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  • The patient safety components make up 30% of the total program measurement They include such things as putting procedures in place to prevent wrong-site, wrong-patient surgeries, to improve the safety of high-alert medications such as potassium chloride. They also include some things I believe you’ve been doing here at VCU-MCV for many years. These important initiatives also have the endorsement of The Leapfrog Group, a collection of the country's biggest corporations that have formed a coalition to to promote and publicize three specific hospital safety practices such as computerized physician order entry – so there won’t be any misreading what the doctor has ordered. The two patient safety indicators are a separate measure from JCAHO –hospitals choose two indicators to report from among 11 Agency for Healthcare Research and Quality safety indicators. Examples: anesthesia complications, infections due to medical care, post-operative bleeding
  • In the health outcomes portion of the program, which makes up 55% of the total program, we are focusing primarily on heart disease. We have done this for two reasons It’s the No. 1 cause of death in the nation & in Virginia There are well-established guidelines and protocols for care We are particularly pleased with the American College of Cardiology’s (ACC) collaboration in this part of the program. With their help, we should be able to engage physicians with hospitals and Anthem in this effort. Finally, in addition to the cardiac measures, hospitals will also choose either a pregnancy related or community-acquired pneumonia indicator. FYI: MI – Myocardial infarction or heart attack FYI: Percutaneous coronary intervention (PCI) is a catheter-based procedure in which a small thin tube (catheter) is inserted through an artery in the arm or groin. The catheter is threaded up through the blood vessel to the heart. Diagnostic and treatment procedures can be performed through the catheter using special instruments to restore normal blood flow. Examples of these procedure include: Angioplasty with or without stenting (also called percutaneous transluminal angioplasty, or PTA). The advantage of PCI is that open chest surgery is avoided and only a small incision is needed to place the catheter in an artery of the arm or leg. FYI: CABG – Coronary Artery Bypass Graft
  • Organization

    1. 1. Rewarding Clinical Performance for Improved Quality of Care 71st Annual Meeting of the New Hampshire Hospital Association September 19, 2005 Samuel R. Nussbaum, M.D. Executive Vice President and Chief Medical Officer
    2. 2. Health Care Quality Defect Rates Occur at Alarming Rates Defects per million  level (% defects) U.S. Industry Best-in-Class Anesthesia-related fatality rate Airline baggage handling Outpatient ABX for colds Post-MI  -blockers Breast cancer screening (65-69) Detection & treatment of depression Adverse drug events Hospital acquired infections Hospitalized patients injured through negligence 1 (69%) 2 (31%) 3 (7%) 4 (.6%) 5 (.002%) 6 (.00003%) Source: modified from C. Buck, GE Overall Health Care in U.S. (RAND)
    3. 3. Hospital Quality Improves, but Quality of Care Remains Inconsistent Nationwide <ul><li>Performance of more than 3,000 accredited hospitals on 18 standardized indicators for acute myocardial infarction (AMI), congestive heart failure (CHF) and pneumonia over two-year period (2002-2004): </li></ul><ul><ul><li>Significant improvement (p<0.01) on 15 of 18 measures </li></ul></ul><ul><ul><li>No measure showed significant deterioration </li></ul></ul><ul><ul><li>Magnitude of improvement ranged from 3 to 33 percent </li></ul></ul><ul><ul><ul><ul><ul><li>Williams, Schmaltz, Morton, Koss, Loeb, NEJM 2005;353:255-64 </li></ul></ul></ul></ul></ul><ul><li>Hospital Quality Alliance data set on 10 quality indicators for AMI, CHF and pneumonia; > 3,500 hospitals reported data on at least one stable measure: </li></ul><ul><ul><li>Half the hospitals scored above 90 percent for 5 of the 10 measures (primarily AMI); level of performance for other 5 measures was much lower </li></ul></ul><ul><ul><li>High quality of care for AMI predicted high quality of care for CHF but not for pneumonia </li></ul></ul><ul><ul><li>Substantial variability in quality of care provided by hospitals in different metropolitan areas </li></ul></ul><ul><ul><li>No consistent association between performance and size of hospital </li></ul></ul><ul><ul><ul><ul><ul><li>Jha, Li, Orav, Epstein, NEJM 2005;353:265-74 </li></ul></ul></ul></ul></ul>
    4. 4. Multiple Collaborations to Improve Quality of Care, Reduce Medical Errors <ul><li>National Quality Forum </li></ul><ul><li>National Committee for Quality Assurance </li></ul><ul><li>Centers for Medicare and Medicaid Services </li></ul><ul><li>Bridges to Excellence </li></ul><ul><li>The Leapfrog Group </li></ul><ul><li>Care Focused Purchasing </li></ul><ul><li>Hospital Quality Alliance (consortium of health care organizations, including AHIP, CMS, JCAHO, AHA, AARP) </li></ul><ul><li>Blue Cross Blue Shield Association (BCBSA) </li></ul><ul><li>Integrated Healthcare Association (IHA) in California; many other state initiatives </li></ul>
    5. 5. Improve Financial Incentives for Quality <ul><li>Dominant methods of payment don’t achieve goal of clinical quality: </li></ul><ul><ul><li>Fee-for-service payments encourage overuse </li></ul></ul><ul><ul><li>Capitated payments encourage underuse </li></ul></ul><ul><ul><li>Neither systematically rewards excellence in quality </li></ul></ul><ul><li>Strategy undercut by lack of broad and deep quality measures; adjusting for risk in way that is meaningful to consumers </li></ul><ul><li>Early experiments in rewarding quality with more favorable payments: </li></ul><ul><ul><li>Premier, CMS </li></ul></ul><ul><ul><li>WellPoint/Anthem </li></ul></ul><ul><ul><li>Medicare Payment Advisory Commission (MedPAC) considerations </li></ul></ul>
    6. 6. Our Vision for Rewarding Clinical Performance Quality broadens the dialogue beyond fees to building a foundation of trust and collaboration. Long-Term Goals Short-Term Goals Foundation Build Trust / Collaboration Structure / Process Meaningful Measures Outcomes Improve Member Health Value
    7. 7. WellPoint Hospital Quality Programs: Goals and Guiding Principles <ul><li>Continuously improve quality of care delivered in network hospitals </li></ul><ul><li>Develop program using comprehensive evidence-based metrics </li></ul><ul><li>Minimize administrative burden to participate </li></ul><ul><li>Promote partnerships with key hospitals </li></ul><ul><li>Drive change in overall health care delivery arena </li></ul><ul><li>Designed to improve care delivered to all patients, not just WellPoint members; reporting for all hospital patients </li></ul><ul><li>Support health care delivery goals and public reporting of outcomes data </li></ul><ul><li>Financial incentives for clinical performance, quality care, error reduction </li></ul>
    8. 8. Pay-for-Performance Programs Partnerships with physicians and hospitals on quality incentives <ul><li>Clinical Outcomes </li></ul><ul><li>Evidence-based medical procedures </li></ul><ul><li>Generic Prescribing Rates </li></ul><ul><li>Technology & streamlined administrative processes </li></ul><ul><li>Patient Satisfaction </li></ul>Focused on primary care physicians. Typical major components: PCP Programs <ul><li>Clinical Outcomes </li></ul><ul><li>Evidence-based medical procedures </li></ul><ul><li>Generic Prescribing Rates </li></ul><ul><li>Technology & streamlined administrative processes </li></ul><ul><li>Patient Satisfaction </li></ul>Focused on specialty care physicians. Early initiatives in: Ob/Gyn, Cardiology, Orthopedics. Measures similar to PCP programs: Specialist Programs <ul><li>Patient Safety </li></ul><ul><li>Clinical Outcomes </li></ul><ul><li>Patient Satisfaction </li></ul>Focused on acute care hospital, typically full service facilities. Hospital programs typically have the following components: Hospital Programs
    9. 9. Coronary Services: Extensive Quality Outcomes Metrics <ul><li>Coronary Artery Bypass Grafts (CABG) </li></ul><ul><ul><li>number of procedures </li></ul></ul><ul><ul><li>mortality </li></ul></ul><ul><ul><li>return to OR </li></ul></ul><ul><ul><li>saphenous vein use </li></ul></ul><ul><ul><li>infections </li></ul></ul><ul><li>Percutaneous Transluminal Coronary Arteriography (PTCA) </li></ul><ul><ul><li>number of procedures </li></ul></ul><ul><ul><li>repeat PTCA </li></ul></ul><ul><ul><li>failed PTCAs which go onto CABG within 24 hours </li></ul></ul><ul><ul><li>primary PTCA for acute myocardial infarction </li></ul></ul><ul><li>Myocardial Infarction (MI) </li></ul><ul><ul><li>number of patients with MI </li></ul></ul><ul><ul><li>time to PTCA </li></ul></ul><ul><ul><li>time to thrombolytic therapy from ER (door to drug) </li></ul></ul><ul><ul><li>aspirin use in 24 hours </li></ul></ul><ul><ul><li>mortality </li></ul></ul><ul><ul><li>ß-blocker use </li></ul></ul><ul><ul><li>critical pathway use </li></ul></ul><ul><ul><li>number with LVEF < 40% prescribed ACE inhibitors </li></ul></ul>
    10. 10. <ul><li>Patient Safety - 25% </li></ul><ul><ul><li>Meet 6 JCAHO patient safety goals: </li></ul></ul><ul><ul><ul><li>Improve the accuracy of patient identification </li></ul></ul></ul><ul><ul><ul><li>Improve the safety of using high-alert medications </li></ul></ul></ul><ul><ul><ul><li>Eliminate wrong-site, wrong-patient and wrong-procedure surgery </li></ul></ul></ul><ul><ul><ul><li>Improve the safety of using infusion pumps </li></ul></ul></ul><ul><ul><ul><li>Improve the effectiveness of clinical alarm systems </li></ul></ul></ul><ul><ul><ul><li>Improve the effectiveness of communication among caregivers </li></ul></ul></ul><ul><ul><li>Implement 3 patient safety initiatives </li></ul></ul><ul><ul><ul><li>Computerized Physician Order Entry (collected via Leapfrog survey) </li></ul></ul></ul><ul><ul><ul><li>ICU staffing standards (collected via Leapfrog survey) </li></ul></ul></ul><ul><ul><ul><li>Automated pharmaceutical dispensing devices </li></ul></ul></ul><ul><ul><li>Report 2 patient safety indicators </li></ul></ul><ul><ul><ul><li>Anesthesia complications, post-operative bleeding, etc. </li></ul></ul></ul>QHIP: WellPoint Quality Insights Hospital Incentive Program Note: Text in red reflects NQF measure
    11. 11. <ul><li>Patient Outcomes - 60% </li></ul><ul><ul><li>Improve indicators of care for patients with heart disease </li></ul></ul><ul><ul><ul><li>Participation in American College of Cardiology cardiovascular data registry </li></ul></ul></ul><ul><ul><ul><li>Cardiac catheterization and angioplasty intervention indicators </li></ul></ul></ul><ul><ul><ul><li>Acute MI or heart failure indicators (collected via JCAHO) </li></ul></ul></ul><ul><ul><ul><ul><li>Administer aspirin, beta blockers at ER arrival, discharge </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Smoking cessation </li></ul></ul></ul></ul><ul><ul><ul><li>Coronary artery bypass graft indicators </li></ul></ul></ul><ul><ul><li>Pregnancy-related or community acquired pneumonia indicators </li></ul></ul><ul><li>Patient Satisfaction - 15% </li></ul><ul><ul><li>Survey of members </li></ul></ul><ul><ul><li>Link between improvement in care processes and outcomes, and patient satisfaction </li></ul></ul>QHIP: WellPoint Quality Insights Hospital Incentive Program Note: Text in red reflects NQF measure
    12. 12. Rewarding Clinical Performance Reimbursement Increase Schedule Relative Reimbursement Rate Proportion of rate increase based on clinical quality Base increase in hospital contract rate Rewarding high scores creates tangible incentive for quality improvement 2002 2003 2004 2005
    13. 13. Rewarding Clinical Performance in New Hampshire: Next Generation of Quality Programs <ul><li>1. Anthem Quality Insights Hospital Program (QHIP) </li></ul><ul><ul><li>Patient safety, patient outcomes, patient satisfaction </li></ul></ul><ul><ul><li>Currently in discussions with several New Hampshire hospitals </li></ul></ul><ul><ul><li>Program payouts scheduled to begin in 2006 or 2007 (depending on timing of contract renewals) </li></ul></ul>Anthem Quality Insights (AQI): A series of innovative quality recognition and health improvement programs, including: <ul><li>2. Anthem Primary Care Quality Incentive Program (PCQIP)) </li></ul><ul><ul><li>Measurement components: outcomes, process, pharmacy, technology </li></ul></ul><ul><ul><li>Providers: primary care physicians, nurse practitioners, physician assistants (designated as primary care providers) </li></ul></ul><ul><ul><li>Program payouts scheduled to begin in July 2006 </li></ul></ul>
    14. 14. Industry Continues to Face Challenges in Rewarding Clinical Performance <ul><li>Trends </li></ul><ul><li>Reward specialist physicians as well as PCPs </li></ul><ul><li>Supplement quality metrics with measures that result in positive savings (generic drug substitution, IT adoption) </li></ul><ul><li>Tiered fee schedules instead of annual bonus payments </li></ul><ul><li>Demonstrate Return on Investment (ROI) </li></ul><ul><li>Balanced scorecards combined with increased transparency </li></ul><ul><li>Rising role of CMS as P4P market driver </li></ul><ul><li>Challenges </li></ul><ul><li>Role of specialists when performance measures are not as well developed </li></ul><ul><li>Different programs (CMS, health plans) and common metrics (NQF, specialty societies, employer coalitions) </li></ul><ul><li>Will information be used wisely (i.e., tiered hospital contracting vs. centers of excellence)? </li></ul><ul><li>Should data be reported at the physician or group level? </li></ul><ul><li>Public reporting, transparency and risk adjustment – easily understood by consumer? </li></ul>