Program and Policy Program and Policy Strategies to Promote Strategies to Promote Healthcare Quality for Healthcare Quality for
ChildrenChildren
Lisa A. Simpson, MB, BCh, MPH, FAAPNational Director, Child Health Policy, NICHQ
Endowed Chair, Child Health PolicyUniversity of South Florida
Today’s Popular Policy Today’s Popular Policy PlatformsPlatforms
Pay for Performance Health Information Technology Consumer driven health care
For each…– What do we know about use and/or
its effectiveness overall? – What do we know of its use and/or
effectiveness for children?
Pay for Performance (P4P)Pay for Performance (P4P) Incentive programs that provide monetary
bonuses to eligible participants linked to specific quality and/or efficiency standards established by the program
Initiated by government agencies, employers & health plans to stimulate quality improvement (one of the earliest from Aetna in 1987)
Financial rewards based on achievement related to – evidence-based clinical quality of care measures– patient satisfaction– efficiency/productivity– infrastructure of the practice (including use of
information technologies)
AMA, Physician Pay for Performance Initiatives, 2004.
P4P ProgramsP4P Programs Average incentive payment around 1-5% of a
physician’s total revenue from a given health plan (AMA, 2004)– in Anthem BC/BS (NH) in 2001, average bonus payment
$1,183 and the highest bonus payment $15,320– in IHA program, average group bonus about $200,000 and
will cover 24,000 primary care physicians (200 physician groups & 7 million beneficiaries)
2004 survey findings:– Majority of programs were targeted to PCPs, confined to
HMO, fully insured products with annual bonus incentives based on HEDIS performance measures
– Dramatic growth: November, 2004: 84 programs w/ 39 million beneficiaries March 2005: 104 programs
– By 2006, predicted to increase to 160 programsBaker & Carter, 2005
AMA, Physician Pay for Performance Initiatives, 2004
Key Trends in P4P ProgramsKey Trends in P4P Programs Product Spread:
– Expansion to PPOs & Consumer Directed Healthcare products– Expansion to specialists with use of specialty-specific measures
Changes in Measures:– Use of measures for positive savings (generic substitution &
efficiency)– Supplementing population-based HEDIS measures– Use of scorecards and actionable results reporting to change
behavior– Use of performance results for public reporting– Significant growth in health information technology adoption
measures Changes in types of payments
– Use of adjustable fee schedules instead of annual bonus payments– Return on investment analyses (i.e., what would have been the
financial and clinical outcome in the absence of a P4P program?) Center for Medicare and Medicaid Services as a P4P
market driver
Baker & Carter, Provider Pay-for-Performance Incentive Programs: 2004 National Study Results, 2005.
Landon et al, 2004
PP4P - Pediatric Pay for PP4P - Pediatric Pay for PerformancePerformance
Leapfrog compendium identifies 12 programs (out of 70)– 4 states (IA, RI, UT, WI) - target health plans– Rest target physicians– 3 BC/BS (IL, MA, MO)
States’ use of quality information– Varies by product: HMO and PPO
Rewarding Results
Leapfrog CompendiumLeapfrog Compendium
Focus on:– well visit (child and adolescent)– immunizations– appropriate antibiotic utilization– asthma (self management plans or
medication management)– IT. (not clear if applies to peds)– volume, timeliness, and quality of electronic
encounter data
New Leapfrog Hospital Rewards New Leapfrog Hospital Rewards ProgramProgram
All short term acute care hospitals Five clinical areas including newborn care
accounting for 33% commercial admissions & 20% commercial inpatient spending
Newborn care measures include: – Neonatal mortality– NICU – Process of Care -- 80%+ adherence: antenatal steroids for
certain high-risk deliveries– 3rd/4th degree lacerations – Computerized physician order entry (CPOE) system– Leapfrog Quality Index (NQF Safe Practices)
Factors in Determining Compensation Factors in Determining Compensation Florida Child Health Provider, 2005Florida Child Health Provider, 2005
Not a Factor (%)
Minor Factor (%)
Major Factor (%)
Use of clinical
IT 71.5 23.2 5.3
Email consultation
with patients
No
96.2
Yes, Health plan/HMO
2.1
Yes, Other
1.7
Note: sample size varies by question, overall N=1219
Effectiveness of Pediatric PFP Programs: Effectiveness of Pediatric PFP Programs: RCT’sRCT’s
Citation (abbr.) Focus
Physicians/Practices Assigned (N) Reward
Differences Between Groups
Davidson (1992)
Well-child Recommendations
Enhanced FFS (40)Control (40)
Higher reimbursement rates for all in FFS
No
Hillman (1999)
Well-child Recommendations & Immunizations
Bonus + Feedback (19)Feedback only (17)Control (17)
Bonus based on rank & degree of improvement
No (but all groups improved over time)
Fairbrother (2001)
Childhood Immunizations
Enhanced FFS (12)Bonus + Feedback (24)Feedback only (21)
Bonus based oncompliance rates
Overall improvement in FFS & bonus groups
Today’s Popular Policy Today’s Popular Policy PlatformsPlatforms
Pay for Performance Health Information Technology Consumer driven health care
For each…– What do we know about use or its
effectiveness overall? – What do we know of its use or
effectiveness for children?
Health Information Technology Health Information Technology (IT) Adoption by Physicians(IT) Adoption by Physicians
Physicians either routinely or occasionally use:– 79% electronic billing– 59% electronic access to patients' test results either
routinely or occasionally– 27% EMRs and electronic ordering of tests,
procedures, or drugs – 21% have automated patient reminders regarding
routine preventive care– 7% e-mail with other doctors– 6% electronic clinical decision support systems – 3% email with patients
Top 3 reported barriers – costs of system start-up and maintenance– lack of local, regional, and national standards – lack of time to consider acquiring, implementing, and
using a new systemAudet et al, Medscape 2004 and Health Affairs, 2005
““Unique” Issues for ChildrenUnique” Issues for Children
Not so unique at the technical level Differences emerge in
– Market availability– Policy focus– Adoption of HIT applications
Child Health Provider Adoption of HIT Child Health Provider Adoption of HIT Total & by Gender, Florida, 2005Total & by Gender, Florida, 2005
Methods– Mailed survey (two waves) between March
and May 2005– All licensed primary care physicians
(MD/DOs) and a 25% sample of ambulatory subspecialists
– N=1219 child health provider respondents Primary care pediatrics, family medicine and
pediatric subspecialists serving >0% children
Child Health Provider Adoption of HIT Child Health Provider Adoption of HIT Total & by Gender, Florida, 2005Total & by Gender, Florida, 2005
Routine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
Total 80.2% 40.1% 18.0% 24.3%
Male 81.2 44.5 18.6 26.5
Female 75.4 31.6 14.5 22.5
p value .046* <.001* .127 .186
Note: sample size varies by question, overall N=1219
Percent Adoption of HIT by Medical Training Percent Adoption of HIT by Medical Training Florida Child Health Providers, 2005Florida Child Health Providers, 2005
Primary CareRoutine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
Primary Care
Pediatrics79.9 38.4 14.3 17.0
Family Medicine
78.4 42.2 21.9 26.8
Other 86.7 38.4 16.4 36.4
p value .052 .419 .005* <.001*
Note: sample size varies by question, overall N=1219
Adoption of HIT by Provider Age Adoption of HIT by Provider Age Florida Child Health Providers, 2005Florida Child Health Providers, 2005
Age (years)Routine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
<40 79.8 40.2 11.5 27.9
40-59 81.8 42.5 20.8 26.9
60+ 67.9 29.3 12.4 17.1
p value .003* .029* .008* .081
Note: sample size varies by question, overall N=1219
Adoption of HIT by Provider RaceAdoption of HIT by Provider RaceFlorida Child Health Providers, 2005Florida Child Health Providers, 2005
RaceRoutine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
White 80.3 39.2 19.9 26.2
Black 77.8 47.7 13.3 21.4
Hispanic 81.5 41.2 15.2 20.0
Asian 79.4 37.9 9.4 23.1
Other/Unknown
79.3 50.0 20.7 14.3
p value .982 .597 .059 .269
Note: sample size varies by question, overall N=1219
Adoption of HIT by Practice SizeAdoption of HIT by Practice SizeFlorida Child Health Providers, 2005Florida Child Health Providers, 2005
No. of Physicians
Routine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
Solo 76.0 34.6 17.3 17.7
2-9 79.0 39.9 17.5 22.4
10-49 91.5 52.2 20.8 43.9
50+ 97.4 68.8 32.4 64.9
p value <.001* <.001* .110 <.001*
Note: sample size varies by question, overall N=1219
Adoption of HIT By Practice TypeAdoption of HIT By Practice TypeFlorida Child Health Providers, 2005Florida Child Health Providers, 2005
TypeRoutine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
Single-specialty
74.1 35.9 17.0 19.5
Multi-specialty
91.1 51.4 23.4 41.4
p value <.001* .002* .100 <.001*
Note: sample size varies by question, overall N=1219
Adoption of HIT By Medicaid VolumeAdoption of HIT By Medicaid VolumeFlorida Child Health Providers, 2005Florida Child Health Providers, 2005
Medicaid Providers
Routine office
computer use
Routine PDA use
Email use with
patients
Routine EHR use
Low-volume 77.1 30.7 20.0 24.5
High-volume (at least 20%
Medicaid)81.8 44.4 13.5 22.0
p value .145 <.001* .028* .460
Note: sample size varies by question, overall N=1219
Today’s Popular Policy Today’s Popular Policy PlatformsPlatforms
Pay for Performance Health Information Technology Consumer Driven Health Care
For each…– What do we know about use or its
effectiveness overall? – What do we know of its use or
effectiveness for children?
Consumer Use of Consumer Use of Quality InformationQuality Information
Consumer driven health care shifts more financial responsibility to consumers on the assumption that this will drive better decisions
Several initiatives to publicly report performance– Medicare driven– State driven
Having an abundance of information does not always translate into its use to inform choices
All health care decisions – plan, provider, treatment requires the use of information that: – Includes technical terms and complex ideas– Compares multiple options on several variables– Requires the consumer to differentially weight the various
factors according to individual values, preferences & and needs
Information presentation has a significant effect on impact and use
Hibbard & Peters, Annual Reviews of Public Health (2003)
Where Consumers FindWhere Consumers FindQuality InformationQuality Information
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Percent who say they would be "very likely" to do each to try to find health care quality information...
16%
18%
20%
36%
36%
37%
65%
65%
Refer to a section of the newspaper or magazine thatlists quality information
Contact a state agency
Order a printed booklet with quality information byphone, mail, or online
Contact someone at their health plan, or refer tomaterials provided by the plan
Contact the Medicare program (age 65+)
Go online to an Internet web site that posts qualityinformation
Ask their doctor, nurse or other health professional
Ask friends, family members or co-workers
Consumer Exposure Consumer Exposure to Quality Informationto Quality Information
Percent who say they saw information in the past year comparing quality among...
9%
15%
23%
11%
22%
28%
Doctors
Hospitals
Health insuranceplans
2004
2000
27%
35%
Percent who saythey saw
information onANY of the
above...
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Consumer Use Consumer Use of Quality Informationof Quality Information
KFF/AHRQ/Harvard School of Public Health. Chart 10. National Survey on Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2005)
Percent who say they saw quality information in the past year and used this information to make health
care decisions...
12%
19%
2000
2004
Importance of Quality RatingsImportance of Quality Ratings
4846 45
49
61
33
50
38
4745
62
32
76
20
52
43
72
25
Surgeon who hastreated
friends/family
Surgeon that israted higher
Plan recommendedby friends
Plan highly ratedby experts
Hospital that isfamiliar
Hospital that israted higher
2004
2000
1996
KFF/AHRQ/Harvard School of Public Health. Chart 7. National Survey on Consumers’ Experiences with Patient Safety & Quality Information, November 2004
(Conducted July7 – Sept 5, 2004)
Parental Use of Quality Parental Use of Quality InformationInformation
Little research specifically looking at this
CAHPS related research points to similarities
Existing evidence points to even greater difficulties for children due to– Poverty– Low educational attainment– LEP
ConclusionsConclusions
Current policy strategies have been less well thought out/tested in child health populations
CHSR community has opportunity to develop more evidence on these questions
Top Related