National Evaluation Team (NET)
Boston University School of Public Health
and
Department of Veterans Affairs
Dan Berlowitz, MD, MPH
Matthew Guldin, MPH
Barbara Bakhour, PhD
Mark Meterko, PhD
James Burgess, PhD
Bert White, MBA, D Min
Gary Young, JD, PhD
Financial support provided by Agency for Healthcare Research
and Quality and Robert Wood Johnson Foundation
1
Seven Demonstration Projects
Measuring Impact of Financial and
Non-Financial Incentives
(2002 – 2005)
•
•
•
•
•
•
•
Blue Cross Blue Shield of Michigan
Blue Cross of California
Bridges to Excellence
California Health Care Strategies/Medi-Cal
Excellus/Rochester IPA
Integrated Healthcare Association: Pay for Performance
Massachusetts Health Plan Quality Partners
2
Blue Cross Blue Shield of
Michigan
• Focus
– Process of care measures
– Medication safety
– Patient safety
– Community health initiatives
• Scope
– 91 hospitals
– $31 million dollars
•
http://www.leapfroggroup.org/RewardingResults/bcbsmi.htm
3
Blue Cross of California
• Focus
– PPO Physician Report Card
– Physician Recognition Payment Program
 Clinical
 Administrative
 Pharmacy
• Scope
– 1,000 physicians with PPO contracts
– BCC members in 6 Bay area counties
– $1 million
•
http://www.leapfroggroup.org/RewardingResults/bcca.htm
4
Bridges to Excellence
• Focus (structural measures of quality)
– Physician clinical performance
• Diabetes Care Link program
• Cardiac Care Link program
– Administrative performance
• Physician Office Link program
• Scope
– 200,000 covered employees in 4 regions: Boston,
Cincinnati, Louisville, Albany
– Diabetes care $100/employee-patient
•
http://www.leapfroggroup.org/RewardingResults/bridges.htm
5
California Health Care Strategies/
Medi-Cal
• Focus
– Contract specific incentives for well-child visits
• Enhanced fees, Bonus
• One-time grant
– Improve encounter claims data
– Improve pediatric access, HEDIS scores
• Scope
– 8 Medicaid HMOs
– 1 million Medi-Cal and SCHIP children
•
http://www.leapfroggroup.org/RewardingResults/chcsmedical.htm
6
Excellus/Rochester IPA
• Focus
– Adherence to Care Pathways for acute and chronic
conditions
– Automated reminder system
• Scope
– 400,000 HMO commercial members
– $17 million dollars
•
http://www.leapfroggroup.org/RewardingResults/excellus.htm
7
Integrated Healthcare Association:
Pay for Performance
• Focus
– Standardized measurement algorithm
• 7 Clinical measures (e.g. pap smear)
• Patient satisfaction
• Information technology investment
– Public, multi-payer scorecard
• Scope
– 6 California health plans
– 8 million HMO commercial members
– Potentially over $100 million dollars
•
http://www.leapfroggroup.org/RewardingResults/ihapay.htm
8
Massachusetts Health
Quality Partners
• Focus
– Public, multi-payer scorecard
– Plan-specific financial incentives
• Scope
– 5 health plans
– 4 million HMO commercial members
•
http://www.leapfroggroup.org/RewardingResults/mhqp.htm
9
Demonstration Projects Differ on
Various Dimensions Regarding
Quality Targets and Incentives
• Selected quality targets
–
–
–
–
–
HbA1c screening
Diabetic eye exam
Mammography
Pap smear
Childhood immunization, MMR
Thresholds
–
–
–
–
–
93%, 89%
75%, 67%, 61%
83%
87%
96%
10
Demonstration Projects Differ on
Various Dimensions Regarding
Quality Targets and Incentives (cont.)
• Eligible recipients
– Contracting entities
 Group practice
 IPA
 IDS
 Hospitals
– Individual physicians
11
Demonstration Projects Differ on
Various Dimensions Regarding
Quality Targets and Incentives (cont.)
• Type of financial incentive arrangements
– Withhold (5% - 20% of claims)
– Block bonus potential to group (e.g.
$60,000/40 PCPs; $1.2 million/280 PCPs)
– PMPM bonus potential for total panel (e.g.
$1.50 PMPM; $3.00 PMPM)
– Hybrid: withhold and bonus
– Enhanced fee schedule in subsequent year
12
Demonstration Projects Differ on
Various Dimensions Regarding
Quality Targets and Incentives (cont.)
• Type of non-financial incentive arrangements
– Honor rolls and handshakes
– Education resources and subscriptions
– Internal practice-wide and peer comparisons
– Public report cards
13
Demonstration Projects Differ on
Various Dimensions Regarding
Quality Targets and Incentives (cont.)
• Components of payout algorithms
– Quality measures (HEDIS, homegrown,
outcome control)
– Utilization – total medical expense trends
– Information systems
– Infrastructure
– Patient access and satisfaction
14
National Evaluation Team
Activities
• Conduct comparative analyses with
uniform data
• Technical support to local evaluators
for each demonstration project
15
Key Research Questions
• Does linking financial incentives to quality goals lead to
better quality of care?
• Is quality of care further enhanced when a combination of
financial and non-financial incentives is linked to quality
goals?
• What key characteristics of providers moderate the impact
of a program that links incentives to quality goals?
• Does linking financialand/or non-financial incentives to
quality goals have unintended consequences for quality of
care?
16
17
Data Collection Protocol
• Draw random sample of contracting entities
in selected demonstration sites (~25-30/site)
• Conduct telephone interview with practice
executive for contracting entity
• Conduct survey of physicians affiliated with
contracting entity (~1500/site)
• Conduct site visits to selected contracting
entities
18
Physician Survey
Multi- Item, Likert Scale Questionnaire
Examples:
• Awareness
– Physicians are aware of the incentive features of health
plan contracts that apply to them.
• Scope of control
– Most physicians are able to achieve the quality targets
set by health plans and other payers.
• Unintended consequences
– Physicians’ efforts to achieve quality targets hinder
them from providing other essential medical services.
19
Preliminary Results
(Telephone Interviews and Pilot Surveys)
• Divergent opinions among physicians about importance of
financial incentives:
– Adequacy of dollars
– Complex distribution formulas
– Clinical validity is key
– Concerns about data validity
• Divergent opinions among practice administrators about
physician’s role:
– Physician-centered
– Doctor is necessary but not sufficient
– System/management-centered
20