Bridging Market Approaches and Professionalism to Further Physician Accountability and ImprovementAmerican Board of Internal MedicineThe Blue Cross and Blue Shield Association

The new role of professionalism in medicine and quality improvement

21st century Board Certification and its link to professionalism

Certifying Boards interest in recognition/reward

Blue Cross and Blue Shield plans interest in board certification

How Blue Cross and Blue Shield plans are using certification as a marker of quality Outline of Presentation

Pay for performance is a third choice vehicle for crossing the quality chasm among Americas purchasers. The first by a country mile is professionalismbut the speed of chasm crossing is too slow.

Arnie Milstein,Medical Director, PBGH Thought Leader, Mercer Consulting*

*Source: 2005 ABIM Foundation Forum Issue Brief

Push/Pull Forces on Performance ImprovementScience of ImprovementBuild design support capabilityPractice analysisExperience and competency in QI and quality assessment

Patient focusTeamworkCommunity resourcesPUSHScienceEvidence-based practiceErrors and quality gapScience of process and outcome measurementsProfessionalismCulture of qualityCurious mindIntolerant of quality gapsProfessional commitmentIncrease number of health care systems measuring qualityIncrease number of practitioners improving qualityImproved population healthBased on Orleans CT, Anderson N and Gruman J Roadmaps for the next frontier: Getting evidence-based behavior medicine into practice: Society of Behavioral Medicine, Annual Meeting, San Diego, March 1999PULLPayers & GovernmentRewarding performanceRegulationPatients/families/ advocacy groupsMarket competitionAccreditationACGME, LCME, NCQA, JCAHOBoard Certification

ProfessionalismThe Physician CharterTraditional Roles: Professional competence and responsibilities HonestyPatient confidentialityAppropriate relations with patientsScientific knowledgeManaging conflicts of interest

ProfessionalismThe Physician CharterNew Roles:Commitment to improving quality of careCommitment to improving access to care (principle of social justice) Commitment to a just distribution of finite resources

Quality Improvement TroikaOverarching goal: Alignment to reduce redundancy and accelerate improvement The Role of Board Certification

Certifying BoardsIndependent, non-profit evaluation organization (not a membership society)70 years of rigorous standard-setting through high stakes examinationsWell-known marker of excellenceTrusted by the profession and the publicProven marker of higher quality care

Board Certification MattersBoard Certification correlates with

Adolescent MedicineCardiovascular DiseaseClinical Cardiac ElectrophysiologyCritical Care MedicineEndocrinology, Diabetes and MetabolismGastroenterologyGeriatric MedicineHematologyInfectious DiseaseInterventional CardiologyMedical OncologyNephrologyPulmonary DiseaseRheumatologySleep MedicineSports MedicineTransplant Hepatology

The Breadth of Internal MedicineCertify 1 of every 3 physicians in US

Over 180,000 valid certificates

More internists than any other specialty

Most frequent patient encounter is with internist

ABIMs MissionTo enhance the quality of health care by certifying internists and subspecialists who demonstrate the knowledge, skills and attitudes essential for excellent patient care.

Board Certification TodayInitial CertificationPeriodic recertification (or Maintenance of Certification) based on ACGMEs 6 competenciesNew emphasis on skills required to measure and improve performance (in the complex world of todays health care)Application of knowledge in patient careInterpersonal and communication skillsSystems-based practicePractice-based learning and improvement

Maintenance of CertificationRequired after 1989, recommended for all ABIM diplomatesCertificate valid for 10 yearsDiplomate must: Hold an unrestricted medical licenseComplete self-evaluation requirementsMedical knowledgePractice performancePass a secure, cognitive examination

The Secure ExaminationCognitive simulation of practicePredominantly assesses higher-order intellectual abilitiesnot recallClinical judgment: >50%Synthesis: 20 to 35%Recall knowledge:

Self -Evaluation of Medical KnowledgeABIM self-evaluation productsRecent advances and annual updatesClinical SkillsSimulation interventional cardiologyQuality improvement knowledgeSociety self-evaluation productsCredit granted if meet ABIM criteriaCurrently ten society products Examples: MKSAP, ACC-SAP

Self-Evaluation of Practice PerformanceDesigned to force a new way of thinking about quality and QIQuality is not what the doctor does (but what the system produces)Quality improvement is not about working harder (or learning more) but about diagnosing and treatment system problemsDesigned to promote adult (experiential) learning by creating a safe and credible mechanism for self-evaluation

If you want to teach people a new way of thinking, dont bother trying to teach them, instead give them a tool, the use of which will lead to a new way of thinking.R. Buckminster FullerSelf-Evaluation of Practice Performance

ABIMs FullerenePerformance ReportImprovementPatient DataImpactPlanDoStudyActPractice SystemsPractice Improvement Module (PIM)

AsthmaCare of the Vulnerable ElderlyClinical PreventionColonoscopyCommunication - Primary CareCommunication - SubspecialistsCommunication with Referring PhysiciansABIM PIMsDiabetes (NCQA DPRP link)Hepatitis CHIVHospital-Based CareHypertensionOsteoporosisPreventive CardiologySelf-DirectedAvailableIn Development Comprehensive Care

Certifying Boards Interest in Recognition and RewardsReduce redundant data collection for physiciansIncrease the economic value of certification and recertification (Maintenance of Certification)Encourage more frequent and continuous participation in Recertification (Maintenance of Certification)

Interest by Certifying Boards (cont.) Encourage Grandfathers to participate in Maintenance of CertificationGuidance for product evolution/ enhancementEfficiencyPatient SafetyFocused RecognitionResearch opportunities

A Blue Cross and Blue Shield Association Presentation

The National Pay for Performance SummitBeverly Hills, CAFebruary 15, 2007Bridging Market Approaches and Professionalism to Further Physician Accountability and Improvement

Office of Clinical Affairs

2007 Blue Cross Blue Shield Association. All Rights Reserved.

BlueCross BlueShield Association Creating relationships with physicians that reinforce consumer confidence in the BluesPromoting public-private collaborations toward measurably improving overall quality and health outcomesSupporting evidence-based decision makingOffice of Clinical Affairs

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Blue Plans and Board CertificationParsimonyPeersProfessionalismMotivationReward / RecognitionMeasurementHEDISAHRQNCQA-recognized ProgramsABIM MOC & PIMsNQF & Quality AlliancesCMSNCQABCBS PlansBridges to ExcellenceBoardsSocietiesMedicare Reporting P4P Credentialing / Network Inclusion$$$ RewardCertificationCME CreditObjective is to make life easier for physicians

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Blue Plans and Board CertificationAdoption of existing, industry-accepted performance measures Collaboration on measuring and improving overall physician performanceReimbursement systems and structures that align incentives for improved overall quality and outcomesSupport knowledge-driven solutionsAchieve better value, i.e., better aggregate health outcomes per dollar spentCollaboration with physicians is essential for transforming physician practices to improve overall quality and affordability

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Blue Plans and Board CertificationEnables broader participation in Blue Plans programs where limited claims experience precludes valid measurementEnhances credibility and transformational potential through integration of clinical data Promotes transparency in recognizing clinical qualityActive participation in Maintenance of Certification complements Blue Plans measurement and reporting

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Network Performance TransparencyPrivate and public sectors pushing for greater transparency on provider / practitioner performancePrivatePublicFour Cornerstones of Value-Driven HealthcareRising Medical Costs / Continued Cost-ShiftingGrowing Consumer-Directed MarketInformation on price and qualityConnecting the SystemMeasure and Publish QualityMeasure and Publish PriceCreate Positive Incentives

2007 Blue Cross Blue Shield Association. All Rights Reserved.

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Goal 1: Engaging consumers to enable them to make more informed health care decisionsGoal 2: Collaborating with providers to improve overall quality outcomes and affordabilityPrograms include:Blue Distinction National Transparency DemonstrationSMBlue Distinction Centers for Specialty CareSMBlue Distinction Provider Measurement and Improvement ProgramSMBlue DistinctionBlues innovative program to create an unprecedented level of transparency:

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Establish best-in-class approach to quality, cost-effective provider selection Launch comprehensive national wellness initiative to support healthier behavior in the workplace and in the homeEnhance national provider locator:Information on price and qualityABIM Practice Improvement Module completionNCQA Physician RecognitionParticipation in Bridges to ExcellenceNational Transparency DemonstrationBlues engaged in a cohesive, dedicated effort to promote consumer engagement through transparency:

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Make criteria publicTransplantsBariatric SurgeryCardiac CareRare Cancer Care (2007)Use aggregate clinical datanot individualized claims dataCenters for Specialty CareTransparent quality criteria and clinical data are foundation

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Provider Measurement and ImprovementInitiatives designed to raise the bar on quality across Blue Plans networksHospitalsPractitionersBlues integrating self-assessment and improvement programsMedical Specialty Board Practice ModulesNCQA Physician RecognitionBridges to ExcellencePatient-centered Medical Home

Blues initiating collaborations with hospitals on:Acute Myocardial InfarctionHeart FailurePneumoniaSurgical Infection PreventionPatient Safety Indicators

2007 Blue Cross Blue Shield Association. All Rights Reserved.

ABIM and The Blues Memorandum of Understanding between BCBSA and ABIM, first of its kind between Board and the health plan industryChris Cassel, MD addresses BCBSA Board of DirectorsJun 2005Mar 2006Nov 2005BCBS of NE first health plan to launch collaboration with BoardHorizon BCBS launches collaboration with Board Independence BC launches collaboration with Board ABIM and The Blues collaboration began with historic agreementHighmark BCBS launches collaboration with Board

2007 Blue Cross Blue Shield Association. All Rights Reserved.

ABIM and The Blues Self-Directed: Health Plan data acceptedPIM:Medical Chart AuditData Submitted to ABIMEXAMPLE: Independence BC provides practice performance data through Practice Quality Assessment Score (PQAS) and / or the ConnectionsSM Program SMARTTM Registry Collaborations promote professionalism while minimizing burden of reporting on physicians

2007 Blue Cross Blue Shield Association. All Rights Reserved.

ABIM and The Blues RewardHighmark BCBSQualityBlueSM quality-based incentive programPIM completion earns points for Best Practice QI initiative component of performance score Enhanced payment per patientBlue Plans aligning incentives for practice transformationRecognitionBCBS of Nebraska Recognition of existing QI activitiesAward certificate for office displayQuality designation in physician directoryReimbursement for annual PIM completionRewardHorizon BCBS of NJPIM completion an option to enhance quality component of performance score Top performance scores receive enhanced fee schedule

2007 Blue Cross Blue Shield Association. All Rights Reserved.

ABIM and The Blues LaunchedIn DiscussionEmerging InterestMTMAAKHIPRMENHVTRINYPANJOHWVMDVANCSCGAFLKSKYTNARLAMSALIAILINMNWIMINDSDNEWYCOOKNMTXAZNVUTCAMTWAORIDDCCTDEDate: January 24, 2007Momentum building among Blue PlansMO

2007 Blue Cross Blue Shield Association. All Rights Reserved.

ABIM and The Blues Additional medical specialty boardsPediatricsFamily MedicineUrologyOthersAdditional Blue PlansExpansion of collaborations planned for 2007:

2007 Blue Cross Blue Shield Association. All Rights Reserved.

Contacts

Allan M. Korn, MD FACPSenior Vice President & Chief Medical OfficerOffice of Clinical Affairs312.297.6840allan.korn@bcbsa.com

Nat Kongtahworn, MSManager, Network StrategiesOffice of Clinical Affairs312.297.6210nat.kongtahworn@bcbsa.com

Kongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPWhen I go through the mission statement, I emphasize that our mission is to enhance the quality of health care. Certification is the tool that we have, but our mission is not to certify doctors. The link between certification and our mission is in the last part of the sentenceto the extent that certification motivates physicians to acquire the knowledge and skills that are essential for excellent patient care, our certification program prepares them to deliver higher quality care (than otherwise they would).Kongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPNow lets turn to self-assessment of practice performance.

The purpose of this component of MOC is for diplomates to demonstrate the quality of their clinical processes and outcomes of care, their patient experiences of care, and the practice structure and function.

It also meets the ABMS requirement to begin to demonstrate diplomate competence in applying quality improvement science in practice. The exercise directs diplomates in the use of quality measures, participation in an attempt to make systematic changes, and to re-measure the impact of that change. Kongtahworn et al--1.02@1.15pm PFPWonder why youve taken the data/reflection/analysis column offKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFPKongtahworn et al--1.02@1.15pm PFP