1

 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

2

Seven Demonstration ProjectsSeven Demonstration ProjectsMeasuring Impact of Financial and Measuring Impact of Financial and

Non-Financial IncentivesNon-Financial Incentives (2002 – 2005)(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

3

Blue Cross Blue Shield of Blue Cross Blue Shield of Michigan 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

4

Blue Cross of CaliforniaBlue 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

5

Bridges to ExcellenceBridges 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

6

California Health Care Strategies/ California Health Care Strategies/ Medi-CalMedi-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

7

Excellus/Rochester IPAExcellus/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

8

Integrated Healthcare Association: Integrated Healthcare Association: Pay for PerformancePay 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

9

Massachusetts Health Massachusetts Health Quality PartnersQuality 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

10

Demonstration Projects Differ on Demonstration Projects Differ on Various Dimensions Regarding Various Dimensions Regarding Quality Targets and IncentivesQuality Targets and Incentives

Thresholds– 93%, 89%

– 75%, 67%, 61%

– 83%

– 87%

– 96%

• Selected quality targets– HbA1c screening

– Diabetic eye exam

– Mammography

– Pap smear

– Childhood immunization, MMR

11

• Eligible recipients– Contracting entities

Group practice IPA IDS Hospitals

– Individual physicians

Demonstration Projects Differ on Demonstration Projects Differ on Various Dimensions Regarding Various Dimensions Regarding

Quality Targets and Incentives (cont.)Quality Targets and Incentives (cont.)

12

• 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

Demonstration Projects Differ on Demonstration Projects Differ on Various Dimensions Regarding Various Dimensions Regarding

Quality Targets and Incentives (cont.)Quality Targets and Incentives (cont.)

13

• Type of non-financial incentive arrangements– Honor rolls and handshakes– Education resources and subscriptions– Internal practice-wide and peer comparisons– Public report cards

Demonstration Projects Differ on Demonstration Projects Differ on Various Dimensions Regarding Various Dimensions Regarding

Quality Targets and Incentives (cont.)Quality Targets and Incentives (cont.)

14

• Components of payout algorithms– Quality measures (HEDIS, homegrown,

outcome control)– Utilization – total medical expense trends– Information systems – Infrastructure– Patient access and satisfaction

Demonstration Projects Differ on Demonstration Projects Differ on Various Dimensions Regarding Various Dimensions Regarding

Quality Targets and Incentives (cont.)Quality Targets and Incentives (cont.)

15

National Evaluation Team National Evaluation Team ActivitiesActivities

• Conduct comparative analyses with uniform data

• Technical support to local evaluators for each demonstration project

16

Key Research QuestionsKey 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?

17

18

Data Collection ProtocolData 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

19

Physician SurveyPhysician SurveyMulti- Item, Likert Scale QuestionnaireMulti- 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.

20

Preliminary Results Preliminary Results (Telephone Interviews and Pilot Surveys)(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