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Quality And Performamce Measurement: The Massachusetts Experience

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

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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>

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