1. Pay-for-performance as a Quality Driver
The Quality Colloquium
August 21, 2006
Francois de Brantes
National Coordinator,
Bridges To Excellence

2. Goals for today Understanding P4P Lessons from the field
Understanding the value of measures

3. From upstream to mainstream
No one called this P4P five years ago
There are more than 100 programs currently
CMS is hungry for more
There’s a right way of doing it

4. The Bridges To Excellence way:
use standard performance measures;
provide physicians with clearly defined costs and benefits which helps them determine the value of participating;
use independent third party organizations to measure the performance of the physicians;
bring together lots of payers and purchasers to make rewards meaningful to physicians;
encourage physicians to adopt better systems of care, including health information technology, to systematically improve the delivery of care.

5. Results from the field – the UK
Average physician gross income increased by $40K
Performance is good in many areas, but the targets were probably too low
Gaming is easy to spot – 1% of practices excluded more than 15% of their patients from the performance measures, claiming some exception – but not endemic
Socio-demographic factors have a limited impact on performance

6. Despite the high scores there is still significant variation
NEJM,

7. Results from the field – NY
Multi-Specialty Physician owned and managed
1 of 3 prominent primary care groups in the region with 30 practice sites
Started the BTE recognition process in 1Q2003, first recognition 2Q2005
11 Physician Office Link recognized practices (65 physicians) now, working on more
Over $400,000 in rewards from BTE alone

8. Community Care Physicians results
The Improvements:
Identified for the 1st time their top three chronic conditions
Created standards, protocols and programs to manage their patients within and across practices
Launched 4 diabetes care improvement programs
Population tracking and follow up, DM and case managers
Developed Diabetic registry
Conducted process audit
Provided benchmarking data
Developed interventions and implement
Re-measured

10. Community Care Physicians results
The Impact:
Implemented EMR system – rolling on a practice every two weeks, with wireless access in all practice sites
More than 40,000 patients now receive care at practices that have demonstrated improvement
Systems mapped to evidenced based care guidelines
Diabetics saw an average 1.5% decrease in A1c levels
Savings in reduced staff, transcription, materials, overtime
“If you want to effect clinical outcomes in patients you first have to make sure your structure and process are in place. This is an opportunity to utilize quality improvement strategies to enhance on going practice development.” Robert Fortini, PNP
Clinical Operations Manager, Community Care Physicians

11. Not all measures are worth the same
NEJM,

12. The distribution of impact is Pareto-like
High clinical value * high cost effectiveness
Towers Perrin
2006

13. These 19 measures are the most valuable
Towers Perrin
2006