N.E.W.T. Level Measurement: Voldemort or Dumbledore? Nathan Spell, MD, FACP Chief Quality Officer, Emory University Hospital Georgia Chapter Scientific Meeting American College of Physicians Savannah, Georgia October 6, 2013 Richard Gitomer, MD, FACP President, CQO and Director of Medical Svcs Emory Healthcare Network
OBJECTIVES After this session you should be able to: Name at least 3 goals of performance measurement Describe challenges to validity of measures for comparison of health care providers Articulate ways performance measurement can help us improve medical practice and the care of patient populations Neither Dr. Spell nor Dr. Gitomer have conflicts of interest
WHAT S YOUR LEVEL? 1. Practicing physician 2. Resident or fellow 3. Medical student 4. Other 0% 0% 0% 0% 1. 2. 3. 4. 10
IF IN PRACTICE, WHAT KIND? 1. Solo or small group (<10) 2. Large group 10 or more) 3. Academic faculty practice 4. Military or VA 0% 0% 0% 0% 1. 2. 3. 4. 9
DO YOU HAVE AN EHR THAT IS MEANINGFUL USE LEVEL 1 CERTIFIED? 1. Yes 2. No 3. Not sure 4. Do not have an EHR 0% 0% 0% 0% 1. 2. 3. 4. 9
DO YOU PARTICIPATE IN A HEALTH INFORMATION EXCHANGE? 1. Yes 2. No 3. Not sure 0% 0% 0% 1. 2. 3. 9
DO YOU HAVE COMMERCIAL INSURANCE CONTRACTS WITH COMPENSATION TIED TO PERFORMANCE ON QUALITY AND/OR COST MEASURES? 1. Yes 2. No 3. Not sure 4. Does not apply (military/va/resident/ fellow) 0% 0% 0% 0% 1. 2. 3. 4. 9
DO YOU HAVE MEDICAL HOME CERTIFICATION? 1. Yes 2. No 3. Does not apply 0% 0% 0% 1. 2. 3. 9
IN YOUR PRACTICE ARE YOU DOING IMPROVEMENT WORK USING DATA OTHER THAN FOR MOC? 1. True 2. False 0% 0% True False 9
Clinically Enriched Data from EMR (near future) Abstracted Data Administrative Data CMS Medpar/PQRS Payors Q-HIP Hospitalcompare.hhs.gov physiciancompare.hhs.gov (group practice performance data coming 2014) 18
DATA SOURCES FOR MEASUREMENT Administrative data (billing) CPT and ICD-9 codes DRG and CPT codes (inpatient HAC, mortality, readmission, etc.) Clinical data Discrete electronic v. manually abstracted Paid claims data Source insurance company
ADMINISTRATIVE DATA Strengths Generated out of our usual activities We have access to what we have billed Incentives for accuracy through payer audits (hospital >> ambulatory) Weaknesses Very high level Variable degrees of thoroughness across providers Professional coders may miss important clinical detail Physicians code variably and for different incentives Cannot identify valid exceptions to most measures Only captures what we billed for
CLINICAL DATA Strengths Much richer data Gives nuance Allows for identifying exceptions to measure compliance Discrete, identifiable data elements can be built into EMRs Can use prompts for data entry Weaknesses Expensive when manual chart abstraction is required Core Measures NSQIP, ACC/AHA, etc PQRS sampling option Current EMRs make data entry awkward and usually increase the amount of time for documentation Can be gamed Only captures what we entered
PAID CLAIMS DATA Strengths Generated through usual activities Captures data outside of our own practice and health systems Weaknesses Usually unobtainable by physicians and health systems Accuracy not verifiable All the weaknesses of our own billing data
ARE YOU CONSIDERED MAGICAL OR MUGGLE?
RANDOM VARIATION EFFECTS OF SAMPLE SIZE ON RATINGS Implications? Multiple insurers assessing only their covered patients
SPECIAL CAUSES OF VARIATION Patient factors SES, race, proper risk adjustment for comorbidities Provider factors Billing, coding, charting practices Legitimate differences in processes of care
CAN WE SEE THE FUTURE OF PUBLIC REPORTING? The crystal ball is only becoming more transparent Performance Costs Patient experience
Public reporting Public health/disease surveillance Payment program Regulatory and accreditation programs APPROPRIATE USE OF MEASURES Professional certification or recognition programs Quality improvement with benchmarking(external benchmarking to multiple organizations) Quality improvement (internal to specific organization) www.qualityforum.org
PUBLIC REPORTING: AN EMORY EXPERIENCE VASCULAR CATHETER-ASSOCIATED INFECTION Location Number Rate* % of National Nationwide 6,868 0.367 100% Emory University Hospital 36 2.313 630% WellStar Kennestone Hospital 21 1.011 275% Emory University Hospital Midtown 13 1.045 285% Atlanta Medical Center 8 1.862 507% *Events per 1000 Medicare patients
NATIONAL INITIATIVES USING MEASURES CMS HOSPITAL QUALITY IP Quality OP Quality IP Rehab Long-Term Care Meaningful Use Value-Based Purchasing OTHER HOSPITAL QUALITY HHS Hospital Compare Leapfrog Hospital CMS MD QUALITY Medicaid Adult Meaningful Use PQRS Value-Based Modifier OTHER MD QUALITY NCQA HEDIS Physician ONC Beacon Bridges to Excellence HEALTHPLAN OR SYSTEM NCQA HEDIS Health Plan Shared Savings Program
CMS PUBLIC REPORTING SITES www.hospitalcompare.hhs.gov www.medicare.gov/physiciancomp are Medicare Claims MedPAR (Medicare Provider Analysis & Review) CMS PQRS & eprescribing
HEALTHGRADES www.healthgrades.com Publically Available Demographics Future: PhysicianCompare CMS MedPAR & Proprietary Algorithm HospitalCompare
OTHER PUBLICALLY-AVAILABLE DATA State-Level Reporting STS Registry (Manual Abstraction)
ACCOUNTABLE CARE Foundational to current healthcare financing strategy Legacy from the 1990 s Perception of rationing Purpose of measurement (payout mechanism) Ensure quality in the setting of cost-reduction incentives Incentivize improved quality Discern (pay for) differences between organizations Align incentives with payer Limit provider payout Data availability administrative vs. EHR
COMMERCIAL VALUE CONTRACT MODEL Cost Target Cost Performance Savings 30% Available 18% Quality 12% Utilization VALUE SCORECARD Weighted Scoring Normalized Standards Tiers - % Total Points 50% Quality Threshold Metrics HEDIS Claims Data Wellness Chronic Conditions Utilization Measures
Cost per patient per year SHARED SAVINGS MODEL OF REIMBURSEMENT OTHER EXAMPLES: Shared Savings ACO (Pioneer & Shared-Savings ACO) IMPACT: Larger returns can support substantive infrastructure change. Diminishing returns over the years. Distributed based on quality performance Time
COMMERCIAL VALUE CONTRACT ACUTE & CHRONIC CONDITIONS Rx acute bronchitis Depression AMI CAD C/V disease CHF Diabetes Med Adherence Medication monitoring DMARD Osteoporosis Asthma PREVENTION Breast cancer screening Cervical cancer screening Chlamydia screening Glaucoma screening UTILIZATION Avoidable ER visits Ambulatory sensitive admissions Generic drug rate
PUBLIC REPORTING BENEFITS Focuses quality efforts Engenders organizational will Facilitates transparency CONSEQUENCES Can diffuse focus Collection burden Inappropriate use for comparison
Responses remain anonymous!
1. Poor 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 0% 0% 0% 1. 2. 3. 4. 5. 10
1. Poor 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 0% 0% 0% Poor Fair Average Good Excellent 10
% % % 1. Yes 2. No 3. N/A 10
1. Poor 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 0% 0% 0% 1. 2. 3. 4. 5. 10
1. Yes 2. No 10