Transcript Clinician Responses to Specific Financial Incentives to

Using Incentives to Improve Quality in Health
Care
R. Adams Dudley, MD, MBA
Professor of Medicine and Health Policy
Philip R. Lee Institute for Health Policy Studies
University of California, San Francisco
Support: Agency for Healthcare Research and Quality, California
Healthcare Foundation, Robert Wood Johnson Foundation
Investigator Award Program
Disclosures: none.
Outline of Talk
• Audience poll: In cardiology, on which measures
of quality or efficiency should rewards be based?
• What do outsiders want to see measured &
rewarded in cardiology?
• Is it all about reimbursement? Or are there other
creative options purchasers have that might move
the needle?
In cardiology, on which measures of quality
or efficiency should rewards be based?
• Suggestions?:
How Would Outsiders Like to
See Cardiology Measured?
• On efficiency (National Priorities
Partnership):
– Appropriateness of diagnostic procedures
– Appropriateness of PCI
• On quality: outcomes (mortality, but also
symptom control, QOL)
– {best if measures could start from symptom
presentation, rather than procedure}
PCI Use in
Coronary Artery Disease
 1.2 million stents placed in US in 2003 (and
rising)
 Large majority are elective
 Medicare pays $12,231 for a drug-eluting stent
placement without complications ($16,428 if there
are complications)
Summary of PCI vs Med therapy trials
Trial
Mortality
Prevent
MI
RITA-2
No diff
No diff
PCI
PCI
No diff
ACME
No diff
No diff
PCI
PCI
N/A
ACME-2
No diff
No diff
PCI
No diff
N/A
MASS
No diff
No diff
PCI
N/A
N/A
MASS-II
No diff
No diff
PCI
PCI
N/A
AVERT
No diff
No diff
PCI
No diff
No diff
TIME
No diff
No diff
PCI
PCI
No diff
COURA
GE
No diff
No diff
PCI*
PCI
No diff
* No difference at 5 years
Short-term Short-term
Longanginal relief
QoL
term QoL
Adapted from Kereiakes, JACC 2007;50:1598-1603
COURAGE: Freedom from angina
Time point
PCI (%) +
OMT
Medical therapy (%)
p
Baseline
12
13
NS
1 year
66
58
<0.001
3 years
72
67
0.02
5 years
74
72
NS
Boden et al. NEJM 2007;356:1503-16
Focus Groups:
Do Docs Agree with the Data?
• Yes!
• In focus group research, one cardiologist
explained: “Yes, medical therapy is as effective
as PCI, but when I see a lesion, the bottom line
is that the ‘oculostenotic reflex’ always wins
out.”
Lin, GA, Dudley, RA, Redberg, RF. Archives of Internal Medicine, 2007; 167(15):1604
Do Clinicians Agree With the Data?
• Another cardiologist said: “I think we all know
that we’re not preventing heart attacks by
treating an asymptomatic stenosis. We’re
going to prevent the next heart attack because
of lipid lowering, aspirin, and ACE inhibitors,
but nonetheless that patient in our practice
leaves the lab with an open artery, the best
that my interventional partners can deliver.”
Lin, GA, Dudley, RA, Redberg, RF. Archives of Internal Medicine, 2007; 167(15):1604
So Why? Rationales Offered…
 Anticipated regret
 Patient anxiety
 Belief in the Benefits of an Open Artery,
notwithstanding the evidence
 Medicolegal concerns
 (Assumption by primary care docs that specialists
know best)
Lin, GA, Dudley, RA, Reberg, RF. Archives of Internal Medicine, 2007; 167(15):1604; and
Lin, GA, Dudley, RA, Reberg, RF. J Gen Int Med, 2008; 23(9):1458
PCI Use in
Coronary Artery Disease
 Rapid increase in use in face of these trials data
are hard for policymakers and purchasers to
understand or accept
 Physicians’ rationale for continuing current
practice doesn’t meet policymakers expectations
for evidence-based medicine
Using Incentives: A Reference
• Today you’ve heard the rationale for using payment
to address quality/efficiency…it’s coming for sure
• In the article referenced on the next slide, we
attempted to synthesize the economic, organizational
behavior, and psychology literature to offer a model
of how clinicians and clinical organizations respond
to incentives
• You should read this article if you are going to try to
get your practice or hospital to respond to incentives
Provider
Incentive
Design of the
Incentive Program:
• Financial
characteristics (e.g.,
revenue potential,
cost of compliance)
• Reputational
aspects (e.g., extent
of efforts to market
data to patients and
peers)
Environmental variables: General
approach to payment; regulatory
and market factors
Provider group
Predisposing/Enabling factors
Organizational factors (if
applicable, e.g., the
organization’s internal incentive
programs or information
technology)
Provider decision-maker
• Psychological
dimensions (e.g.,
salience of quality
measures to
provider’s practice)
Patient factors (e.g., education,
income, cost sharing)
Provider response: change in
care structure or process
Change in outcomes:
• Clinical performance measures
• Non-financial outcomes for the provider
(e.g., provider satisfaction)
• Financial results for the provider
Source: Frolich et al. Health Policy,
2007; 80(1):179
13
Beyond Payment Reform and Public
Reporting
• Purchasers could try to improve quality and/or
efficiency in other ways that have largely gone
unused
– Help docs with actual clinical practice
– Allow volunteer docs/hospitals to begin to measure/report
the really high value clinical stuff for rewards
– CAD in CAD: Coalition Against Defensive Medicine in
CAD
Helping Physicians Practice: Taking
Advantage of Health Plans’ Information
• Change “1-800-prior authorization” to “1-800Information Valet”
– A health plan “Information Valet” would help
your staff find prior tests done and results, prior
medications tried, before the office visit
• A formulary compendium:
– Insurers could put all their formulary info into a
compendium, so docs could develop prescribing
patterns that reduced paperwork (e.g., each time
you need an ACE-I, you start with “always
covered-ipril” to prevent pharmacy callbacks)
Let Volunteers Provide More Information
• Many health plans are designating cardiac “Centers
of Excellence”
– Sometimes, this includes requests for ACC
NCDR data and other clinical data
– However, MUCH more could be done, such as
measuring appropriateness, and because it’s for
COE designation, it’s optional
CAD in CAD: Coalition Against Defensive
Medicine in CAD
• Doctors say they do unnecessary tests and treatments
for medicolegal reasons (patients demand them)
• Drug and device manufacturers have extensive
communications programs to docs and patients
• Why shouldn’t specialty organizations have
messaging for patients and docs
– Teach patients that “more is not always better”
– Provide materials docs could submit in the event
of a lawsuit (like an amicus brief)
– Health plans and employers could sponsor this
Using Incentives:
Summary
• There are important areas in cardiology in which
there are legitimate questions about quality and
efficiency or appropriateness
• Payment has some impact on performance, so
reform might help, but many other factors are
important
• Health plans and other policymakers have barely
scratched the surface of increasing info availability
• Making the discussion about more than payment
could improve relationships and the tenor of the
discussion
Just in case
• The next 2 slides are for use only if someone objects
to basing payment on performance
• The last 4 are in case someone says performancebased payment has tried and failed
AAN Leadership Uses Bonuses:
AAN Leadership Uses Penalties:
Using Incentives: Some Pictures
Would you clip that coupon?
Would you clip that coupon?
Enjoy your latte!
• CMS Physician Quality Reporting Initiative
(PQRI): 1.5%
• CMS-Premier demonstration:
– Top 10% of hospitals get extra 2% of selected
covered payments, second 10% get 1%