- a Rewarding Results National Grant Pay for Performance: Driving Improvement through Provider...

- a Rewarding Results National Grant

Pay for Performance:Driving Improvement through

Provider Recognition & Reward

MCOL Healthcare Web Summit

Participating Provider Reimbursement

June 2003


Who Are These People?Who Are These People?

Integrated Healthcare Association

A California leadership group of health plans, physician groups, and health care systems, plus academic, purchaser, consumer, and pharmaceutical industry representatives, committed to policy development, public dialogue, and special projects associated with the continuing evolution of managed care.


Pay for Performance involves:

• Common metrics for physician group performance

•A public scorecard displaying the results

•Individual health plans’ “significant” $$$ to reward physician group performance

What Are They Doing?What Are They Doing?


And Why are They Doing This?

And Why are They Doing This?

•Purchasers want value for premium $

•Need to create a business case for quality at the provider level

•Create more constructive health plan – physician group relationship

•Need single, respected medical group report card to promote competition on quality and help consumer choices


Participating Health PlansParticipating Health Plans

•Aetna•Blue Cross of California•Blue Shield of California•CIGNA HealthCare of California•Health Net•PacifiCare •Others in year 2……?

Approx. 8 million HMO enrollees now


The Health Plans’ Delegated Model Dilemma

The Health Plans’ Delegated Model Dilemma

•Most non-Kaiser plans contract with same physician groups

•No plan > 25% of a physician group’s revenue

•Quality improvement at the physician group level benefits many plans

•Therefore, competition works against an individual plan’s incentive to improve the infrastructure of its physician groups


•Commercial HMO/POS enrollees•A balanced scorecard•Audited admin data for clinical scores• Independent entity validate data•Public reporting of results•Reward improvement and performance•The Power of Multiples

–Common metrics drive performance –Concentrated payments = real $$$

The P4P FundamentalsThe P4P Fundamentalsr


•Collaboratively designed

•Balanced–Clinical – 50%–Patient satisfaction – 40%–IT investment – 10%

•Evolving over time–Raise the bar, carefully add measures

The MeasuresThe Measures


The Clinical Measures

The Clinical Measures

Preventive Care

• Breast Cancer Screening

• Cervical Cancer Screening

• Childhood Immunizations

Chronic Disease Care

• Appropriate Medications for People with Asthma

• Diabetes HbA1c Testing • Cholesterol

Management: LDL Screening


Patient Satisfaction DomainsPatient Satisfaction Domains

•Communication with doctor (10%)

•Overall ratings of care (10%)

•Specialty care(10%)

•Timely Access to care(10%)

TOTAL = 40%


IT MeasureIT Measure

Group can demonstrate capabilities in either or both of two key domains:

1. Clinical data set integration (group level)

– any two of encounter, lab results, pharmacy, inpatient or ER, radiology

2. Clinical decision support (point of care)


Scorecard DecisionsScorecard Decisions

•Scorecard will be public•We will make every effort to make it consumer friendly

•Will include non-English availability•Will require a separate 3d party vendor•Will partner with State OPA•Requires adequate encounter data


Health Plan PaymentsHealth Plan Payments

•Each plan individually decides source, amount, and payment method

•2004 payment based on 2003 results•Contract amendment process is key•Not all plans have completed their 2004 budgets and program designs

•IHA urging plans to do 5-10% bonus


What it MeansWhat it Means

•Unprecedented cooperation by health plans•First statewide, multi-plan initiative of its kind•Changes the plan-group conversation?•Speeds up physician group consolidation?•Preserves the delegated model •Begins long term QI process •Benefits all patients, not just HMO enrollees


Key Implementation IssuesKey Implementation Issues

•Group variation in encounter data submission

•Plan variation in “catching” group data

•Health plans want to collect and use other data

•Some plans REALLY like their own scorecards

•Amending group contracts is VERY tricky

•“Unbundling” P4P from regular contract cycle

•Will purchasers recognize/reward plan?

•Possible adverse selection for best groups?


How to Provide InputHow to Provide Input

•Consult web site for updates – www.iha.org

•Sign up for e-Updates: e-mail to [email protected]

• Contact IHA directly:

Beau Carter, Executive Director

Integrated Healthcare Association

49 Quail Court, Suite 205

Walnut Creek, CA 94596

Tel: 925/746-5100 Fax: 925/746-5103

- a Rewarding Results National Grant Pay for Performance: Driving Improvement through Provider...

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