Program and Policy Strategies
to Promote Healthcare Quality
for Children
Lisa A. Simpson, MB, BCh, MPH, FAAP
National Director, Child Health Policy, NICHQ
Endowed Chair, Child Health Policy
University of South Florida
Today’s Popular Policy Platforms
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
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Pay for Performance
Health Information Technology
Consumer driven health care
For each…
– What do we know about use and/or its
effectiveness overall?
– What do we know of its use and/or
effectiveness for children?
Pay for Performance (P4P)


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Incentive programs that provide monetary bonuses
to eligible participants linked to specific quality
and/or efficiency standards established by the
program
Initiated by government agencies, employers &
health plans to stimulate quality improvement (one
of the earliest from Aetna in 1987)
Financial rewards based on achievement related to
–
–
–
–
evidence-based clinical quality of care measures
patient satisfaction
efficiency/productivity
infrastructure of the practice (including use of information
technologies)
AMA, Physician Pay for Performance Initiatives, 2004.
P4P Programs

Average incentive payment around 1-5% of a
physician’s total revenue from a given health plan
(AMA, 2004)
– in Anthem BC/BS (NH) in 2001, average bonus payment
$1,183 and the highest bonus payment $15,320
– in IHA program, average group bonus about $200,000 and
will cover 24,000 primary care physicians (200 physician
groups & 7 million beneficiaries)

2004 survey findings:
– Majority of programs were targeted to PCPs, confined to
HMO, fully insured products with annual bonus incentives
based on HEDIS performance measures
– Dramatic growth:
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November, 2004: 84 programs w/ 39 million beneficiaries
March 2005: 104 programs
– By 2006, predicted to increase to 160 programs
Baker & Carter, 2005
AMA, Physician Pay for Performance Initiatives, 2004
Key Trends in P4P Programs
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Product Spread:
– Expansion to PPOs & Consumer Directed Healthcare products
– Expansion to specialists with use of specialty-specific measures
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Changes in Measures:
–
–
–
–
–
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Use of measures for positive savings (generic substitution & efficiency)
Supplementing population-based HEDIS measures
Use of scorecards and actionable results reporting to change behavior
Use of performance results for public reporting
Significant growth in health information technology adoption measures
Changes in types of payments
– Use of adjustable fee schedules instead of annual bonus payments
– Return on investment analyses (i.e., what would have been the
financial and clinical outcome in the absence of a P4P program?)

Center for Medicare and Medicaid Services as a P4P market
driver
Baker & Carter, Provider Pay-for-Performance Incentive
Programs: 2004 National Study Results, 2005.
Landon et al, 2004
PP4P - Pediatric Pay for
Performance

Leapfrog compendium identifies 12
programs (out of 70)
– 4 states (IA, RI, UT, WI) - target health
plans
– Rest target physicians
– 3 BC/BS (IL, MA, MO)

States’ use of quality information
– Varies by product: HMO and PPO
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Rewarding Results
Leapfrog Compendium
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Focus on:
–
–
–
–
well visit (child and adolescent)
immunizations
appropriate antibiotic utilization
asthma (self management plans or
medication management)
– IT. (not clear if applies to peds)
– volume, timeliness, and quality of electronic
encounter data
New Leapfrog Hospital Rewards
Program
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All short term acute care hospitals
Five clinical areas including newborn care accounting
for 33% commercial admissions & 20% commercial
inpatient spending
Newborn care measures include:
– Neonatal mortality
– NICU
– Process of Care -- 80%+ adherence: antenatal steroids for
certain high-risk deliveries
– 3rd/4th degree lacerations
– Computerized physician order entry (CPOE) system
– Leapfrog Quality Index (NQF Safe Practices)
Factors in Determining Compensation
Florida Child Health Provider, 2005
Not a Factor
(%)
Use of clinical
IT
Email
consultation
with patients
Minor Factor
(%)
Major Factor
(%)
71.5
23.2
5.3
No
Yes, Health
plan/HMO
2.1
Yes,
Other
1.7
96.2
Note: sample size varies by question, overall N=1219
Effectiveness of Pediatric PFP Programs:
RCT’s
Citation
(abbr.)
Physicians/Practices
Assigned (N)
Focus
Davidson
(1992)
Well-child
Recommendations
Enhanced FFS (40)
Control (40)
Higher
reimbursement
rates for all in
FFS
No
Hillman
(1999)
Well-child
Recommendations
& Immunizations
Bonus + Feedback (19)
Feedback only (17)
Control (17)
Bonus based on
rank & degree of
improvement
No (but all
groups
improved over
time)
Fairbroth
er (2001)
Childhood
Immunizations
Enhanced FFS (12)
Bonus + Feedback (24)
Feedback only (21)
Bonus based on
compliance rates
Overall
improvement
in FFS & bonus
groups
Reward
Differences
Between
Groups
Today’s Popular Policy Platforms




Pay for Performance
Health Information Technology
Consumer driven health care
For each…
– What do we know about use or its
effectiveness overall?
– What do we know of its use or
effectiveness for children?
Health Information Technology (IT)
Adoption by Physicians

Physicians either routinely or occasionally use:
– 79% electronic billing
– 59% electronic access to patients' test results either
routinely or occasionally
– 27% EMRs and electronic ordering of tests, procedures,
or drugs
– 21% have automated patient reminders regarding routine
preventive care
– 7% e-mail with other doctors
– 6% electronic clinical decision support systems
– 3% email with patients
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Top 3 reported barriers
– costs of system start-up and maintenance
– lack of local, regional, and national standards
– lack of time to consider acquiring, implementing, and using a
new system
Audet et al, Medscape 2004 and Health Affairs, 2005
“Unique” Issues for Children
Not so unique at the technical level
 Differences emerge in

– Market availability
– Policy focus
– Adoption of HIT applications
Child Health Provider Adoption of HIT
Total & by Gender, Florida, 2005
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Methods
– Mailed survey (two waves) between March
and May 2005
– All licensed primary care physicians
(MD/DOs) and a 25% sample of ambulatory
subspecialists
– N=1219 child health provider respondents

Primary care pediatrics, family medicine and
pediatric subspecialists serving >0% children
Child Health Provider Adoption of HIT
Total & by Gender, Florida, 2005
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
Total
80.2%
40.1%
18.0%
24.3%
Male
81.2
44.5
18.6
26.5
Female
75.4
31.6
14.5
22.5
p value
.046*
<.001*
.127
.186
Note: sample size varies by question, overall N=1219
Percent Adoption of HIT by Medical Training
Florida Child Health Providers, 2005
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
Primary Care
Pediatrics
79.9
38.4
14.3
17.0
Family
Medicine
78.4
42.2
21.9
26.8
Other
86.7
38.4
16.4
36.4
p value
.052
.419
.005*
<.001*
Primary Care
Note: sample size varies by question, overall N=1219
Adoption of HIT by Provider Age
Florida Child Health Providers, 2005
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
<40
79.8
40.2
11.5
27.9
40-59
81.8
42.5
20.8
26.9
60+
67.9
29.3
12.4
17.1
p value
.003*
.029*
.008*
.081
Age (years)
Note: sample size varies by question, overall N=1219
Adoption of HIT by Provider Race
Florida Child Health Providers, 2005
Race
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
White
80.3
39.2
19.9
26.2
Black
77.8
47.7
13.3
21.4
Hispanic
81.5
41.2
15.2
20.0
Asian
79.4
37.9
9.4
23.1
Other/
Unknown
79.3
50.0
20.7
14.3
p value
.982
.597
.059
.269
Note: sample size varies by question, overall N=1219
Adoption of HIT by Practice Size
Florida Child Health Providers, 2005
No. of
Physicians
Routine
office
computer use
Routine
PDA use
Email use
with
patients
Routine
EHR use
Solo
76.0
34.6
17.3
17.7
2-9
79.0
39.9
17.5
22.4
10-49
91.5
52.2
20.8
43.9
50+
97.4
68.8
32.4
64.9
<.001*
<.001*
.110
<.001*
p value
Note: sample size varies by question, overall N=1219
Adoption of HIT By Practice Type
Florida Child Health Providers, 2005
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
Singlespecialty
74.1
35.9
17.0
19.5
Multispecialty
91.1
51.4
23.4
41.4
<.001*
.002*
.100
<.001*
Type
p value
Note: sample size varies by question, overall N=1219
Adoption of HIT By Medicaid Volume
Florida Child Health Providers, 2005
Medicaid
Providers
Routine
office
computer
use
Routine
PDA use
Email use
with
patients
Routine
EHR use
Low-volume
77.1
30.7
20.0
24.5
High-volume
(at least 20%
Medicaid)
81.8
44.4
13.5
22.0
p value
.145
<.001*
.028*
.460
Note: sample size varies by question, overall N=1219
Today’s Popular Policy Platforms




Pay for Performance
Health Information Technology
Consumer Driven Health Care
For each…
– What do we know about use or its
effectiveness overall?
– What do we know of its use or
effectiveness for children?
Consumer Use of
Quality Information


Consumer driven health care shifts more financial
responsibility to consumers on the assumption that this will
drive better decisions
Several initiatives to publicly report performance
– Medicare driven
– State driven
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Having an abundance of information does not always translate
into its use to inform choices
All health care decisions – plan, provider, treatment requires
the use of information that:
– Includes technical terms and complex ideas
– Compares multiple options on several variables
– Requires the consumer to differentially weight the various factors
according to individual values, preferences & and needs

Information presentation has a significant effect on impact
and use
Hibbard & Peters,
Annual Reviews of Public Health (2003)
Where Consumers Find
Quality Information
Percent who say they would be "very likely" to do each to
try to find health care quality information...
Ask friends, family members or co-workers
65%
Ask their doctor, nurse or other health professional
65%
Go online to an Internet web site that posts quality
information
37%
36%
Contact the Medicare program (age 65+)
Contact someone at their health plan, or refer to
materials provided by the plan
Order a printed booklet with quality information by
phone, mail, or online
Contact a state agency
Refer to a section of the newspaper or magazine that
lists quality information
36%
20%
18%
16%
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on
Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Consumer Exposure
to Quality Information
Percent who say they saw information in the past
year comparing quality among...
Health insurance
plans
28%
23%
Doctors
Percent who say
they saw
information on
ANY of the
above...
2004
22%
Hospitals
15%
2000
11%
9%
35%
27%
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on
Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Consumer Use
of Quality Information
Percent who say they saw quality information in the
past year and used this information to make health
care decisions...
19%
12%
2000
2004
KFF/AHRQ/Harvard School of Public Health. Chart 10. National Survey on
Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2005)
Importance of Quality Ratings
76
72
2004
2000
1996
61 62
48
52
50
46
45
47
49
45
43
38
33 32
25
20
Surgeon who has
treated
friends/family
Surgeon that is
rated higher
Plan recommended Plan highly rated
by friends
by experts
Hospital that is
familiar
Hospital that is
rated higher
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on
Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Parental Use of Quality Information
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Little research specifically looking at this
CAHPS related research points to
similarities
Existing evidence points to even greater
difficulties for children due to
– Poverty
– Low educational attainment
– LEP
Conclusions
Current policy strategies have been less
well thought out/tested in child health
populations
 CHSR community has opportunity to
develop more evidence on these
questions
