pennsylvania’s pay for performance programs david k. kelley md, mpa pennsylvania office of medical...

Pennsylvania’s Pay for Performance Programs

David K. Kelley MD, MPA

Pennsylvania Office of Medical Assistance Programs

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Pay for Performance (P4P)

• Access Plus- P4P program targeted to reward PCPs for quality of care and participation in disease management

• Hospitals- P4P targeted to reward hospitals that improve care and focus on patient safety

• HealthChoices ® - P4P targeted to managed care plans to improve 10 defined HEDIS ® measures

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What is the ACCESS-Plus Program?

1. Access Plus is an Enhanced Primary Care Case Management (EPCCM) medical home

2. Disease Management (DM) Program-CAD, CHF, Asthma, COPD, Diabetes

3. Complex Case Management

4. 280,000 members, excludes dual eligibles, 32,000 with chronic diseases covered by DM

5. Vendor has guaranteed cost savings, and is at risk for DM performance

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ERIEGatewayMedPLUS+Ion Health

CRAWFORDMedPLUS+UPMC

WARREN

FORESTMedPLUS+

McKEANPOTTER

CAMERONELKVENANGOMERCERGatewayMedPLUS+UPMC

BEDFORDUPMC

BLAIR

SOMERSETGatewayMedPLUS+UPMC

CAMBRIAINDIANA

JEFFERSONGatewayMedPLUS+

CLINTON

LYCOMING

SULLIVANMedPLUS+

TIOGA BRADFORD

WAYNE

WYOMINGMedPLUS+Gateway

PIKEMedPLUS+GatewayAmeriHealthLUZERNE

AmeriHealthMedPLUS+Gateway MONROE

MedPLUS+AmeriHealth

SCHUYLKILLGatewayMedPLUS+

CARBONMedPLUS+GatewayAmeriHealth

LEHIGH

COLUMBIAGatewayMedPLUS+

BUCKS

BERKS

CHESTER

LANCASTER

MONTGOMERY

YORK

LEBANON PERRY

CUMBERLAND

DAUPHINJUNIATAMIF

FLIN

UNION

SNYDER

CENTRE

ADAMS

FRANKLINMedPLUS+Gateway

FULTON

HUNTINGDON

CLEARFIELD UPMC

CLARIONGatewayMedPLUS+

LACKAWANNAAmeriHealthGatewayMedPLUS+

MONTOURGatewayMedPLUS+

NORTHUMBERLANDGateway

PHILADELPHIA

DELAWARE

SUSQUEHANNA MedPLUS+ Gateway

LAWRENCE

BUTLER

ARMSTRONG

FAYETTE

WESTMORELAND

ALLEGHENY

BEAVER

WASHINGTON

Mandatory Managed Care - HealthChoices

September 2004

ACCESS-Plus Program Service Area

GREENE

GatewayMedPLUS+UPMCIon Health

GatewayMedPLUS+UPMCIon Health

MedPLUS+MedPLUS+

UPMC

NORTHAMPTON

ACCESS Plus and Voluntary Managed Care (where available)

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Guidelines for Success

• Involve stakeholders

• Avoid relative scales and scoring

• Link payment to clearly defined “widgets”

• Reward quickly!!

• Don’t “penalize” for patient non-compliance

• AMA P4P guidelines

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ACCESS Plus P4P Program Design

Payment to eligible* providers for 3 critical areas:

• Assistance with enrollment of eligible patients in DM programs

• Collaboration in care management of DM enrollees

• Delivery of key clinical interventions that help

improve quality of care and clinical outcomes * Any individual provider (including certified registered nurse practitioners) or provider entity participating in the Pennsylvania ACCESS Plus network who has any patient with at least one of the targeted diseases (i.e., congestive heart failure, diabetes, asthma, chronic obstructive pulmonary disease or coronary artery disease), regardless of risk level.

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P4P Payments

• Support of Program-$200 per practitioner

• Enrollment Support-$40/high risk pt contacted by a participating office

• Enrollment Support-$30/high risk pt where office provides new contact information

• Chronic Care Feedback Form (CCF)$60 per completed CCF 2X a year

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Clinical Interventions – Year One

Based upon patient self-report at six-month telephonic assessment:

• Payment for each instance when pt reports taking Key Medications for the target condition: CHF: Beta Blocker Diabetes: Aspirin Asthma: A “controller” medication (persistent asthma) CAD: Aspirin

• Substitute medications will count in cases of contraindications

• High risk patients only

Payment frequency: Every 12 monthsPayment amount: $17 per patient

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Clinical Interventions – Year Two

Based on claims data (one Rx or lab per year)• Key Medications and labs:

CHF: Beta Blocker Diabetes: measurement of LDL-C Asthma: A “controller: medication if patient has persistent

asthma CAD: Statins

• Substitute medications count in cases of contraindications

• Both high risk and low risk patients

Payment frequency: Every 12 monthsPayment amount: $17 per patient

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Initial Six Month Assessment Results

Condition Indicator

Initial Assessment Six-month Assessment

Percent Change from Initial Assessment to Six-Month AssessmentNumerator % Numerator %

Diabetes Daily Aspirin or Antiplatelet Agent* 245 36% 415 61% 69%

Denominator=680

Heart Failure

Beta Blocker 243 66% 243 66% 0%Denominato

r=368

Asthma Inhaled Corticosteroid Controller 524 60% 577 66% 10%

Denominator=874

Coronary Artery Disease Daily Aspirin

or Antiplatelet Agent 236 79% 251 84% 7%

Denominator=299

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P4P Potential Revisions

• Increase funding to $1 pmpm• Lead screening• Assessment and management of childhood

obesity• Chronic Feedback Form for children with special

needs• ACE/ARB use in CHF-- current self reported use

<60%• B-Blocker use post-MI-- current self reported use

<80%• Smoking cessation counseling

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Lessons Learned

• Need more incentives for pediatric providers

• Payment issues to large health systems that employ providers

• Transfer of information via electronic format versus paper

• Provider and consumer education

• Provider and consumer feedback

• Need to align incentives

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Hospital Care Incentive Program

• Implemented 2005, first payment 4/06

• Provides incentives to hospitals that demonstrate commitment to improved management of the healthcare needs of Medical Assistance consumers – It rewards: Better management of chronic disease Better management of drug therapies Better coordination with physicians, MCOs and Access Plus Investment in quality related infrastructure

• Uses data already reported by hospitals

• Children’s Hospitals are treated separately

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Hospital P4P Program

• Use scoring methodology to adjust rate increases provided to acute care DSH hospitals Key measures are 7 day re-admission rates for the most common chronic

diseases in the MA population, and measures related to left ventricular function (LVF) assessment and community acquired pneumonia

Re-admits are a reasonable proxy for

- Appropriate care management in the hospital

- Appropriate discharge planning

- Effectiveness of patient education

- Effectiveness of coordination with community physicians

- Effectiveness of coordination with MCOs and Access Plus Other measures focus on hospital treatment of chronic disease and common

illness

• Set aside pool for support of quality related investments

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Scoring Method(Acute – non Children’s DSH Hospitals)

• Hospitals will be scored on the following system2 pts if 7-day re-admit rate for asthma is below average1 pt if 7-day re-admit rate for asthma is average0 pts if 7-day re-admit rate for asthma is above averageSame scoring for re-admit rates for Diabetes, CHF, and COPD2 pts if hospital LVF assessment score is above average1 pt if hospital LVF assessment score is average0 pts if hospital LVF assessment score is below average2 pts if mean time to first antibiotic dose for pneumonia is below average1 pt if mean time to first antibiotic dose for pneumonia is average0 pts if mean time to first antibiotic dose for pneumonia is above average1 pt if hospital has implemented the use of a single medical record1 pt if hospital has implemented a formal pharmacy error reduction program1 pt if hospital is reporting to Leapfrog(Total possible score = 15 points)

• Re-admits will be based on all payer data collected by HC4; remaining measures will be based on all payer data currently being reported by all hospitals

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Hospital P4P- Use of Scores

• 13-15 points 150% of increase for inpatient DSH and med ed


• 6-8 points Average increase for inpatient DSH and med ed


• 0-1 points no increase

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Scoring Method for Children’s DSH Hospitals

• Hospitals will be scored on the following system2 pts if re-admit rate for asthma is below average1 pt if re-admit rate for asthma is average0 pts if re-admit rate for asthma is above average1 pt if hospital has implemented the use of a single medical record1 pt if hospital has implemented a formal pharmacy error reduction program1 pt if the hospital has 24 hour intensevist coverage1 pt if hospital is reporting to Leapfrog or is field testing pediatric quality

measures for JCAHO(total possible score = 6)

• Scores used to adjust base rate and DSH increases6 points 150% of increase5 points 125% increase3-4 points average increase1-2 point 75% increase0 points – no increase

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Hospital Investment Incentives

• Provide grants up to $100,000 to DSH hospitals who have made investments in the following

Pharmacy Error Reduction– Pharmacy Legibility Improvement Program

– Participation in ECRI, ISMP and DVHC Regional Medication Safety Program

– Completion of ISMP's Medication Safety Assessment for 2004 – Participation in PRHI's Medication Safety Program – Use of medication error reporting tool such as MEDMARX – Established confidential medication error reporting system – Implemented point of care bar coding medication administration system

or CPOE – Automated Pharmacy System – 24 hour Pharmacist available

Single Medical Record Other quality related investments as approved by the Department

• Annual Incentive fund set aside = $1 million

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HealthChoices ® - MCO P4P Program

•Implemented July 2005

•Uses 10 HEDIS® measures

•Department identified areas for improvement or continued high

performance

•Financial incentives based on MCO specific goals

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HealthChoices ® - MCO P4P Program

Seven Core Measures:

Controlling High Blood Pressure

Diabetes: HbA1c Poor Control

Diabetes: Cholesterol LDL Control < 130

Cholesterol Management: LDL Control <130

Frequency of Prenatal Care: > 81%

Breast Cancer Screening Cervical Cancer Screening

Three Sustaining Measures:

Prenatal Care in the 1st Trimester

Use of Appropriate Medications for People With Asthma

Adolescent Well-Care Visits

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Setting Goals – Core Measures

• Based on the larger of the following criteria:- Increase to reach the 50th percentile

benchmark; or

- Statistically significant increase from the 2004 actual rate; or

- Increase of 10% of the difference between the 2004 actual rate and 100%.

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Setting Goals- Sustaining Measures

If the prior year’s rate was below the 50th percentile benchmark; the larger of:- increase needed to reach the 50th percentile benchmark, or - a straight increase of 4 percentage points

If the prior year’s rate was above the 50th and below the 75th percentile benchmark; - the goal is a straight increase of 4 percentage points

If the prior year’s rate is above the 75th and below the 90th percentile benchmark; - the goal is a straight increase of 3 percentage points

If the prior year’s rate is at or above the 90th percentile benchmark- the goal is a straight increase of 2 percentage points.

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Payment Rules

• Must reach 100% of goal unless 2005 rate is at or above the 90th percentile benchmark

• If goal was met, and the 2005 rate is: below the 50th percentile benchmark = 0% above the 50th and below the 75th percentile

benchmark = 50% above the 75th and below the 90th percentile

benchmark = 75%

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Payment Rules

If the current rate is at or above the 90th percentile benchmark, and:

- The prior year’s rate was below the 90th percentile benchmark but the MCO did not reach its goal;

- Incentive = 90% of the maximum payment.

- The prior year’s rate was below the 90th percentile and the MCO reached its goal; - Incentive = 100% of maximum payment.

- The prior year’s rate was above the 90th percentile benchmark and there was a statistically significant decrease in the 2005 actual rate; however, the 2005 rate remains at or above the 90th percentile benchmark;

- Incentive = 90% of the maximum payment

- The prior year’s rate was above 90th percentile benchmark and there was not a statistically significant decrease but the 2005 rate remains at or above the 90th percentile benchmark;

- Incentive = 100% of maximum payment.

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Timing Issues

Care charted Results auditedHEDIS ®

reportedHEDIS ® benchmarks Payment

Payment budgeted

calendar 2005 Spring 2006 Summer 2006 Fall 2006 Fall 2006 State FY 06-07



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2006 Performance Incentives

$4,463,097

$6,158,480

Total Incentive Unearned

Total Incentive Earned

Total Available = $10,621,577

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Pay For Performance2006 Aggregate Rates and Goals

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Controlling HighBlood Pressure

*DiabetesMonitoring -Poor HbA1c

Control

DiabetesMonitoring - LDL

<130

** CholesterolManagement -

LDL <130

Frequency ofPrenatal Care >

81%

Breast CancerScreening

Cervical CancerScreening

Prenatal Care -1st Trimester

Appropriate Useof Medicationsfor Asthmatics


2005 Avg. Rate 2006 Hc Avg. Rate

* For this measure, lower rate indicates better performance.

** Due to changes in the technical specifications for this measure it cannot be trended from 2004 to 2005. Rate not calculated for P4P initiative.

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UPMC2006 P4P Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


* DiabetesMonitoring -Poor HbA1c

Control


<130


LDL <130


81%






2004 Rate 2005 Goal 2005 Rate 90thPercentile Benchmark



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Unison2006 P4P Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Control


<130


LDL <130


81%






2004 Rate 2005 Goal 2005 Rate 90th Percentile Benchmark

•For this measure, lower rate indicates better performance.

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Gateway 2006 P4P Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ControllingHigh BloodPressure


Control

DiabetesMonitoring -

LDL <130

CholesterolManagement -

LDL <130


81%




AppropriateUse of

Medications forAsthmatics

AdolescentWell-Care

Visits



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Keystone 2006 P4P Results

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%



Control


<130


LDL <130


81%









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What’s New in 2007

•Increased from 10 to 12 measures Same 10 measures used in 2006 Add Early Childhood Blood Lead Screening to

core measures (19 months old & 3 years old)

•Cholesterol Management: LDL Control lowered to <100 mg/dL

•Finalizing 2007 goals

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Future Considerations

•Increase quality incentive payout to MCOs (2-3% of premium)

•Add 0.75-$1.00 pmpm for provider incentive program

•Explore alternate measures

•Explore use of incentives coupled with disincentives

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Lessons Learned

• Use nationally accepted measures

• Anticipate NCQA changes in parameters

• Must plan ahead 10-12 months

• Initial implementation- MCO discussion/feedback

• Peoplestat- meet every 6 months with senior leadership of MCOs to discuss results and goals

• Statistically significant improvement in 7 of 9 measures

Questions??David K. Kelley MD, [email protected]

“Energy and persistence conquer all things”. Benjamin Franklin

pennsylvania’s pay for performance programs david k. kelley md, mpa pennsylvania office of medical...

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