steering consumers to them
WHAT WE’LL EVALUATE
(working draft)
Provider Directories—completeness, usability, accuracy
Hospital value information (move towards standardization)
Physician value information (move towards standardization)
Tools to help members identify value providers
Incentives for high value providers
Goal: Alignment with Leapfrog; large employer RFPs
HOW WE’LL EVALUATE
CAHPS questions such as:
Ease of use of provider directory
Ratings of providers
Performance standards for:
Quality of information in provider directory
New metrics such as:
PPSI* progress index, initially
PPSI* complete measure in future
Use of provider value measures developed by Value MAP
Sources: Leapfrog,GE RFP, Provider Directory project
*Leapfrog Provider Performance Sensitivity Index
Pacific Business Group on Health, 2005

11. Hospital Choice Tools
• Hospital quality linked to treatment choice information • Network, cost and quality information linked to tiered benefit design
Member preference-based ranking: • Volume • Mortality • Complications • Length of Stay • Leapfrog • Cost • Patient Experience
Pacific Business Group on Health, 2005

12. Why Pay for Performance?
Shifts payment from toxic to performance-based
Drives performance transparency & market rewards
Promotes quality improvement & IT adoption
Pacific Business Group on Health, 2005

13. California P4P—Key Stakeholder Roles
Integrated Health Care Association
The “neutral table” for plans, providers and consumers to design and administer program
Health Plans
Medical Groups
Purchasers and Pacific Business Group on Health
Early (1999/2000) promoter of pay for performance
Representation on IHA program design committees
Plan participation built into health plan performance guarantees
Public and behind-the-scenes support during critical times
Grant-funded technical development
State of California
Publishes consumer scorecard with results
California HealthCare Foundation
Funded technical development & program evaluation
Pacific Business Group on Health, 2005

14. Performance Metrics—An Evolving Scorecard
Clinical Quality (50% weighting)
10 HEDIS-based measures
Reported with Administrative data
Patient Experience (30% weighting)
5 measures ( i.e. access, specialty care, MD communication)
Collected through common statewide CAHPS-like survey
Investment and Adoption of IT (20% weighting)
2 Measures: point of care and population management
Collected through web-based survey plus audit
Clinical Measures (50% weight)
Preventive Care
Breast Cancer Screening
Cervical Cancer Screening
Childhood Immunizations
Chlamydia Screening
Acute
Treatment for Upper Respiratory Infection in Children
Chronic Disease Care
Appropriate Meds for Persons with Asthma
Diabetes: HbA1c Testing and Treatment
Cholesterol Management: LDL Testing and Treatment
Patient Experience (30% weight)
Communication with doctor
Care Coordination
Specialty care
Timely Access to care
Overall ratings of care
Pacific Business Group on Health, 2005

15. Information Technology (20% weight)
Identify populations of patients needing care – integrates at least two electronic data sets at the patient level – e.g. encounters, lab results, pharmacy, inpatient or ER, radiology
Provide physicians clinical decision support – delivers patient clinical information electronically to physician’s office – e.g. lab results, patients due for tests, electronic prescribing

16. Physician Incentive Bonus
“Extra Credit” for instituting a program to measure physician performance on clinical and patient experience; provide regular feedback to those physicians and offer rewards based on performance

17. P4P First Year Results — Largest Program in Nation: 2004
Estimated $100 million in total paid to California physician groups for quality (includes all products and efficiency, e.g. including use of generics vs. brand)
$50 million based on common P4P measures in 2004
Pacific Business Group on Health, 2005

18. Future Steps for P4P in California
Reward year-to-year improvement
Dramatically increase in number of clinical metrics (from 12 to 50)
Increase in percentage of revenue devoted to performance-based pay
Develop efficiency metrics
Expand to other product lines: i.e. Medicare, PPO
Pacific Business Group on Health, 2005