Medicare’s Physician Performance Agenda: Understanding Next Steps and Shaping the Future Course

Debra NessCo-Chair, Consumer-Purchaser Disclosure ProjectPresident, National Partnership for Women & Families

Peter V. LeeCo-Chair, Consumer-Purchaser Disclosure ProjectCEO, Pacific Business Group on Health

Overview and Key IssuesBased on Invitational Working SessionFebruary 28, 2007

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Agenda For Meeting• Welcome and Introductions

– Debra Ness, Disclosure Project and NPWF

• Overview of Physician Measurement: Opportunities and Obstacles– Peter Lee, Disclosure Project and PBGH

• Shaping Medicare’s Physician Quality Reporting Initiative – Herb Kuhn, Acting Deputy Administrator for CMS– Tom Valuck, MD, Director of Special Program Office of Value-Based

Purchasing for CMS

• Building for the Future: Moving to Administrative Sources and Electronic Health Records– Marc Overhage, MD, Indiana Health Information Exchange– David Bates, MD, Partners HealthCare System

• Advancing Medicare’s Physician Quality Reporting Initiative

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CMS’ Physician Quality Reporting Initiative (PQRI): Why Care?

• Foundation for providing information to consumers, physicians and to inform payment

• Directionally correct, but imperfect: will need a strong, united consumer/purchaser voice to offset physicians’ criticisms

• Key opportunity to shape near-term (2008-2009) physician performance transparency

• Real money at play: $300 million estimated payout for 2007 PQRI program; $1.35 billion set aside for 2008

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Cost Pressures: Health Care/Earnings Disconnect

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Adherence to Quality Indicators

10.5%

22.8%

32.7%

40.7%

45.2%

45.4%

48.6%

53.0%

53.5%

53.9%

57.2%

57.7%

63.9%

64.7%

68.0%

68.5%

73.0%

75.7%

0% 20% 40% 60% 80% 100%

Alcohol Dependence

Hip Fracture

Ulcers

Urinary Tract Infection

Headache

Diabetes Mellitus

Hyperlipidemia

Benign Prostatic Hyperplasia

Asthma

Colorectal Cancer

Orthopedic Conditions

Depression

Congestive Heart Failure

Hypertension

Coronary Artery Disease

Low Back Pain

Prenatal Care

Breast Cancer

Percentage of Recommended Care Received

Quality Shortfalls: Getting it Right 50% of the Time

Adults receive about half of recommended care

54.9% = Overall care 54.9% = Preventive care 53.5% = Acute care56.1% = Chronic care

Not Getting the Right

Care at the Right Time

Source: McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635-2645

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0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

0.00 0.20 0.40 0.60 0.80 1.00 1.20 1.40 1.60 1.80 2.00

Efficiency Index (higher is better)

Qu

alit

y In

dex

(h

igh

er i

s b

ette

r)

Each Point on This Graph Represents a Physician Which Ones Would You Prefer to See?

Rattray MC, Andrianos J, Stam DT. Used with the permission of The Regence Group, Copyright 2006. All rights reserved.

For full presentation on Efficiency Performance Measurement given at Electronic Data Discussion Forum, go to: http://healthcaredisclosure.org/docs/files/PhysicianEfficiency092906.ppt

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Physician Information:

Basics: • Specialty • Board Certification • Hours/Contact

Performance: • Disease management • Preventive Care • Patient Experience

Reporting Issues: • Transparency of “Target Rate” • Almost all look “above average” • Combines practice site and individual physician results

Physician Performance Information … The “Good”

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Physician Performance Information … The “Bad”

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Physician Performance Information … The “Ugly”

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PQRI is part of the “deal” between the AMA and Congress to fix the SGR

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What is PQRI? • Prevented 5% cut in 2007 Medicare physician

payment

• Allows for up to 1.5% bonus on all Medicare billings for eligible professionals

• Providers must report on at least 3 measures (or all if less than 3 available) for bonus out of total of 74 measures

• Confidential performance reports provided to participants

• For complete information go to: www.cms.hhs.gov/PQRI

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General Questions for Consideration

• How does PQRI relate to other existing initiatives (e.g., AQA and NQF measures, BQI’s, health plans, etc.)?

• How will performance results be shared and with whom?

• What are the next steps for moving physician performance transparency forward?

• What physician measures can be generated from claims? electronic health records?

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Future Directions from a Consumer and Purchaser Perspective

• Support more robust performance measures• Required public disclosure• Move from “pay to report” to “pay for

performance”• Move BEYOND pay-for-performance to

broader payment reform• ENGAGE – comments to CMS for 2008-2009

PQRI; discuss with policymakers and key stakeholders

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Potential Consumer and Purchaser Input on 2008 and Beyond• Expanded measures

– Address full spectrum of care (safe, timely, effective, efficient, equitable, patient-centered)

– Competency vs. standards of care– Cross-cutting measures that apply to all providers– Provide important information to consumers and purchasers

• Measure selection– Establishing criteria for provider self-selection– Increasing the number of measures required by CMS

• Measure collection– Move beyond claims to other electronic data (e.g., lab, pharmacy, EHR)– Providers need to be equipped to include CPT-II codes and g-codes on claims– Not all measures have developed CPT-II or g-codes

• Public reporting of provider-specific results • Incentives

– Link meaningful and significant payment to performance (move beyond reporting)– Increase the portion of funds allocated to performance-based payment over time to

reach a substantial portion of Medicare payment

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The Consumer-Purchaser Disclosure Project is a coalition more than 50 of the nation’s leading consumer, labor, and employer organizations that are working to advance publicly reported, nationally standardized measures of clinical quality, efficiency, equity, and patient centeredness for health plans, hospitals, medical groups, physicians, other providers, and treatments. The Disclosure Project is supported by financial and in-kind support of participating organizations and by financial support from the Robert Wood Johnson Foundation.

Previous Discussion Forums are available at:http://healthcaredisclosure.org/activities/forums/

Using Electronic Data to Assess Physician Quality and Efficiency – September 29, 2006

Provider Payments: How They Work, Implications for Cost & Quality, and Creating a Consumer/Purchaser Policy Agenda – July 26, 2006

Cost/Price Transparency – May 25, 2006

About the Disclosure Project