Addressing Issues

Aligning Payment Policies with Care: Fixing the Quality Care Problem

Institute of Medicine (IOM) Recommendations 5

The IOM recommends that private and public purchasers examine their current payment methods to remove barriers that currently impede quality improvement, and to build in stronger incentives for quality enhancement. Payment methods should:

• Provide fair payment for good clinical management of the types of patients seen. Clinicians should be adequately compensated for taking good care of all types of patients, neither gaining or losing financially for caring for sicker patients or those with more complicated conditions.
• Promote patient centered, effective, efficient and timely care in a safe environment.
• Provide an opportunity for providers to share in the benefits of quality improvement, such as mal practice risk reduction.
• Provide the opportunity for consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly. In particular, consumers need to have good information on quality and the ability to use that information as they see fit to meet their needs. For example, an online report card could compare ratings on HMO services for people with diabetes.
• Align financial incentives with the implementation of care processes based on best practices and the achievement of better patient outcomes.
• Reduce fragmentation of care. Payment methods should not pose a barrier to providers' ability to coordinate care for patients across settings.

The purchaser role in fixing the problem

Whether purchasers are public or private, small or large, insured or self-insured, strategies are available that allow them to play a leadership role in addressing the human and financial costs of the quality care problem. The Midwest Business Group on Health suggests a four-step process that responsible purchasers can employ. 3

• Step 1: Analyze employer-specific health care data in order to identify high-priority problems.
• Step 2: Measure the performance of plans and providers, and engage them in continuous improvement programs.
• Step 3: Educate consumers and share performance information with them.
• Step 4: Reward high-quality health plans and providers through direct incentives, public recognition of best performers, incentives for consumers to choose quality, shared-savings contracts, and/or selective contracting.

Implementing these initiatives will require a commitment of both time and money on the part of purchasers, health plans, and provider organizations. Purchasers must be willing to share some of the cost savings generated from quality improvement with those plans and providers that make the effort to improve. In the short term, these outlays may significantly cut into the net financial savings. Over the long term, however, the implementation costs should fall while the cost savings from quality improvement continue to accrue - and potentially increase - year after year. 3

Most companies should consider collaborating with others through business coalitions, associations, health plan user groups, and/or local employer associations. In addition to providing access to needed expertise, a cooperative approach creates added leverage and economies of scale, as providers and plans are more likely to pay attention to quality improvement initiatives if the sponsors of that initiative represent more people.3

Please note: Some links on this page take you outside the Better Diabetes Care website. The NDEP does not endorse or otherwise guarantee the accuracy of links that take you out of this website.

The Health Plan Employer Data and Information Set (HEDIS®)
www.ncqa.org/Programs/HEDIS
HEDIS is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. The performance measures in HEDIS are related to many significant public health issues such as cancer, heart disease, smoking, asthma and diabetes. HEDIS also includes a standardized survey of consumers' experiences that evaluates plan performance in areas such as customer service, access to care and claims possessing. HEDIS is sponsored, supported and maintained by the National Committee for Quality Assurance.

The Foundation for Accountability (FACCT)
www.facct.org
FACCT is a not-for-profit organization that helps Americans make better health care decisions. The board of trustees is made up of consumer organizations and purchasers of health care services and insurance representing 80 million Americans. These groups are committed to measuring health care quality and communicating results in a way that makes sense to consumers. With information about quality, consumers can make sound buying decisions, participate effectively in their own care and encourage the health system to focus on health.

FACCT has diabetes quality measures for:

• Good care -- foot exam, frequency of A1C testing, retinal exam and advice to quit smoking
• Patient satisfaction
• Results -- patient functional status, A1C in good control, lipid levels, smoking cessation, and patient ability to maintain daily activities.

An annual survey, claims, or the medical record provide the data to assess the level of care achieved on these measures and report findings. (This info on FACCT is the same as in Section 4. Measuring Change)

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The provider role in fixing the problem

To promote quality improvement, providers can implement clinical quality improvement programs and the use of outcomes measurement, diabetes management programs, or practice guidelines. Aids include reminder systems (e.g., charts, computerized reminders, checklists, or medical record flags) or standing orders for treatments or services that are known to be effective, such as preventive exams of eyes, kidney and feet for patients with diabetes. Systems that provide real-time prompts to caregivers are highly effective in reducing under use. 3

To promote adoption of automated information systems, purchasers could recommend that providers have an implementation strategy for using electronic medical record and/or computerized decision-support tools to guide diabetes treatment.

Examples:

• National Committee for Quality Assurance (NCQA)/ American Diabetes Association (ADA) Diabetes Physician Recognition Program
  www.ncqa.org/dprp
  NCQA/ADA has developed a "Pay for Quality" initiative to promote the use of providers recognized by the Diabetes Physician Provider Recognition Program. Employers including General Electric, United Parcel Service, and other national employers will offer bonus payments to recognized physicians and additional reimbursement based on each physician's volume of diabetes patients. The Washington Business Group on Health suggests that its employer members consider replicating the initiative and use additional strategies, such as working with health plans to highlight Recognized physicians in provider directories or giving employees financial or other incentives such as waiving co-payments to use recognized physicians. For more information on the NCQA/ADA Diabetes Physician Recognition Program click here.
  
• Application of The Health Plan Employer Data and Information Set (HEDIS®)
  A study conducted in a large health maintenance organization (HMO) compared health care costs for patients who fulfilled HEDIS criteria for diabetes and were in an HMO-sponsored disease management program with costs for those not in disease management. Of 6,799 patients fulfilling HEDIS criteria for the diagnosis of diabetes, 3,118 (45.9 percent) patients were enrolled in a disease management program (program), and 3,681 (54.1 percent) were not enrolled (nonprogram).
  
  The program interventions, given over 1 year, promoted diabetes clinical guidelines by nurses in their day-to-day interaction with primary care physicians and patients, HMO-sponsored continuing medical education for primary care providers, early and appropriate specialty clinic referral, and primary care site-based patient education and case management by the HMO nurses. Patients needed to volunteer for the program and were seen by the nurse one to four times from the date of referral. Per member per month paid claims averaged 394.62 dollars for program patients compared with 502.48 dollars for nonprogram patients (P < 0.05). This difference was accompanied by lower inpatient health care use, fewer emergency room visits and a higher number of primary care visits for program participants than in nonprogram participants. Program patients also achieved higher HEDIS scores for A1C testing as well as for lipid, eye, and kidney screenings. A1C values were lower in program participants.18
  
• The Centers for Medicare and Medicaid Services (CMS) role in fixing the problem
  www.ahqa.org/pub/connections/162_694_2450.cfm
  CMS administers the Quality Improvement Organization (QIO) Program that is designed to monitor and improve utilization and quality of care for Medicare beneficiaries. The program consists of a national network of fifty-three QIOs (formerly known as Peer Review Organizations) responsible for each U.S. state, territory, and the District of Columbia. Each QIO maintains a staff of highly qualified, multi-disciplinary experts in medicine, quality improvement, health information management, statistical analysis, computer programming and operations, communications, public relations, and clerical/administrative support. Their mission is to ensure the quality, effectiveness, efficiency, and economy of health care services provided to Medicare.
  
  The American Health Quality Association (AHQA) represents QIOs and professionals working to improve health care quality and patient safety. AHQA serves as a professional resource and as a partner on projects with CMS, the Department of Health and Human Services, the National Quality Forum, major professional medical and health care associations, and the Medicare Payment Advisory Commission.
  
  CMS is developing a policy regarding aligning payment policies with quality improvement. In October 2000, major newspapers across the country reported the performance on quality measures for nursing homes. In 2003, data will be published on home health agencies. Hospitals and medical clinics can anticipate that data on their performance will follow in subsequent years. Hospitals are being asked to start collecting (currently on a voluntary basis) their performance on several quality measures. The data collection is likely to become mandatory in the next several years and then it is likely to be made available on the web and in newspapers. The administration is not looking to pay on a differential basis, but they do expect the data to drive consumer behavior and choice. In turn, they expect market forces to create the "business case" for quality improvement as consumers "vote with their feet."
  
• CMS Doctor's Office Quality Project
  This CMS initiative is a measurement, improvement, and incentive pilot for chronic disease and preventative care taking place in Iowa, New York, and California between 2002 and 2005. The goal is to develop strategies for quality improvement in physician's offices and to test incentives for physicians. Possible incentives include malpractice risk reduction, paid CME programs related to quality improvement, public recognition, and public reporting. NCQA systems measures will be used and patient-derived measures will be determined.

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