Dennis P. Scanlon, Ph.D. Jeff Beich, Ph.D. Patti Simino Boyce RN, Ph.D. AcademyHealth, June 30, 2009

Transcription

1 Dennis P. Scanlon, Ph.D. Jeff Beich, Ph.D. Patti Simino Boyce RN, Ph.D. AcademyHealth, June 30, 2009

2 Many policymakers and stakeholder organizations have suggested the need for sustainable community level QI capacity It is not clear what a successful model of sustainable community level QI capacity looks like e.g., Institute for Clinical Systems Improvement (ICSI) in Minnesota With support from the Robert Wood Johnson Foundation and guidance from George Washington University, AF4Q communities are striving to develop plans for building local QI capacity Work in this area is in the early stages (e.g., pilot activities) Being informed by technical assistance from national experts (The MacColl Institute in WA)

3 Key Questions of Interest: How to get participation of practices, including competing practice organizations? Where does the financing come from? Is it scalable? What is the best organizational configuration? What model to use? Practice based consulting services Information warehouse Payment incentive model development

4 Regional Quality Improvement (RQI) initiative sponsored by The Center for Health Care Strategies (CHCS) Four community-based initiatives targeting improvement in chronic care delivery Goal: Motivate Medicaid and private insurers to work together towards common QI objectives Rochester RQI Targeted improvement in diabetes care among safety net primary care practices Participants: Local health plans, Medicaid, Dept. of Health, American Diabetes Association, local business group on health

5 RQI provided incentives to physicians to participate in NCQA s Diabetes Physician Recognition Program (DPRP) Incentives included Honorarium of $1000 per physician/per year of participation Payment of NCQA s DPRP fees ($350 individual/$2,700 group) Provision of consulting services to assist with quality improvement activities and DPRP application process Provision of patient specific registry reports combining claims data from multiple insurers Intervention targeted 11safety net primary care practices in the Rochester, NY vicinity

6 Developed by NCQA in conjunction with ADA to promote improvements in diabetes care Physicians may participate individually or as a group Participating physicians must audit 25 charts for results on 10 performance measures Performance measures are assigned weights and threshold values (see next slide) Physicians achieving a score of 75 or higher (out of 100) receive DPRP recognition The Bridges to Excellence program uses DPRP

7 NCQA 2008 DPRP Requirements and Scoring Criteria Diabetes Recognition Measures Threshold (% of patients in sample) Points HbA1c Control >9.0% * 15% 15 HbA1c Control <7.0% 40% 10 Blood Pressure Control >=140/90 mm Hg * 35% 15 Blood Pressure Control <130/80 mm Hg 25% 10 LDL Control 130 mg/dl * 37% 10 LDL Control <100 mg/dl 36% 10 Diabetic Retinal Examination 60% 10 Foot Examination 80% 5 Nephropathy Assessment 80% 5 Smoking Status & Cessation Advice 80% 10 Total Points 100 (*) Denotes poor control Points needed to Achieve Recognition 75

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9 Objective: To assess the feasibility and impact of a pay-for-participation pilot program Research Questions Was the program effective in recruiting physician participation? What factors motivated participation. Was the program effective in achieving improvements in diabetes care among the participating practices? What were the characteristics of the physician groups receiving DPRP recognition? Is this program scalable at the community level?

10 Exploratory case study of a pilot program Caveat: Lack of pre-post data, control sites and small sample size limits generalizability of our findings Data collection Physician performance data relative to DPRP indicators Interviews with key members of the RQI leadership team and other stakeholders Interviews with physician managers and QI specialists within participating practices Participation in on-site RQI meetings and telephonic progress reports with site leader and CHCS staff Observations from QI consultant using a standard data collection protocol

11 Practice Number of Participating Physicians Achieved DPRP Recognition FQHC EMR Registry Multi-site practice Teaching site with residents A 1 1 No Yes Yes No No B No Yes Yes Yes No C 19 0 No Yes No No Yes D 11 0 Yes No Yes Yes Yes E 2 2 Yes No Yes No No F 4 3 No Yes No No Yes G 4 4 Yes No Yes Yes No H 1 0 No No No No Yes All (47%)

12 Eight of 11 invited practices participated 37 (47%) of 79 participating physicians received DPRP recognition Relative to DPRP performance measurement indicators, practices performed: Well in LDL and BP control Moderately well in HbA1c control, foot examinations and neuropathy assessment Poorly in documentation of diabetic retinal exams (see next slide)

13 Percentage of physicians submitting individual DPRP applications reaching indicator thresholds in their first round of participation Threshold % Meeting Diabetes Recognition Measures (% of patients) Threshold HbA1c Control >9.0% 15% 60% HbA1c Control <7.0% 40% 75% Blood Pressure Control >=140/90 mm Hg 35% 83% Blood Pressure Control <130/80 mm Hg 25% 81% Diabetic Retinal Examination 60% 13% Smoking Status & Cessation Advice 80% 88% LDL Control <100 mg/dl 36% 100% LDL Control 130 mg/dl 37% 94% Foot Examination 80% 60% Nephropathy Assessment N = 52 80% 65%

14 General Expansion of patient education and facilitation of patient self-management activities Use of diabetes protocols/flow sheets Introduction/enhancement of patient registries Increasing the frequency of visits for individuals with poor control of key clinical indicators (e.g. HbA1c) Indicator Specific Signage in exam rooms requesting removal of shoes Development of ophthalmology referral forms for diabetic retinal exams Introduction of on-site HbA1c analyzers

15 NCQA s DPRP as a Program Platform DPRP process was more difficult and timeconsuming than originally estimated Sampling requirements and chart auditing process was challenging, particularly for practices without dedicated QI staff Original motivation for engaging the QI consultant was to assist practices in the engagement of QI activities. The majority of the consultant s time was spent on assistance with DPRP procedures.

16 Reasons for Participating in the DPRP Program: 75% of practices noted that provision of incentives (primarily the honorarium) was a significant factor in their decision to participate while the DPRP program was appealing, the honorarium greased the wheels in our decision process. All practices noted their desire to improve quality. The RQI provided a good opportunity to interact with peers and engage in quality improvement activities All practices were interested in measuring their performance against nationally recognized indicators Chart audit process provided an opportunity to do this using data from their own records rather than from external sources (data trust issue) One physician manager noted: While it was not our primary reason for participating (in the program) the prestige of having certification is appealing in and of itself.

17 Program Outcomes Receipt of DPRP recognition was the result of both pre-existing performance and process improvements that occurred during the application period Even the practices that did not receive DPRP recognition engaged in process improvement during the initiative Due to lack of baseline performance data we were unable to assess the impact of process changes on performance measures Practice characteristics and DPRP outcomes Size of practice unrelated to receipt of DPRP recognition All practices with EMR and registry received recognition Practices did not find claims-based registry to be useful due to attribution and timeliness issues QI consultant observed that practices with strong physician leadership and established QI infrastructure were more likely to receive recognition

18 Pay-for-participation may help to motivate physician quality improvement, but difficult to know if this is cost-effective due to the pilot study design May simply be documenting existing performance Provides up-front compensation to offset physician and staff time devoted to QI Sustainability: Absent other incentives, will the participating practices continue their QI activities in the future? Need better designed research studies to examine different approaches to community wide quality improvement Ability to control for selection effects Adequate pre-period data to document whether care is changing as opposed to simply being measured for the first time Long enough time horizon to capture program impacts More granular documentation of practice level changes More information on models for financing community level QI Who pays? (CMS, commercial insurance, philanthropy, practices) Can QI be tied to performance measurement reporting?