Transcript No Slide Title

Pay for Performance:
Driving Improvement through
Provider Recognition &
Reward
MCOL Healthcare Web Summit
Participating Provider Reimbursement
June 2003
- a Rewarding Results National Grant
Who Are These People?
Integrated Healthcare Association
A California leadership group of health
plans, physician groups, and health care
systems, plus academic, purchaser,
consumer, and pharmaceutical industry
representatives, committed to policy
development, public dialogue, and
special projects associated with the
continuing evolution of managed care.
- a Rewarding Results National Grant
What Are They Doing?
Pay for Performance involves:
• Common metrics for physician group
performance
• A public scorecard displaying the results
• Individual health plans’ “significant” $$$
to reward physician group performance
- a Rewarding Results National Grant
And Why are They
Doing This?
•Purchasers want value for premium $
•Need to create a business case for
quality at the provider level
•Create more constructive health plan –
physician group relationship
•Need single, respected medical group
report card to promote competition on
quality and help consumer choices
- a Rewarding Results National Grant
Participating Health Plans
• Aetna
• Blue Cross of California
• Blue Shield of California
• CIGNA HealthCare of California
• Health Net
• PacifiCare
• Others in year 2……?
Approx. 8 million HMO enrollees now
- a Rewarding Results National Grant
The Health Plans’
Delegated Model Dilemma
• Most non-Kaiser plans contract with same
physician groups
• No plan > 25% of a physician group’s revenue
• Quality improvement at the physician group
level benefits many plans
• Therefore, competition works against an
individual plan’s incentive to improve the
infrastructure of its physician groups
- a Rewarding Results National Grant
The P4P Fundamentals
r
• Commercial HMO/POS enrollees
• A balanced scorecard
• Audited admin data for clinical scores
• Independent entity validate data
• Public reporting of results
• Reward improvement and performance
• The Power of Multiples
–Common metrics drive performance
–Concentrated payments = real $$$
- a Rewarding Results National Grant
The Measures
• Collaboratively designed
• Balanced
–Clinical – 50%
–Patient satisfaction – 40%
–IT investment – 10%
• Evolving over time
–Raise the bar, carefully add measures
- a Rewarding Results National Grant
The Clinical
Measures
Preventive Care
Chronic Disease Care
• Breast Cancer
• Appropriate Medications
Screening
for People with Asthma
• Cervical Cancer
Screening
• Diabetes HbA1c Testing
• Cholesterol
• Childhood
Immunizations
Management: LDL
Screening
- a Rewarding Results National Grant
Patient Satisfaction
Domains
•Communication with doctor (10%)
•Overall ratings of care (10%)
•Specialty care(10%)
•Timely Access to care(10%)
TOTAL = 40%
- a Rewarding Results National Grant
IT Measure
Group can demonstrate capabilities in
either or both of two key domains:
1. Clinical data set integration (group
level)
– any two of encounter, lab results,
pharmacy, inpatient or ER, radiology
2. Clinical decision support (point of care)
- a Rewarding Results National Grant
Scorecard
Decisions
• Scorecard will be public
• We will make every effort to make it
consumer friendly
• Will include non-English availability
• Will require a separate 3d party vendor
• Will partner with State OPA
• Requires adequate encounter data
- a Rewarding Results National Grant
Health Plan Payments
• Each plan individually decides source,
amount, and payment method
• 2004 payment based on 2003 results
• Contract amendment process is key
• Not all plans have completed their 2004
budgets and program designs
• IHA urging plans to do 5-10% bonus
- a Rewarding Results National Grant
What it Means
• Unprecedented cooperation by health plans
• First statewide, multi-plan initiative of its kind
• Changes the plan-group conversation?
• Speeds up physician group consolidation?
• Preserves the delegated model
• Begins long term QI process
• Benefits all patients, not just HMO enrollees
- a Rewarding Results National Grant
Key Implementation
Issues
•Group variation in encounter data submission
•Plan variation in “catching” group data
•Health plans want to collect and use other data
•Some plans REALLY like their own scorecards
•Amending group contracts is VERY tricky
•“Unbundling” P4P from regular contract cycle
•Will purchasers recognize/reward plan?
•Possible adverse selection for best groups?
- a Rewarding Results National Grant
How to Provide Input
•Consult web site for updates – www.iha.org
•Sign up for e-Updates: e-mail to [email protected]
• Contact IHA directly:
Beau Carter, Executive Director
Integrated Healthcare Association
49 Quail Court, Suite 205
Walnut Creek, CA 94596
Tel: 925/746-5100 Fax: 925/746-5103
- a Rewarding Results National Grant