New York State Demonstration Grant
Pay for Performance
The New York Quality Alliance
Performance & Measurement to Drive
Quality of Care
NY Chapter of the American
College of Physicians and the
Physician Alliance
Presentation Outline
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Health Care Quality: The Case for Change
Pay for Performance as a Driver for Change
New York State Department of Health
Demonstration Projects
New York Quality Alliance (NYQA)
 Physician Alliance (PA)
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Chartered Value Exchanges: The Next Wave
Learning Objectives

The physician will understand the extent of concerns about the quality, cost & availability of
health care services in the US.
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The physician will become familiar with national organizations addressing health care quality and
learn about standards for development and use of performance (quality) measures; The physician
will understand the potential benefits and limitations of performance measurement and pay-forperformance programs.
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The physician will learn about the New York State Department of Health P4P projects and be
able to define the terms New York Quality Alliance (NYQA) and the Physician Alliance (PA).
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The physician will understand Chartered Value Exchanges and the four cornerstones of value
driven health care.
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The physician will understand the specifics regarding the NYQA/PA and their role within the
NYDOH Grant.
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The physician will be educated regarding the 10 HEIDIS measures that will be utilized in the
NYSDOH P4P Grant including their specifications.
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The physicians will be provided information regarding best practice guidelines for the selected
measures including, where available, tools to facilitate provision of efficient effective care,
complete documentation and accurate billing.
The Need to Change
Why The Status Quo is Not
Acceptable
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Costs continue to rise
Over 47 million citizens are without insurance
No clear association between spending and quality
Perception that current payment methodologies
are misaligned- pay the same for care regardless of
the quality of care provided. Pay for Performance
(performance based reimbursement) programs are
designed to align incentives
The Needs Of The Uninsured Are
Not Being Met
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Declines in health insurance coverage have been recorded in all
but four years since 1994.
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1994: 36.5 million nonelderly individuals were uninsured
2006: 46.5 million nonelderly individuals were uninsured
In spite of substantial growth of the Medicaid population
83% of uninsured are from working families
Additional cost of the uninsured: over $100 billion annually
Worse health outcomes for the uninsured
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25% increase in mortality
Cancer diagnosed in later stages
Use of ER for routine care
Sources: Agency for Healthcare Quality and Research; American College of Physicians, Employee Benefit Research Institute
US Health Care Spending, % of GDP
18
16
2005: 16.0%
14
12
10
8
6
4
1960
1929=4%
1970
1980
1990
2000
Source: CMS
Source: Congressional Budget Office report, The Long-Term Outlook for
Health Care Spending, Nov. 13, 2007
Health care outstrips inflation
Source: Kaiser Family Foundation (2005)
Percentage of Patients Receiving Recommended
(Evidence-Based) Care
Average 54.9%
Hip Fracture
Atrial Fibrillation
Pneumonia
Diabetes
COPD
CHF
CAD
Low Back Pain
Breast Cancer
0%
20%
40%
60%
80%
100%
Source: McGlynn, et. al., The quality of health care delivered to adults in the
United States, N Engl J Med 2003; 348:2635-45
National Health Care Spending 2005

$2 trillion ($6,697 per capita)
Growth higher than inflation for decades
 6.9% increase from 2004
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16.0% of GDP
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Highest in the world
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Other developed countries: 8-12%
7th largest economy in the world
Medicare $408 billion
Medicaid $291 billion
Figures in actual dollars. Data from CMS
The Future
• Health Care spending in 2016
– $4.1 trillion
– 20% of GDP
– Annual rate of increase 6.5-7.0%
• Estimate based on projection of current trends
– Assumes:
• optimistic economic projections
• conservative spending projections
• no change in fundamental structure of the system
• Medicare will grow 7.5-9.0% annually
• Unknown cost of new technologies and standards of
practice
– Implantable defibrillators
– Apo-A1 Milano
– 64-slice CT scanners for cardiac disease
Data from CMS reported in Poisal, JA. et. al., Health Spending Projections Through 2015, Health Affairs web exclusive Feb 21, 2007
The New Vision
• The Value Equation
Quality
Value 
Cost
• Are we currently getting value?
– Medicare spending: 50% in the last year of life
– Many studies: more Medicare spending does not
prolong life, improve quality of life or result in higher
quality of care
– US ranks low vs. other countries in commonly accepted
measures of health care quality and efficiency
The Future is Here
Clearly, the focus of the health care debate is
moving toward demanding efficient and
effective care and only paying when such care
is provided. Quality measurement is embraced
as fundamental to quality improvement and
increasingly Pay for Performance is being
investigated and implemented in multiple
forms.
The Field of Quality Measurement &
Reporting is Getting Crowded
• National Committee for Quality Assurance (NCQA)
-- Founded 1990 to ensure quality of care to health plan members, develops
Health Effectiveness Data Information Set (HEDIS) measures
-- www.ncqa.org
• New York Quality Assurance Reporting Requirements (QARR)
– NYS Department of Health (NYSDOH) collects QARR measures from all
NY managed care plans health plans, based on HEDIS since 1996
– www.nyhealth.gov/health_care/managed_care/reports/
• National Quality Forum (NQF)
-- Created in 1999 to develop a national strategy for health care quality
measurement and reporting.
-- A not-for-profit, public-private, membership organization with broad
participation from all sectors of the health care system including consumers
-- www.qualityforum.org/about/
Quality Measurement & Reporting
• Institute of Medicine Reports
– To Err is Human, 2000; www.iom.edu/?id=12735
– Crossing the Quality Chasm, 2001; www.iom.edu/?id=12736
• AMA Physician Consortium for Performance Improvement
-- Established 2000 to develop performance measures for physicians from
evidence-based clinical guidelines for select clinical conditions
-- Broad representation from the “house of medicine” with AHRQ and the
Center for Medicaid and Medicare Services (CMS)
-- www.ama-assn.org/ama/pub/category/2946.html
• Hospital Quality Alliance (HQA)
– Established 2002 to make information about hospital performance
accessible to the public and to encouraging efforts to improve quality
– www.hospitalqualityalliance.org; www.HospitalCompare.hhs.gov
Quality Measurement & Reporting
• AQA Alliance
• In 2004 medical specialty societies, insurance plans and the Agency for
Healthcare Research and Quality (AHRQ), joined to determine how to
most effectively and efficiently improve performance measurement, data
aggregation, and reporting in the ambulatory care setting
• Originally known as the Ambulatory Care Quality Alliance
• www.aqaalliance.org/
• Quality Alliance Steering Committee (QASC)
• Established in 2006 to develop an overall framework for the effective use
of standard health care quality and cost measures nationwide
• www.brookings.edu/projects/qasc.aspx
Quality Measurement & Reporting
• Value Driven Health Care Initiative
– Established 2006 by executive order
– Four cornerstones: interoperable health information technology; measure
and publish quality information; measure and publish price information;
promote quality and efficiency of care.
– Certified Value Exchanges (CVE): local and regional multi-stakeholder
collaborative organizations working to improve quality and value in health
care by measuring the performance of local health care providers and
reporting these findings publicly.
– NYQA designated one of 14 nationally recognized CVEs
– www.hhs.gov/valuedriven/index.html
– 64-slice CT scanners for cardiac disease
Pay For Performance
Pay For Performance
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Pay-for-performance programs are growing,
but there is little evidence on their
effectiveness or of their potential unintended
consequences and effects on the patientphysician relationship.
Pay-for-performance has the potential to help
improve the quality of care if it can be aligned
with the goals of medical professionalism.
Annals Int Med 2007;146:792-794
Pay – For -Performance
“It is no longer enough to take good care
of the patient in front of you. To improve
results, we must find ways to help patients
who do not come to the office regularly.
Keeping track of all this data requires a
whole new set of skills and resources; this
is new work, it costs time and money and it
has to be compensated.”
Dr Janet (Jessie) Sullivan, Chief Medical Officer of Hudson Health Plan)
PROFESSIONAL ISSUES
Pay-for-performance programs stir debate
Ethics Forum. Nov. 6, 2006.
Examples of P4P Initiatives
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CMS
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NY State
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Hospital Core Measures
PQRI
Ambulatory “Core Measures”
NYQA Grant and other similar pilots
Commercial and Medicaid Health Plans in NY
Purchaser/Employer
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Bridges to Excellence
Pay For Performance: Issues To
Consider
Measures
 Data collection
 Data validation/reconciliation
 Reports
 Impact on care and cost, desired and
otherwise
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Measures
Ideal Measures
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Valid
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Evidence based
Reliable
Identify real differences in provider quality
 Must be risk adjusted
 Actionable
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Measure what is intended
 No unintended consequences
 Measures should be Feasible
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Measure Collection
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Types of Measures
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Data sources
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Process
Outcomes
Structural
Administrative/claims and billing data
Medical Record Abstraction
Electronic clinical data: EHR, registries, RHIOS
Hybrid combinations
Data reconciliation
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Opportunities to review and correct errors prior to publication
Discrepancies between data sources
Missing Data
Transcription and coding errors
Reports
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Attribution issues
Whose patient is it?
 Reports for group vs. individual
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Small numbers
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Samples too small for valid conclusions
Report timeliness
Time for claims to be filed and processed
 Time for abstraction, aggregation, processing data
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Report actionable
Identified vs de-identified data
 Current but incomplete vs. complete but out-of-date
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Potential Benefits
System
 Reduce costs and improve
 underuse, overuse, misuse
Physician
 Economic
 Quality
of Care
 Preparing for the Future
quality
Ethical Concerns
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Inequitable impact
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Inefficient use of resources and tendency to focus on
efficiency (cost) not other facets of quality
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Unreliable (therefore unfair) measures
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Concern that Pay for performance is
deprofessionalizing
Matthew Wynia, MD, MPH
Institute for Ethics at the American Medical Association
Inequitable impact
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Physician
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Large practices with HIT will win
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Those already doing well will win
Patient
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Non-adherent patients will be shunned
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Minorities/elderly/immigrants will be shunned
P4P Aimed At Hitting Target Performance
Level Might Be Counterproductive
Organizations in this area
have little hope of gaining
the bonus
Organizations in this area
have an incentive to improve
Organizations in this area
will get the bonus with no
additional work
Quality
P4P Target
Will the Vulnerable be Neglected?
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Some evidence from public reporting…
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Pt transfers to Cleveland Clinic from NY increased 31% after
public reporting on CABG, sicker patients more likely to be
sent. (Omoigui 1996)
59% of internists in PA say harder to find surgeon for high
risk patients after public reporting (Schneider 1996)
Such programs could also result in the de-selection of
patients, “playing to the measures” rather than focusing
on the patient as a whole……..
Annals Int Med 2007;146:792-794
What do physicians say?
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“Dr. Brook correctly states that the use of physicianspecific outcome data would radically change how we
practice medicine. Based on his system, I would assess each
patient's risk. If it differed dramatically from the
"sickness" scale that he proposes, I would consider asking
the patient to seek care elsewhere.”
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Stephen Clement, MD, Annals of Intern Med 1994
“If my pay depended on A1c values, I have 10-15 patients
whom I would have to fire. The poor, unmotivated, obese
and noncompliant would all have to find new physicians.”
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Physician in a 2006 survey on P4P
“39% of physicians in this study were willing to discharge
hypothetical patients who were nonadherent or questioned
the physician’s decision-making.”
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Farber et al. JGIM 2007
Inefficient Use of Resources
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Documentation (rather than quality) improves
Inappropriate emphasis on what’s measured
Little
more $ for lots more work – not enough to offset
costs of measurement
“ Incentives based on a handful of measures of quality
may encourage physicians to focus their efforts on
improving quality in the areas targeted by the programs,
neglecting other important aspects of care” (Epstein et al. 2004)
Unfair Measures: Reliability
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Importance of data aggregation
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“The largest participating plan in the IHA program
has about 1.4 million members, less than 23% of the
entire 6.2 million population. Even a plan of this
size using its own data often lacks sufficient sample
size to allow for statistical reliability.” (Integrated
Healthcare Association, 2006)
Unfair Measures: Data Reliability

Assigning responsibility (attribution)
Medicare beneficiaries see a median of 2 PCPs and 5
specialists working in 4 different practices per year
 35% of patients’ visits are with their assigned
physicians
 33% change PCP each year
 A PCP’s “assigned” patients are only ~39% of the
Medicare patients they see

(Pham et al. 2007)
Unfair Measures: Data Reliability

Not enough patients per practice for reliable
results year to year
Among 232 PCPs, 4% of the variance of their
diabetic patients’ outcomes was attributable to
physician practice patterns
 Reliability of measures never better than 0.40
 Would need >100 diabetic patients to get reliability
of 0.80
 Outliers could dramatically improve performance by
dropping 1-3 patients
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Hofer 1999
Impact on the Profession of Medicine
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Doctors shouldn’t be motivated by greed…
“…P4P programs insinuate that the existing moral and
social incentives for providing excellent care are not
sufficient – that financial incentives will succeed where
the clinician’s professional character failed.” (Satin,
2006)i.e., If they work… it would be embarrassing.
“Increasing external incentives reduces internal motivation… [so
the worst problem with P4P would be] “if you ended
up with a system where… doctors only did anything
because they were paid for it and had lost their
professional ethos.” Martin Rowland, NHS (Health
Affairs interview, Sept 2006)
A Possible Path to Take
New York State
Department of Health
Demonstration Grant
New York State Demonstration P4P
Grant
The legislative intent of the demonstration project is to
promote the development of pay-for performance
programs, involving multiple payers that achieve
increased quality and cost effectiveness.
The
to:
legislation extended authority to the Commissioner of Health
A. Convene a workgroup to delineate the ambulatory and
inpatient measures of performance to be used in the
demonstration programs;
B. Oversee a grant program which will provide funding to
purchaser and provider coalitions to establish regional pay-forperformance programs
The Process

The NYS DOH Commissioner’s Workgroup convened in July
2005 . The workgroup consisted of representatives from
managed care plans, hospitals, statewide and regional provider
associations, payers, labor unions, and consumers.

Charged with seeking consensus on the inpatient and ambulatory
measures to be included in the pay-for-performance
demonstrations, the workgroup met on four occasions between
July and December 2005.
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In May 2006 DOH issued a RFP making $9.5 million available to
support demonstration projects for a period of two years.
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The workgroup agreed to begin with administrative data, but
acknowledged that this was just a first step and over the long run
administrative data needed to be replaced with outcome data.
Elements of The Demonstration Grant

To study and test incentive programs, including
performance-based payments to physicians, hospitals
and clinics that provide high-quality care to their
patients.
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The state funding will pay project costs and help fund
rewards to providers.

Participating health plans will select the incentive
structure they use, but typical incentives include
bonuses or increases in reimbursement rates provided
to physicians, hospitals and clinics based on their
performance meeting various measures of quality.

The projects are part of the State Health Department’s
efforts to encourage providers and insurers to work
collaboratively to improve the quality of care that is
delivered in New York State.

State Health Commissioner Richard F. Daines, M.D.
said: “Evidence-based care that improves patients’
ability to live healthier, productive lives is crucial to
reforming our health care system and reducing health
care costs. This is an area where the public and private
sectors can work together to foster change.”
The Four State Demonstration
Projects
1.
Independent Health Association Inc. (Buffalo)
2.
Taconic Health Information Network and Community Regional
(THINC RHIO) in Hudson Valley Region)
3.
Montefiore Medical Center (Bronx)
4.
*New York Health Plan Association (NYHPA)
This project is a statewide collaboration involving 12 health plans – Aetna,
Affinity, CDPHP, Elderplan, GHI HMO, HealthNet, HealthNow, HIP,
Hudson Health Plan, Independent Health Association, MVP, and Oxford.
HPA will partner with physician, business and consumer groups, Capital
District hospitals and RHIOs .
New York Health Plan
Association (NYHPA)
Demonstration Grant
NYHPA Demonstration Grant
Overview
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Goal
Collaborators
Structure
Clinical Measures
Data Collection/Management/Validation
Timelines
Physician Reports
Incentives
NYHPA Demonstration Grant Goals

Project is to promote patient safety and quality of
care through the development of pay-forperformance programs in New York State.

A two year demonstration Project.

Brings all the stakeholders together Patients,
Physicians and Health Plans, and consumer
advocates.
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Develop policies and procedures for long lasting
P4P programs in New York.

Develop a mechanism to have ongoing Dialogue
with the Health Plans
Grant Elements
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The New York State Health Plan Association through
the grant has created the New York Quality Alliance
(NYQA), which is a multi-stakeholder collaborative
partnership that will guide the adoption and use of
evidence based measures to: measure, report and drive
improvements.
The reports generated under the guidance of NYQA
will be used in pay for performance programs initiated
by the Health Plans so that physicians will be
financially rewarded that have good patient outcomes.
Grant Elements

Standardized set of measures for all participating
Health Plans, so a physician collects one data set.

Establish one set of goals to reach a financial incentive
(Because of anti-trust concerns, the amount of the
financial incentives for each indicator will be
established by the individual health plan.)

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Data Collection will be administrative billing data.
Subcontract with NYACP to educate physicians
regarding the Demonstration Grant and to support
development of and staff the Physician Alliance
Clinical Measures
The project will use tested and familiar HEDIS®/QARR measures;
to simplify data collection only administrative (claims) data will
be used.
Preventive Care Domain (women’s services)



Breast Care Screening
Chlamydia Screening
Cervical Cancer
Heart Disease Domain

Persistence of Beta-blocker therapy post MI
Diabetes Domain
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HbA1C Testing
Lipid Measurement
Urine Protein Screening
Eye Exam in Diabetics
Appropriate Antibiotic Use (pediatric)
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Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Appropriate Testing for Children with Pharyngitis
Time Line For NYDOH Grant
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2007 will be the baseline year –a baseline report will be
distributed toward the end of 2008. (Don’t wait until
then to start!)
2008 will be the measurement year. That’s now, the
clock is ticking.
The data collection will consist of health plan
administrative data that will be supplemented with an
adjusted medical record factor, such as the hybrid
claims adjustment factor utilized by the Massachusetts's
Health Quality Partner ( MHQP).
Grant Incentives

Grant funding is available due to matching funds being
provided by payers participating in the demonstration
project and the DOH.

The Health Plans have committed $8,740,968 in potential
incentives.

The NYS Department of Health have awarded $1,379,278 in
matching incentives.
Grant Incentives

All Plans will collect data on all 10 measures
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All plans will utilize the same report for
determining performance payment

The determination for achieving payment will
vary from plan to plan
Bonus Payments
Health plan specific payments are within the
control of the plans due to
ANTITRUST concerns
New York Quality
Alliance
multi-stakeholder collaborative partnership
created within the Grant that will guide the
adoption and use of evidence based measures to:
 Measure
 Report
 Drive
improvements.
NYQA Collaborators
PROVIDER GROUPS
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NY Chapter of the American College of
Physicians
NYS Academy of Family Physicians
Medical Society of the State of NY
NY Medical Group Mgmt. Association
Hudson Headwaters Health Network
Institute for Urban Family Health
Community Health Care Association of
NYS
CONSUMER GROUPS
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American Heart Association
Niagara Health Quality Coalition
NY Diabetes Coalition
Center for Medical Consumers
BUSINESS
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Business Council of NYS
New York Business Group on Health
HEALTH PLANS
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Aetna
Affinity Health Plan
CDPHP
Elderplan
GHI HMO
Health Net
HealthNow NY
HIP of New York
Hudson Health Plan
Independent Health
MVP Health Care
Oxford Health Plans
NYQA Work Group Structure and Function
A work in progress
Workgroups

Governance
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Data Management
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Project Evaluation
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Operations

Legal
Physician Alliance
NYQA Structure and Function
Governance Workgroup
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Develop general operating rules for the NYQA
Synthesize the materials and produce general operating
principles until a formal structure is in place
Develop a mission statement and framework to allow the
project to meet the grant deliverables and ensure an open and
transparent process
Development of a permanent structure (i.e. bylaws, tax
status) that will enable to NYQA to continue beyond the
DOH grant funded component
NYQA Structure and Function
Data Management
Workgroup
Review the responses to the Request for
Information from potential data mangers and assist
in the selection of a NYQA project vendor
 Responsible for issues related to the data inputs and
outputs as well as issues related to performance
benchmarking, inpatient measurement and reporting
for the AMI project component and development of
a matching funds allocation methodology

NYQA Structure and Function
Project Evaluation Workgroup
Develop the questions to be addressed to the project
evaluator.
 Develop the desired framework for the project
evaluation and will work to define the deliverables
from the evaluator that will form the contract.
 Monitor the evaluation progress and assist with the
ongoing evaluation data collection and analysis.

NYQA Structure and Function
Operations Workgroup
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Responsible for vetting project component issues,
not addressed by the other workgroups that will
need to be addressed by the voting members of the
NYQA
Legal Workgroup

Develop standard Business Associate Agreements
and Data Use Agreements.
NYQA Physician Alliance
 Structure
and Membership

Formed in 2007, the Physician Alliance, spearheaded by the
New York Chapter of the American College of Physicians
consists of a diverse geographically dispersed group of
primary care physician organizations across New York State.

The Alliance membership is composed of nine physician
representatives from the American College of Obstetrics and
Gynecology, the American Academy of Pediatrics, New York
Chapter American College of Physicians (Internal Medicine),
the New York Chapter of the American Academy of Family
Physicians and the Medical Society of the State of New York.
NYQA Physician Alliance

Goals of Physician Alliance

Short term, the PA is committed to working jointly
with the NYQA to develop fair and reasonable
practices of data collection and scoring standards for
the P4P demonstration project, funded by New
York State over the next two years.

The long range goal of the PA will be to work with
the NYQA and other entities to develop fair,
reasonable and SUSTAINABLE policies and
procedures for quality improvement truly impact
patient care and safety in a cost effective fashion.
NYQA Physician Alliance

Responsibilities of Physician Alliance

Define and promote the use of nationally
recognized best practices for the 10 selected
clinical measures adopted from the National
Committee for Quality Assurance Health Plan
Employer Data and Information Set (NCQA/
HEDIS®) that the health plans have all agreed
upon to measure and report
NYQA Physician Alliance

Responsibilities

(CONTINUED)
Develop the core curriculum for NYQA and with NYACP
provide education for Primary care physicians.

The core curriculum will include the description of the
P4P Grant, NYQA and the PA, best practice materials
and administrative specifications. The training will
involve web-based materials, performance improvement
tools and checklists that will allow practices the ability to
evaluate themselves. The educational materials will be
available on the web, CD and in traditional lectures
modalities.
NYQA Physician Alliance

Responsibilities


(CONTINUED
Represent clinicians interest in the development of the data
collection methodology, measurement benchmarking, measurement
reports and project evaluation;

Provide input to the NYQA on proposed data collection methodology and
aggregation standards;

Provide input to the NYQA on the “adjustment factor” to be employed for
selected HEDIS measures;
Identify process improvement activities, develop checklists to
facilitate implementation of best practices and develop corrective
action plans to assist clinicians with measurement improvement;
NYQA Physician Alliance
■
Responsibilities
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(CONTINUED
Work with the NYQA to develop fair, reasonable and
sustainable policies and procedures for quality improvement
designed to impact patient care and safety in a cost efficient
fashion.
Education to Improve coding/compliance so that the
correct information can be obtained form billing data.
Development of tools to document compliance
Conduct 30 total presentations (10 hospital Grand Rounds
and 20 conferences, meetings or other educational events).
Clinical Measures
The project will use tested and familiar HEDIS®/QARR measures;
to simplify data collection only administrative (claims) data will
be used.
Preventive Care Domain (women’s services)
 Breast Care Screening
 Chlamydia Screening
 Cervical Cancer
Heart Disease Domain
 Persistence of Beta-blocker therapy post MI
Diabetes Domain
 HbA1C Testing
 Lipid Measurement
 Urine Protein Screening
 Eye Exam in Diabetics
Appropriate Antibiotic Use (pediatric)
 Appropriate Treatment for Children with Upper Respiratory Infection (URI)
 Appropriate Testing for Children with Pharyngitis
Preventive Health
(Indicators for Women)

Chlamydia screening
Women 16–25 years as of December 31 of the measurement year who
were identified as being sexually active and had at least one Chlamydia
test

Cervical Cancer
Women 21–64 years of age who received one or more Pap tests to
screen for cervical cancer as of December 31 of the measurement
year.

Breast Care Screening
Women 42–69 years as of December 31 of the measurement year who
have had a mammogram to screen for breast cancer during the
measurement year and the year prior to the measurement year
Indicators for Heart Disease

Persistence of Beta-blocker Therapy After a Heart Attack
The percentage of members 18 years of age and older during the measurement year
who were hospitalized and discharged alive from July 1 of the year prior to the
measurement year to June 30 of the measurement year with a diagnosis of acute
myocardial infarction and who received persistent beta-blocker treatment for six
months (180 days) after discharge as evidenced by pharmacy claims data (prescriptions
filled.)
Indicators for Diabetes
(For members aged 18-75 identified with diabetes based on an encounter during
the measurement year with either ICD-9 diagnosis codes: 250.xx, 357.2,
362.0x, 366.41, 648.0x; or DRG 294,295)

HbA1C Testing

Lipid Measurement

Nephropathy Screening

Eye Exam in Diabetics
A retinal or dilated eye exam by an eye care professional as of December 31st of the
One A1C test as of December 31st of the reporting year evidenced by CPT code
83036 or 83037; or CPT Category II Code 3044F, 3045F, 3046F or 3047F; or LOINC
code 4548-4, 4549-2 or 17856-6.
One LDL-C test as of December 31st of the reporting year as evidenced by CPT
codes 80061,83700, 83701, 83704, 83716 0r 83721; or, CPT Category II code 3084F,
3049F or 3050F; or, LOINC 2089-1,12773-8, 13457-7, 18261-8, 18262-6, 22748-8, 24331-1 or 39469-2.
One nephropathy (microalbumin) test as of December 31st of the reporting year as
evidenced by listed CPT, CPT Cat II, or LOINC codes; or, evidence of nephropathy
indicated by a positive macroalbumin test confirmed by automated laboratory result
data; or evidence of ACE inhibitor/ARB treatment or treatment for nephropathy
indicated by listed CPT, CPT cat II, HCPCS, ICD-9, UB Revenue, or DRG codes.
reporting year or a negative retinal exam by an eye care professional in the prior year.
Indicators for Children
 Appropriate Treatment for Children with Upper
Respiratory Infection (URI)
The percentage of children 3 months – 18 years of age who had an encounter
with a diagnosis of acute upper respiratory infection (ICD9-CM code 460 or
465) and who were not dispensed an antibiotic for the episode. Children with
a listed competing diagnosis or who received antibiotics in the prior 30 days
are excluded.

Appropriate Testing for Children with Pharyngitis
Percentage of children 2-18 years of age who had an encounter with only a
diagnosis of pharyngitis (ICD-9-CM codes 462, 463 or 034.0), who were
dispensed an antibiotic and who received a group A streptococcus test for
the episode evidenced by listed CPT or LOINC codes. Children who
received antibiotics in the prior 30 days are excluded.
Data Collection, Management and
Validation



A Data Manager (vendor) will aggregate and analyze the
participating health plan claims and lab information and
create measurement reports. The data from all NYS
P4P Demonstration projects will be forwarded to
IPRO for analysis.
Public Reporting is not a component of this
demonstration project
The Physician Alliance will be involved in all aspects of
data collection, management and appeals process.
How to Succeed with Performance
Measures

#1 Designate an office “Quality Manager,”
--someone to be responsible for performance measurement

#2 Bill all services provided

#3 Code accurately and completely
-- review encounter forms to be sure that codes used will count.
-- verify with your billing company that correct codes are billed.

#4 Request current “actionable” reports from plans and
review baseline NYQA report
-- to improve coding and billing practice
-- to identify practice patterns not consistent with measured standards
-- to identify patients who need to be called in for care

#5 For future success, reinvest bonus money
-- to strengthen skills and resources related to data management:
-- consider implementation of a registry or an electronic health record
with a registry function. .
Participating Health Plans
Plan
Contact
Hudson Health Plan
Marlene Ripa (914)372-xxxx or your
Hudson Health Plan Provider relations
representative
Methodology for
award
TBD—will coordinate with existing p4P
programs and with THINC RHIO project
Summary





The status quo is not sustainable: cost, quality, access
Performance (Quality) Measurement is increasingly seen
nationally and locally as a cornerstone of building a better health
care delivery system
Pay-for-performance programs have been embraced by CMS and
health plans and are increasingly common
The “House of Medicine” is already extensively present on the
national scene; The Physicians Alliance of the NYQA gives New
York physicians a voice and a vote in how measures are
implemented locally
To survive and thrive learn to manage data as well as you
manage patients.
Why Should Physicians Be Involved?

You have physician representation on the project and
input.

Physicians will be working with the Health plans to
adopt FAIR and REASONABLE principles for P4P.

Get in on the Ground Floor and Help shape the future!

Next steps for physicians.

Physician participation and support is critical.
Value Exchanges
 NYQA
has been designated a Certified
Value Exchange
Value Exchanges

Multi-stakeholder collaborative organizations that are
working to improve quality and value in health care by
measuring the performance of local health care
providers and reporting these findings publicly.

The plan would be to bring the local collaboratives into
a nation-wide system, and the collaboratives would use
nationally-recognized standards to measure and
improve quality of care in their local areas.

The chartered collaboratives would be called Value
Exchanges
Value Exchanges



The Exchanges could also pioneer new quality
improvement strategies and share results through the
Learning Network.
The new system would be administered by HHS'
Agency for Healthcare Research and Quality (AHRQ).
AHRQ Director Carolyn M. Clancy, M.D., said
providers would lead in the development of standards.
Advance the four cornerstones of Value-Driven Health
Care.
Four Cornerstones of Value-Driven
Health Care

Interoperable Health Information Technology
(Health IT Standards):



Interoperable health information technology has the potential
to create greater efficiency in health care delivery.
develop standards that enable health information systems to
communicate and exchange data quickly and securely to
protect patient privacy.
all health care systems and products should meet these
standards as they are acquired or upgraded.
Four Cornerstones of Value-Driven
Health Care

Measure and Publish Quality Information (Quality
Standards):



To make confident decisions about their health care
providers and treatment options, consumers need quality of
care information.
Similarly, this information is important to providers who are
interested in improving the quality of care they deliver.
Quality measurement should be based on measures that are
developed through consensus-based processes involving all
stakeholders, such as the processes used by the AQA (multistakeholder group focused on physician quality measurement)
and the Hospital Quality Alliance.
Four Cornerstones of Value-Driven
Health Care

Measure and Publish Price Information (Price
Standards):



To make confident decisions about their health care
providers and treatment options, consumers also need price
information.
Efforts are underway to develop uniform approaches to
measuring and reporting price information for the benefit of
consumers.
In addition, strategies are being developed to measure the
overall cost of services for common episodes of care and the
treatment of common chronic diseases.
Four Cornerstones of Value-Driven
Health Care

Promote Quality and Efficiency of Care
(Incentives):


All parties - providers, patients, insurance plans, and payers should participate in arrangements that reward both those
who offer and those who purchase high-quality,
competitively-priced health care.
Such arrangements may include implementation of pay-forperformance methods of reimbursement for providers or the
offering of consumer-directed health plan products, such as
account-based plans for enrollees in employer-sponsored
health benefit plans.
Value Exchanges

Participation as a Chartered Value Exchange offers
several benefits.


Members can join their peers in a nationwide Learning
Network sponsored by the Agency for Healthcare Research
and Quality (AHRQ). Often called communities of practice,
A Learning Network provides peer-to-peer learning
experiences through facilitated meetings, both face to face
and on the Web. The network also features tools, access to
experts, and an ongoing private Web-based knowledge
management system.
Value Exchanges
The Learning Network allows members to:






Share their experiences.
Identify promising practices.
Point out gaps where innovation is needed.
Raise issues for national consensus-building organizations
Provide an on-the-ground perspective to participate in
setting national priorities for improvement.
Chartered Value Exchanges will have access to summary
Medicare provider performance results, which can be
combined with similarly calculated private-sector results
to produce and publish all-payer performance results.