COPD in the Workplace:How benefit design can lower costs and improve care

• OPDisrelativelyeasytodiagnoseusingaspirometrymachinebutHEDISmeasuresshowonly40%ofpeoplewithaCOPDdiagnosisinaPPOhadreceivedthetest

• COPDpatientsreceivetherecommendedcareonlyabouthalfofthetime

• Preventablehospitalizationsandreadmissionsresultinhigherclaimsexpenses

Pay-for-performance can improve the quality of care for COPD patients, and lower medical costs.

ReportPreparedByGuyD’Andrea

DiscernConsulting

The Problem

The Burden of COPDChronicobstructivepulmonarydisease(COPD)isanumbrellatermusedtodescribeprogressivelungdiseaseincludingemphysema,chronicbronchitis,refractory(non-reversible)asthma,andsomeformsofbronchiectasis.Thisdiseaseischaracterizedbyincreasedbreathlessness.2SignsofCOPDvaryandareoftenpersistentinnature.Symptomsinclude:• Shortnessofbreath• Wheezing• Chesttightness• Chroniccough3

TheprimaryriskfactorforCOPDissmoking,whichaccountsfor85-90%ofCOPDdeaths.AsecondmajorriskfactorforCOPDisexposuretoairpollutants,includingthosefoundinoccupationalsettings.2ThediseaseaffectsAmerica’sworkingpopulation.Oftheestimated24millionpeoplewithsomedegreeofimpairedlungfunction,only30%areabovetheageof65.4ThesefiguresputtheprevalenceofCOPDclosetodiabetes.

COPDisthenation’sthirdleadingcauseofdeath.2Ofthe6majorcausesofdeathfrom1970-2002,COPDwasoneofonlytwowhoseraterose;themortalityrateforCOPDincreasedby102%whilediabetesonlyrose3.2%.7In2006,thediseasewasalsoresponsiblefor672,000hospitaldischarges.2

In2010,thetotalestimatedeconomicburdenofCOPDwasestimatedtobe$49.9billion,including$29.5billionindirecthealthcarecostsand$20.4billioninindirectcosts.1

Challenges in COPD CareIn2008,theGlobalInitiativeforChronicObstructiveLungDisease(GOLD)publishedupdatedCOPDcareguidelines.Accordingtothoseguidelines,optimalcareofCOPDconsistsoffourmaincomponents:

• Assessandmonitorthedisease• Reduceriskfactors• ManagestableCOPD• Manageexacerbations.5

DespiteadvancesinCOPDcareandtheevolutionoftreatmentguidelines,COPDpatientsnationwideoftenarenotreceivingthecaretheyneed.AstudyinthejournalChestreportsthatCOPDpatientsreceiverecommendedcareonlyabouthalfofthetime.6What’sworse,deliveryofpropercarethatcouldpreventhospitalizationisseverelylacking.Thesamestudyfoundthatrecommendedcarewasprovidedatahigherratefordiseaseexacerbationsthanforroutinecare. Aswithchronicdiseaseslikediabetes,whenCOPDpatientsreceivepoorqualitycare

thereisacorollaryincreaseincomplicationsrelatedtotheirdisease.Increasedcomplicationrateshaveadirectrelationshiptoincreasedcostofcare.WhenoneconsidersthattheaverageCOPDpatientonlyreceiveshalfofthecarethat

isrecommended,thereisahugeopportunitytoimprovethequalityofCOPDcaredelivered.SuchimprovementscanreducetheoverallnumberofCOPDcomplicationsandinturnreducethecostsassociatedwithCOPD.

COPD Patients nationwide often are not receiving the care they need

The Solution

Let’s Pay for QualityBetterqualityisacommonthemeofmanyhealthcarereformefforts,especiallyinlightofthegrowingevidencebasethatsuggestsqualityofcareisoftenfarfromideal.Forexample,arecentreportissuedbytheCommonwealthFundstates:

“Everyfamilywantsthebestcareforanillorinjuredfamilymember.Mostaregratefulforthecareandattentionreceived.Yet,evidenceintheNationalScorecardonU.S.HealthSystemPerformance,2008,showsthatcaretypicallyfallsfarshortofwhatisachievable.Qualityofcareishighlyvariable,andopportunitiesareroutinelymissedtopreventdisease,disability,hospitalization,andmortality.Across37indicatorsofperformance,theU.S.achievesanoverallscoreof65outofapossible100whencomparingnationalaverageswithbenchmarksofbestperformanceachievedinternationallyandwithintheUnitedStates.”7Forexample,in2010,onlyapproximately40%ofthosewithanewCOPDdiagnosisreceivedspirometrytesting.8

Onequalityreformmovementgainingtractionhasbeenpayforperformance(P4P)systemsthatrewardproviderswhodeliverhigherqualityhealthcare.Ina2006report,theAgencyforHealthcareResearchandQualityestimatedthattherewereover100P4PinitiativesintheU.S.sponsoredbyhealthplans,employercoalitions,andpublicinsuranceprograms.ThesamereportdefinesaP4Pprogramas,“anytypeofperformance-basedproviderpaymentarrangementsincludingthosethattargetperformancecostmeasures.”9P4Pprogramsaredesignedtoaddressafundamentalflawinourhealthcaresystem:paymentisoften

A P4P program is one way for employers and payers to align financial incentives with evidence-based quality care

notalignedwithoptimalperformance,butinsteadrewardshighvolumeandhighintensityservices.

Employerspaymanyofthehealthcarebillsinthiscountry,whichputstheminthepositionofpossessingboththemotivationtolowercostsandimprovequalityofcare,aswellastheinfluencetodoso.LargecompaniesmayhaveenoughresourcesandinfluencetodesignandimplementtheirownP4Pstrategiesaimedatimprovingthehealthoftheiremployeesandthevalueoftheirhealthcaredollar.Otheremployershaveformedcoalitionsthat

combinetheirpurchasingpowerinanefforttoinfluencehealthplanstoimplementvaluebasedinitiativeslikeP4P.

AP4Pprogramisonewayforemployersandpayerstoalignfinancialincentiveswithevidence-basedqualitycare.P4P

helpsensurethatpayersarenotjustspendingmoneyformorecare,butinsteadqualitycare.P4Phasthepotentialtoeffectivelyaddressboththeissuesofqualityimprovementandcostefficientspending.SupportingthedevelopmentofaCOPDP4PstrategyisonewayinwhichemployerscanproactivelyaddresstheproblemfortheiremployeesanddependentssufferingfromCOPD.

REFERENCES1AmericanLungAssociation.ChronicObstructivePulmonaryDiseaseCOPD.http://www.lungusa.org/assests/documents/publications/solddc-chapters/copd.pdf.UpdatedFebruary2010.AccessedJanuary10,2012.

2COPDFoundation.WhatisCOPD?http://copdfoundation.org/.UAccessedJanuary10,2012.

3MayoClinic.COPD:Symptoms.http://www.mayoclinic.com/health/copd/DS00916/DSECTION=symptoms.UpdatedMarch15,2011.AccessedJanuary10,2012.

4ManninoDM,etal.(2002).CentersforDiseaseControlandPrevention.ChronicObstructivePulmonaryDis-easeSurveillance-UnitedStates,1971-2000.http://www.cdc.gov/MMWR/preview/mmwrhtml/ss5106a1.htm.UpdatedAugust2,2002.AccessedJanuary10,20120.

5GlobalInitiativeforChronicObstructiveLungDisease(GOLD).GlobalStrategyfortheDiagnosis,ManagementandPreventionofCOPD.p.1-108.http://www.goldcopd.org/Guidelineitem.asp.AccessedJanuary10,2012.

6MularskiRA,etal.TheQualityofObstructiveLungDiseaseCareforAdultsintheUnitedStatesasMeasuredbyAdherencetoRecommendProcesses.Chest,2006;130(6),1844-1850.http://www.chestjournal.org/con-tent/130/6/1844.full.AccessedJanuary10,2012.

7TheCommonwealthFund.WhyNottheBest?ResultsfromtheNationalScorecardonU.S.HealthSystemPerformance,2008.http://www.commonwealthfund.org/publications_show.htm?doc_id692682.PublishedJuly17,2008.AccessedJanuary10,2012.

8NCQA.StateofHealthcareQuality2011.http://www.ncqa.org/tabid/836/default.aspx.Published2011.Ac-cessedJanuary10,2012

9Dudley,RAandRosenthal,MB;AgencyforHealthcareResearchandQuality.PayforPerformance;ADecisionGuideforPurchasers.http://www.ahrq.gov/QUAL/p4pguide.pdf.UpdatedApril2006.AccessedJanuary102012.

How COPD P4P Works

Pay-for-performanceprogramshavethreekeyingredients:1. Qualitymeasures2. Measurementandscoring3. Rewards

Quality MeasuresThequalitymeasuresintheCOPDP4PprogramwereselectedbyapanelofphysicianexpertstoalignwithbestpracticesinthecareofCOPDpatients,withthegoalofimprovingpatientoutcomesandreducingcostsassociatedwithcomplicationsofthedisease.Themeasureare:

DocumentationofspirometryPrescriptionof1ormoreinhaledbronchodilators(long-actingpreferredifpersistentsymptoms)ifFEV/FVC<0.70&dyspneaDocumentationofsmokingstatus(byinquiry)ateveryvisitSmokingcessationinterventionPrescriptionoflong-termcontinuousO2forpatientswithrestingO2sat<88%AdministrationofpneumococcalvaccineAdministrationoflatestinfluenzavaccineDocumentationofexacerbationfrequencyinlastyearPrescriptionofatleast1long-termbronchodilatorandconsiderationofaninhaledcorticosteroidforpatientswithahistoryofexacerbationorhospitalizationAssessO2satonroomairatrestatleastonceannually

Measurement and ScoringBridgestoExcellence(BTE),anationalleaderinP4Pprogramimplementation,hasestablishedprocessestocollectandreviewphysicianqualitydatafortheCOPDprogram.Formoreinformation,visit:http://www.hci3.org/node/31/#/6

HealthplansandemployerscanalsotakethemeasuresandotherdetailsoftheCOPDP4PprogramandintegratethemintotheirownneworexistingP4Pefforts.ThefullblueprintfortheCOPDP4Pprogramisavailableinthedocument“WhitePaperandTechnicalSpecifications:Pay-for-PerformanceforCOPD,”foundinthereferencessectionoftheCOPDFoundationEmployerToolkit.

RewardsRewardsactasamotivationforphysicianstoimprovethequalityofcare.SavingsfromthisP4Pprogramaccruetopayersasaresultofdecreasedhospitalizations,anddecreasedhospitalizationsarearesultofreducedcomplicationsthroughbetterphysiciancare,andsomeofthesesavingsaresharedwithphysiciansthroughtheP4Pprogram.

HealthplansandemployersthatsponsorCOPDP4Pcouldadjusttheamountoftherewards,keepinginmindthattherewardsmustbelargeenoughtomotivatephysicians.BridgestoExcellencerecommendsrewardsfrom$45to$140perCOPDpatient,dependingonhowcompletelythephysicianmeetsthequalitystandards.

Take Action Now! Talk with your health plan, local business coalition, or a group such as Bridges to Excellence about how you can use P4P to improve

care and reduce costs for COPD patients.