Quality Measures: Background

• IOM 1999 “To Err is Human” (Rx related deaths); 2001 “Crossing the Quality Chasm” (“aims for 21st century”)– gaps in quality of healthcare / disparities– cost of care quality of care– incentives can change behavior– managed care / single payor experiences

• pharmacy risk / formulary adherence / restrictions• utilization payment adjustments • facilitated via electronic medical record (EMR)

– “Pay for Performance” (P4P)

> 100 private P4P programs in USA

California P4P Measures

• Clinical Domain (50%) (Quality + Efficiency)– HEDIS (Health Plan Employer Data and Information

Set) Indicators (years 1 and 2)– Measurement of Control (year 3+)

• Patient Experience Domain (30%)– Timeliness/Access– Coordination– Overall Rating

• Information Technology Investment (20%)• Bonus Opportunity (10%)

– Feedback Provided at Individual Provider Level

Clinical Domain Evolution-Examples

• Earlier Years– Hgb A1C Screening– LDL Screening– Breast Cancer

Screening– Cervical Cancer

Screening

• Later Years– HgbA1C Control– LDL Control– Nephropathy Control

in Diabetes– Appropriate Treatment

of Children with URIs– Chlamydia Screening

of Young Women

Problem: bad patients (non-compliant, comorbidity etc.) = “bad quality care”

P4P in USA: Current and Future• Multiple Variations Currently• CMS Setting Expectations and Standards

– Voluntary Ambulatory Indicators (voluntary for now!!!)– Evidence-Based– Chosen By Consensus– Major Medical Societies Represented

• Expect All Payers Will Follow• All Indicators Will Be Within CMS Universe• Driver of Healthcare IT• Higher Quality Will Become the Expectation• P4P May Yield to Minimum Quality Thresholds• P4P Reimbursement May Not Be Upside

– Poor Performers =Lower Reimbursement

Quality: The Players in the USA• Centers for Medicare and Medicaid Services (CMS):

www.cms.hhs.gov/quality/pfqi.asp. Physician Focused Quality Initiative (PFQI). Physician Voluntary Reporting System (PVRS). Doctor’s Office Quality (DOQ) project.

• American Medical Association (AMA): www.ama-assn.org/ama/pub/category/2946.html. Physician Consortium for Performance Improvement (PCPI). Major source of material for NQF, AQA

• Ambulatory Quality Alliance (AQA): www.ambulatoryqualityalliance.org Started in 2004 by America’s Health Insurance Plans, AAFP, ACP, and Agency for Healthcare Research and Quality (AHRQ). Leader in selecting performance measures for physician practices (26 as of 5/06).

• National Committee for Quality Assurance (NCQA): www.ncqa.org A supplier of performance measurements, especially for managed care. Invited ACR et al to participate in back pain measures.

• National Quality Forum (NQF): www.qualityforum.org Non-profit group developing performance measures

It Ain’t Going Away

Slide taken from UCSD Quality Council Presentation 4/5/06

QUALITY MEASURES

• “Quality” – a prerequisit for reimbursement

• Definition of “quality”

• Action points

Quality – a prerequisit for reimbursement

• Disease Management Programs

• Certified QM as pre-requisit for re-imbursement by German insurance companies (planned for the near future)– formal QM systems

(KTQ®)– outcome-oriented

systems (EFQM®)

Definition of “Quality”

• Provide EBM– Document disease severity using „approved“

measures• What are these?

– Document therapeutic choice• Example: Germany

– Document efficacy using „approved“ measures• What are these?

– Participate in registries!!!

Document therapeutic choice: the German way

ACTIONS

• “GRAPPA checklist on quality”?