Philip D. Sloane, MD, MPH, Philip D. Sloane, MD, MPH, Jacquie Halladay, MD, MPH, Sally Stearns, PhD, Jacquie Halladay, MD, MPH, Sally Stearns, PhD,

Thomas Wroth, MD, MPH, Paul Bray, MA, Thomas Wroth, MD, MPH, Paul Bray, MA, Lynn Spragens, MBA, & Sheryl Zimmerman, PhDLynn Spragens, MBA, & Sheryl Zimmerman, PhD

From the North Carolina Network Consortium and the Cecil G. From the North Carolina Network Consortium and the Cecil G. Sheps Center for Health Services Research, University of Sheps Center for Health Services Research, University of

North Carolina at Chapel HillNorth Carolina at Chapel Hill

Funded by the US Agency for HealthCare Research and Funded by the US Agency for HealthCare Research and Quality (AHRQ)Quality (AHRQ)

Performance Data Performance Data Reporting: Impact on Reporting: Impact on

Primary Care PracticesPrimary Care Practices

DisclosureDisclosure

I have no relationships to disclose, andI have no relationships to disclose, and I will not discuss off label or I will not discuss off label or

investigational use in my presentation investigational use in my presentation

BackgroundBackground

2006 AHRQ publication: barriers and challenges 2006 AHRQ publication: barriers and challenges to collecting and reporting healthcare datato collecting and reporting healthcare data

Barriers Identified:Barriers Identified:

Data system inefficiencies of data systemsData system inefficiencies of data systems Variation in indicatorsVariation in indicators Technological barriersTechnological barriers Competing prioritiesCompeting priorities Economic pressuresEconomic pressures Organizational and cultural issues.Organizational and cultural issues.

ObjectivesObjectives

Detail the costs of implementation Detail the costs of implementation and maintenance of performance and maintenance of performance data reportingdata reporting

Gather information on how practices Gather information on how practices successfully overcome challenges to successfully overcome challenges to data reporting.data reporting.

Programs EvaluatedPrograms Evaluated

Physician Quality Reporting Initiative (PQRI)

Bridges to Excellence

Improving Performance in Practice (IPIP)

Community Care of North Carolina (CCNC)

PQRIPQRI

Medicare’s reporting program.Medicare’s reporting program. 74 quality measures (practices can 74 quality measures (practices can

choose).choose). ““G” codes are added to billing G” codes are added to billing

submissions.submissions. Must have 80% of cases reported on three Must have 80% of cases reported on three

quality measures.quality measures. Incentive payment of Incentive payment of < 1.5% of Medicare 1.5% of Medicare

allowable.allowable.

Bridges to ExcellenceBridges to Excellence Started in 2006 as a three-year pilot program by Started in 2006 as a three-year pilot program by

BC/BS.BC/BS.

Incentive: $$, based on achieving quality Incentive: $$, based on achieving quality thresholds and # of patients with BCBS insurance.thresholds and # of patients with BCBS insurance.

Two programs studied:Two programs studied: Diabetes CareDiabetes Care: HbA1c, BP, LDL, Eye exams, Foot : HbA1c, BP, LDL, Eye exams, Foot

exams, Nephropathy assessments, smoking exams, Nephropathy assessments, smoking status/cessation.status/cessation.

Physician Office ConnectionsPhysician Office Connections: Office systems and : Office systems and processes such as electronic prescribing, referral processes such as electronic prescribing, referral tracking, performance reporting (9 items total).tracking, performance reporting (9 items total).

Improving Performance Improving Performance in Practice (IPIP)in Practice (IPIP)

State-based, nationally led QI initiativeState-based, nationally led QI initiative Pilots in CO and NC. Pilots in CO and NC. Uses quality improvement coaches (QICs) Uses quality improvement coaches (QICs)

who go who go intointo physicians’ offices and work with physicians’ offices and work with the practice on improvement efforts, the practice on improvement efforts, including:including: Data system assistanceData system assistance Decision support and protocol developmentDecision support and protocol development Office team involvement in quality improvement Office team involvement in quality improvement

and measurementand measurement

Community Care of Community Care of North Carolina (CCNC)North Carolina (CCNC)

Statewide system of 14 regional Medicaid Statewide system of 14 regional Medicaid care networkscare networks Each has a program director, medical director, steering Each has a program director, medical director, steering

committee, case managerscommittee, case managers

Attention to chronic diseases (mainly Attention to chronic diseases (mainly diabetes and asthma)diabetes and asthma)

Guideline dissemination & case managementGuideline dissemination & case management Yearly statewide audits and reports with Yearly statewide audits and reports with

comparison data to local practicescomparison data to local practices

Eight Practices Selected Eight Practices Selected For Variety and For Variety and

Program ParticipationProgram ParticipationPractice Size by Total Number of Providers (MD's and PA/NP's)

4 3

189

3

8

6

11

112

2 3 3

0

5

10

15

20

25

Pvt-sm Non-P-Med

Non-P-Med

Pvt-sm Teaching Pvt-Lg Pvt-sm Non-P-Med

Nu

mb

er

MD's PA/NP's

Quality Data Quality Data Reporting Programs Reporting Programs

RepresentedRepresented

Of the 8 practices in the COMP project, 4 participated in PQRI, 3 in IPIP, 2 in BTE-Diabetes, 1 in BTE- PPC, 1 in a chronic disease collaborative

Programs

43

21

6

0

1

2

3

4

5

6

7

PQRI IPIP CCNC BTE DM BTE PPC

# o

f p

ract

ices

par

tici

pat

ing

Conditions EvaluatedConditions Evaluated

Disease or Quality Measures

6

32 2

8

0123456789

Diabetes Asthma COPD Falls RiskAssessment

others

# pr

actic

es

Medical Data SystemsMedical Data Systems

Types of Electronic Medical Record Systems

3

2

3

0

1

2

3

Paper record andelectronic registry

EMR w/o populationfunctions

EMR with populationqueries

Nu

mb

er

Study MethodologyStudy Methodology

Intensive site visits by economist, QI Intensive site visits by economist, QI specialist & qualitative researcherspecialist & qualitative researcher

Meticulous detailing of costs (see next slide)Meticulous detailing of costs (see next slide) Interviews with:Interviews with:

quality champion, quality champion, care providers, care providers, other practice staffother practice staff

Quantitative and qualitative analysesQuantitative and qualitative analyses

Cost Categories - 1Cost Categories - 1

Total Resource Costs

Costs to Practice• Total rather than marginal costs

Cost to QI program• In-practice only

Total Practice Costs

Supplies, Equipment, Application Fees

Staff Time:Non-measure Specific

(data entry, meetings)

Staff Time:Measure-Specific

(eye exam referrals, HbA1c)

Cost Categories - 2Cost Categories - 2Cost Categories - 2Cost Categories - 2

Total Practice Costs

Maintenance PhaseStart-Up Phase

Cost PhasesCost Phases

PQRI Implementation PQRI Implementation Costs in Four PracticesCosts in Four Practices

$0

$5,000

$10,000

$15,000

$20,000

$25,000

Total Per FTE

Practice A

Practice B

Practice D

Practice H

PQRI Implementation in PQRI Implementation in Practices A and HPractices A and H

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Total Per FTE

Practice A

Practice H

Cost Per FTE of Cost Per FTE of Implementing CCNC vs IPIPImplementing CCNC vs IPIP

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

CCNC IPIP

Practice B

Practice C

Average Practice & Program Costs Average Practice & Program Costs per FTE of CCNC*, IPIP**, and PQRI***per FTE of CCNC*, IPIP**, and PQRI***

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

CCNC IPIP PQRI

Practice Costs

In-OfficeProgram Costs

Combined

Maintenance Phase * 6 practices ** 3 practices *** 4 practices

Estimated Costs and Reimbursement Estimated Costs and Reimbursement for Participation in B to E Diabetesfor Participation in B to E Diabetes

$0$200$400$600$800

$1,000$1,200$1,400$1,600$1,800

Practice A Practice G

Diabetes Cost

Diabetes Reimb

Estimates are per provider FTE

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

Practice A

Diabetes Cost

Diabetes Reimb

Med Home Cost

Med HomeAnnual Reimb

Estimated Costs and Reimbursement Estimated Costs and Reimbursement for Participation in B to E Medical Homefor Participation in B to E Medical Home

Estimates are per provider FTE

Lessons from Lessons from Qualitative InterviewsQualitative Interviews

Methods:Methods: Interviews with practice championInterviews with practice champion Group interviews with practice staffGroup interviews with practice staff Medical director joined for lunchMedical director joined for lunch Dedicated note taker present; case Dedicated note taker present; case

reports generated; research team reports generated; research team reviewed for themes and lessonsreviewed for themes and lessons

Motivation to Participate Motivation to Participate is a Key to Successis a Key to Success

““Pay for performance seems inevitable, Pay for performance seems inevitable, and we wanted to prepare our practice and we wanted to prepare our practice for it” for it”

“ “If we are providing quality of care, we If we are providing quality of care, we want to separate ourselves out and be want to separate ourselves out and be recognized” recognized”

Leadership is Crucial to Leadership is Crucial to Getting StartedGetting Started

Leaders with quality improvement Leaders with quality improvement experience and an interest in experience and an interest in participation; staff who then get participation; staff who then get motivated motivated

“ “The providers set the tone and The providers set the tone and empower the staff”empower the staff”

Three Major Logistical Three Major Logistical ChallengesChallenges

Staff time and effortStaff time and effort "The clinicians and staff are being driven to a "The clinicians and staff are being driven to a

frazzle”frazzle”

IT challengesIT challenges ““I’m sure that the EHR vendor could develop a I’m sure that the EHR vendor could develop a

query to do this, if we paid them enough” query to do this, if we paid them enough”

Difficulties changing physician behaviorDifficulties changing physician behavior ““Once you start to measure quality, the first thing Once you start to measure quality, the first thing

the providers do is question the measures”the providers do is question the measures”

Going Through Hoops to Going Through Hoops to Achieve Data ConsistencyAchieve Data Consistency

One practice had to train the physicians One practice had to train the physicians to record “feet” instead of “extremity” to record “feet” instead of “extremity”

Another had to create a report on Another had to create a report on smoking cessation counseling three smoking cessation counseling three times before it was in an acceptable times before it was in an acceptable formatformat

Involving the TeamInvolving the Team

Practices reported difficulty finding enough Practices reported difficulty finding enough time to review and act on quality data reportstime to review and act on quality data reports

““(The practice manager) presents the data in (The practice manager) presents the data in a fun way…she puts time into preparing it for a fun way…she puts time into preparing it for you, in charts, so that we have clarity” you, in charts, so that we have clarity”

"Initially providers are burdened by a new "Initially providers are burdened by a new reporting activity. But after a while it takes reporting activity. But after a while it takes less effort because they figure out how to less effort because they figure out how to give it to nursing"give it to nursing"

Perceived Effects on Perceived Effects on Productivity & FinancesProductivity & Finances

Slowed down productivity initially, but overall productivity increase over time

Positive:Positive: "Good income for good medicine" "Good income for good medicine" Negative:Negative: “They are taking money out of my “They are taking money out of my

pocket"pocket"

External and Internal Barriers and Facilitators

Infrastructure Development

Practice Precondi-

tions Program Initiation

Program Maturation

Sustainability

Preconditions1. Exposure to QI2. Leader with QI experience3. Focus on quality > income

Infrastructure Development

1. Medical director support2. Administrator support3. Data entry & reporting resources4. Staff meeting times

Sustainability1. Tangible constructive change2. Financial benefit3. Enhanced practice reputation4. Strategic partnerships that foster culture of quality

Catalyst

Catalysts1. Committed leader or mandate2. Collaborative atmosphere3. Outside encouragement

Theoretical Model: Factors Involved in Developing Theoretical Model: Factors Involved in Developing and Maintaining Quality Assessment, Improvement, and Maintaining Quality Assessment, Improvement,

and Reporting in a Primary Careand Reporting in a Primary Care

Image