Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Quality And Performamce Measurement: The Massachusetts Experience


Published on

MMS President Bruce S. Auerbach, MD, speaks at a quality summit of the American College of Emergency Physicians in Washington

Published in: Health & Medicine, Business
  • Be the first to comment

Quality And Performamce Measurement: The Massachusetts Experience

  1. 1. Physician Performance Measures: The Massachusetts Experience Bruce Auerbach, MD, FACEP President Massachusetts Medical Society
  2. 2. The Massachusetts Environment <ul><li>Fourth highest managed care penetration in U.S. (88%) </li></ul><ul><li>Massachusetts health plan premiums are 7.4% higher than US average </li></ul><ul><li>Premiums rising 17% faster than the US average </li></ul>
  3. 3. Mass. Group Insurance Commission <ul><li>Buys health insurance for 294,000 public employees </li></ul><ul><li>Largest single purchaser of health care insurance in Massachusetts </li></ul><ul><li>Six health plans participate … except Blue Cross (50% of the market) </li></ul>
  4. 4. Cost & Quality: The GIC Approach “Clinical Performance Improvement initiative” <ul><li>Measure cost efficiency via “ETG” methodology </li></ul><ul><li>Measure quality via HEDIS, etc. </li></ul><ul><li>Squeeze quality and cost scores from claims data </li></ul><ul><li>Incent patient and physician behavior via differentials in co-payments </li></ul>
  5. 5. MMS-GIC Dialogue: Timeline Highlights 2002-03: GIC begins work Aug. ’04 MMS, GIC dialogues begin 2004 2005 2006 2007 2003 2008 … more … <ul><li>Early questions … </li></ul><ul><li>Do we fight it? </li></ul><ul><li>Do we try to improve it? </li></ul><ul><li>What do we tell the doctors? </li></ul><ul><li>What do we tell patients? </li></ul>
  6. 6. . . . Early Decisions <ul><li>Physicians need to be deeply engaged in the cost and quality dialogues </li></ul><ul><ul><li>If we don’t, others will </li></ul></ul><ul><li>Internal alignment is necessary </li></ul><ul><li>But physicians cannot do it alone </li></ul><ul><ul><li>External research, external validation </li></ul></ul>
  7. 9. RHI Quality Measures Assessment (Claim Years 2003-2005) Doctor's 08-ID: 401134   Doctor's Last Name: MAGEE   Doctor's First Name: BDALE   Doctor's Specialty: OBSTETRICS & GYNECOLOGY Applicable RHI Measure Invoked Cases Compliance Compliance Rate HEDIS: CervCA_screen_PQP 111 107 96% HEDIS: BrCA_Screen_PQP 57 53 93% Preventive Care 26: High-risk_Pap Smear_PQP 13 12 92% HEDIS: Chlamydia_screen_PQP 13 8 62% Drug Safety 1: Pregnancy_Accutane_PQP 3 3 100% Breast Cancer 8: BrCA_mammogram_PQP 1 1 100% Osteoporosis 1: Women 66-67y_BMDTest_PQP 1 0 0% Prenatal Care 10: Pregnancy Screen_ Rubella_PQP 1 0 0% Prenatal Care 11: Pregnancy Screen_ Hep B_PQP 1 0 0% Prenatal Care 12: Pregnancy_HIV_PQP 3 0 0% Your Quality Assessment Results: 204 184 90%     Peer Specialty Results: 171,145 139,393 81%     Your Final Quality Score (q-score): 1.11
  8. 11. Public Reports
  9. 12. Public Reports
  10. 13. MMS Principles and the CPI * Partial list <ul><li>None </li></ul><ul><li>Monitor for unintended consequences </li></ul><ul><li>Uneven </li></ul><ul><li>Transparency </li></ul><ul><li>No adjustments for health status </li></ul><ul><li>Meaningful data analysis </li></ul><ul><li>Inadequate for individual physicians </li></ul><ul><li>Adequate sample sizes </li></ul><ul><li>Subspecialist quality measures are limited; not representative of important activities </li></ul><ul><li>Measures are clinically important and sound </li></ul><ul><li>Only 2 of 6 plans did so </li></ul><ul><li>Share data prior to release </li></ul><ul><li>None </li></ul><ul><li>Involve physicians in design and implementation </li></ul>Researcher Findings MMS Principles*
  11. 14. The GIC’s New Rules for 2008-11 <ul><li>Must individually rate MD’s in six specialties </li></ul><ul><ul><li>Cardiology Endocrinology </li></ul></ul><ul><ul><li>Orthopedics Gastroenterology </li></ul></ul><ul><ul><li>Rheumatology OB-GYN </li></ul></ul><ul><li>Three tiers for all plans </li></ul><ul><ul><li>Tier 1: 20% </li></ul></ul><ul><ul><li>Tier 2: 65% </li></ul></ul><ul><ul><li>Tier 3: 15% </li></ul></ul><ul><li>Must use GIC’s data </li></ul><ul><li>Standardized reports </li></ul>
  12. 15. The Net Result <ul><li>Standardized reports - but methodologies differ </li></ul><ul><li>More specialties being tiered without good measures </li></ul><ul><li>Individual tiering – without good data </li></ul><ul><li>Errors, complaints, injustice </li></ul>
  13. 16. What Physicians Are Saying <ul><li>“ I am apparently treating patients for epilepsy, according to the GIC. Somewhat unusual for an ophthalmologist .” </li></ul><ul><li>“ Several patients listed couldn't possibly be mine, as I don't perform the designated type of surgery .” </li></ul><ul><li>“ There are procedures on my list that I have never performed. I called GIC and there was only voice mail .” </li></ul><ul><li>“ We received our data March 11 and were told that all feedback was due by March 14. I called the health plan to give feedback March 12. I left a message and my call was not returned .” </li></ul><ul><li>“ This program is unfair, and I'm hopping mad. Please let me know what I can do .” </li></ul>
  14. 17. MMS-GIC Dialogue: Timeline Highlights 2002-03: GIC begins work Aug. ’04 MMS, GIC dialogues begin April ’06: Enrollment begins 2004 2005 2006 2007 July ’07: Year 2 begins 2003 2008 April ’08: Patient Charter July ’06: Year 1 begins Nov. ’07: NY & MMS Principles July ’08: Year 3 begins May ’08: MMS files litigation
  15. 18. The Litigation <ul><li>Asks courts to “correct the wrongs” of the CPI </li></ul><ul><li>Defendants: GIC, Tufts, Unicare </li></ul><ul><li>Allegations </li></ul><ul><ul><li>Physicians falsely ranked and defamed </li></ul></ul><ul><ul><li>Patients misled and financially penalized </li></ul></ul><ul><li>Petition: Require that it been done right </li></ul><ul><ul><li>Transparency and 60 days prior notice </li></ul></ul><ul><ul><li>Feedback and correction process </li></ul></ul><ul><ul><li>Meaningful physician input </li></ul></ul><ul><ul><li>Accuracy, validity and reliability </li></ul></ul><ul><ul><li>If it can’t be done right, stop it </li></ul></ul><ul><li>Arguments on validity of claims to be heard Dec. 18 </li></ul>
  16. 19. Other Health Plan Incentive Programs <ul><li>HEDIS-based measures, including: </li></ul><ul><ul><li>Annual mammograms </li></ul></ul><ul><ul><li>HbA1c, LDL, retinopathy, nephropathy tests and screens </li></ul></ul><ul><ul><li>Regular well-child care visits appropriate for each age group; lead screening </li></ul></ul><ul><ul><li>EHR and e-prescribing adoption </li></ul></ul><ul><li>Blue Cross Blue Shield of Massachusetts </li></ul><ul><ul><li>New global capitation model + challenging incentives </li></ul></ul><ul><ul><li>Slow uptake by health systems or practices </li></ul></ul>
  17. 20. Doing It the Right Way … (1) <ul><li>New York settlement with 5 national health plans </li></ul><ul><ul><li>Tiering not based solely on cost </li></ul></ul><ul><ul><li>Use established quality standards (e.g., NQF) </li></ul></ul><ul><ul><li>Disclose how it’s designed and how MDs are ranked </li></ul></ul><ul><ul><li>Valid reliable information </li></ul></ul><ul><ul><li>Allow physicians to review and correct their data </li></ul></ul><ul><ul><li>Adjust for risk </li></ul></ul><ul><ul><li>Independent “ratings examiner” </li></ul></ul>
  18. 21. Doing It the Right Way … (2) <ul><li>Consumer-Purchaser Disclosure Project </li></ul><ul><ul><li>Collaborative of AARP, AFL-CIO, Kodak, Leapfrog, Mass Health Purchasers Group, & 56 others </li></ul></ul><ul><ul><li>Meeting since 2002 </li></ul></ul><ul><ul><li>Involved with New York decision </li></ul></ul><ul><ul><li>Agreement April 1, 2008: AMA, AAFP, ACP, ACS, AHIP, Aetna, Cigna, United & Wellpoint </li></ul></ul>
  19. 22. Doing It the Right Way . . . (3) Hill Physicians Group
  20. 26. Another “Right Way”
  21. 27. Another “Right Way”
  22. 28. Where we are today <ul><li>Public reporting is OK </li></ul><ul><li>Rewarding physicians for quality is OK </li></ul><ul><li>Most current programs are seriously deficient, and patients seem to know it </li></ul><ul><li>Where the program is harming care, we have been proactive (i.e., litigation) </li></ul><ul><li>We continue the effort to find and reward true value in health care </li></ul>