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Shaping value based payment �to reward improved outcomes �

and reduce waste�*OzHPHS10m17 �

Acknowledgements to: Robert Moore CMO, Partnership HP of california;�René Frick and Jennifer Winchester BlueCross South Carolina�

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John Øvretveit, Director of Research, Professor of Health Innovation and Evaluation, Karolinska Institutet, Stockholm, Sweden

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Objectives

1)VBP/P4P overviewIts coming; payment for outcome has to be better; devil in the data and detail

2)Why clinicians need to shape the tool and how to do so3)Groups4)Conclusions

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Why are we doing this?�Mary: 84 yrs obstructive airways (COPD) and heart disease

Stable at home on meds, fiercely independent

Unpaid motivational coach and security-guard - “Matty”

Mary - six weeks later

§ Mary, after hospitalisation

§  Sent home with no support

§  Readmitted in emergency

§ Avoidable cost to health system 4600ECU

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Missing

§ Done well – individual caring § Less well – delays, organised for flow

and handover§ Payment rewards fast discharge (no

time or systems for handover)§ No system to detect and respond§ Capacity to improve under-developed

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In 2022 NSW, § Will there be more or fewer Mary’s?§  Will payment reward quality and

outcomes, or just activity?§ Will physicians have shaped the financing

system to reward right care and better care? (monitor adverse effects)

§ Built the capacity to respond? ú Data & reportingú Quality improvement

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Points § Payment powerful driver of behaviour

and change – for good or ill

§ Data showing poor quality ú & systems to ensure effective action on

priorities

§ Incentive to respond § Capability to recognise and change –

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Conclusion 1 Two ingredients for improvement

1)Change how hospital is paid to penalise poor outcomes & reward good2)Hospital capacity to improve

Effective quality projectsPhysicians involvement in projects

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1) Overview of VBP/P4P

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Types External funder pays§  Individual physicians - for items of service

ú  Include quality or outcome requirementsú  Special payments to perform e.g. screeing

ú  Physician organisations agree contract

§ Hospital or service ú  How is this transmitted to salaried physicians? Payment?

§  Episode of care spanning organisations – pay an organising entity for a “bundle of care” (e.g. ACO, disease management)

§ Capitation – range of services at defined quality10

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1)PHC clinicQuality data reporting - 6 sets measures for: § Diabetes (next slide) § Hypertension § Coronary Artery Disease § Asthma §  Pediatric Preventive Health §  Preventive Screening Twice/ year, practices pull and submit data through BCBSSC population management tool or a qualified vendor. 11

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PHC clinic.

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Australia PHC DHT incentive - requirements so far…§  Patient assigned a standard disease code for

each diagnosis. §  Clinical software may use recognised disease

classification/ terminology system. §  Choosing a diagnosis from your system’s

‘condition list’ rather than free texting into the record you are acting in a way that is compliant with this PIP requirement

§  Guidelines by RACGP guide self-assessment of data quality & content of patient records and suggest proven methodologies for improvementhttp://www.digitalhealth.gov.au/get-started-with-digital-health/pip-ehealth-incentive

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2) P4P Hospitals - USA§  2008 : “No pay for “never events”

ú  Hospitals CMS from Oct 2008

§  2012: Reduced pay for e.g. readmissions <30d (same or other hospital (estimated excess readmissions ratios))

   AMI, CHF and pneumonia Penalty 1% , 2% 2013, 3% 2014    2015 add COPD, CABG and PTCA procedures, and other vascular

procedures.

§  Implications ú  Q methods to prevent never events

ú  Re-admission- reduction strategies (data, target, link to PHC)ú  Measurement and reporting (extra or by product) 14

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Details - Handout.

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3) & 4) P4P Health System1)”Bundled” payment (e.g. hip replacement and

rehabilitation: Episode of care spanning providers)

2) Fixed payment for population to “ACO”ú  E.g. diabetes, HFú  E.g. comprehensive popú  ACO distributes savings or losses between hospitals

physicians and others

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Groups

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Groups – measuring and paying for quality, as well as activity

§  The never events list – is there valid data reportable on these events?

§ Would no pay for these result in fewer never events?

§ Does my organisation have the capacity to reduce these events?

§  The coming value based payment system - How can we shape the design & report –ve effects?1

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Summary

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Do the data reward the right things?“Value added” calculated on outcome (or adherence)1) Expected vs actual outcome (control for case mix)

Expectology an inexact scienceData validityData variable for model Algorithm computation – choice of modelConfounder control APACHE ICU valid

2)Choice of indicator valid?3)Data entered valid?4)If margin of error – before and after difference double5)If compare to control or expected – add error

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Key points§  VBF is coming §  Evidence uncertain & mixed§  Many schemes to reward for quality/outcome as well as

quantity§  Impact depends on

§  How quality is measured and reported – data & analysis systems

§  Incentive design

§  Capacity to change to improve performance on measures – quality project

§  Potential of tool for good or ill§  Poor data and wrong incentives – expensive harm and destroys

altruism / commitment

§  Shape it for good and have mechanism to report –ve effects and improve scheme

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Research & examples: �Sweden �

& USA Blue X schemes

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Swedish VBP for hip replacement

Bone on bone

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Example - Hips

§  .

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Key issues

§  VBP – which patient groups§ Define process / episode§  Provider information system to track patient

quality and cost §  Physicians and patients involved in choice of indicators

§  Risk adjustmentú  Payment related to severity of illness and comorbiditiesú  Otherwise pay less to those with most ill patients

§  Sophisticated IT makes feasibleú  Reporting of quality performance and patient outcomes

§  What can be done more simply?25

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VBP – bundled payment and quality indicators

§  Physicians and patients involved in choice of indicators

§  Risk adjustmentú  Payment related to severity of illness and comorbidities

ú  Otherwise pay less to those with most ill patients

§  Sophisticated IT makes feasibleú  Reporting of quality performance and patient outcomes

§ What can be done more simply?

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Equity: USA findings – punish hospitals treating low income sicker patients

Penalties for readmissions within 30days §  risk adjustment strategies fail to control for many

patient characteristics (Barnett 2015) §  hospitals with high readmission rates penalizedx § …hospitals treating a large proportion of low-

income people face penalties, reducing resources at hospitals that often operate at a loss. Reiter 2014

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Key points§  Payment powerful

driver of behaviour and organisation’s activitiesú  But also evidence of non-

financial incentives to support value-based financial payment initiatives

§  such as pay-for-performance, gain sharing, bundled payments, and capitated payments 2

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.§ Surprises?§ Might not be true for us?§ Next – Research & examples of Blue X schemes

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Research

§ Cluster randomized trial of VA § when individual clinicians are incentivized,

instead of groups. §  outpatient clinics showed better performance on

measures §  Peterson et al 2013, JAMA: Effects of Individual

Physician‐Level and Practice‐Level Financial Incentives on Hypertension Care)

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Public comparison providers - S.Carolina “Blues”

§  ,

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Robert Moore’s advice �(CMO, Partnership HP of california)

The number of inter‐related variables in play mean : 1)No general statement about all of P4P looking at a few variables 2)In designing P4P, consider as many of the variables as possible, § Then measure, quantitatively and qualitatively

what happens, and try to understand it. 32

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Case: Organization Self assessment of 15 Health Centers �Robert Moore (CMO, Partnership HP of California)�

§  1 Measures were improved with entering of data §  Staff ordering actions (all process measures) § Cervical Cancer screening § Breast Cancer screening § Ordering blood tests Measures not improved: require more comprehensive approach including activation of the patient to achieve. (DM, LDL, BP control) §  • Illustrates “gaming” of measures

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PHC case – examples: methods for P4P

§  “Quality conversation” about Advance Care Planning ú  Payment amount stable: $100 per attestation ú  Submitted, per patient per year, up to maximum of 100 attestations

per site. (total potential: $10,000/site)

§  Paid quarterly “For many sites, the Leadership became dedicated to capturing the P4P dollars. For one site, the Leadership was dedicated to §  globally improving advance care planning systems at the

health center. Side effect was improved score.

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PHC case - experience §  Better performers (quality outcomes) showed

ú  strength of organizational operations and management in the organization.

ú  Includes Human Resource Management (HRM) and IT infrastructure. (48 questions; 9 domains)

§  Lower staff turnover most correlated with quality of care. ú  Staff turnover at Baldridge award winning sites also low

§  Note also : Sophisticated Electronic Health record systems important to improved quality in small practices in NYC (Bardach et al. 2013 JAMA 3

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For effective design and implementation – use behavioural science principles

1)Loss aversion ú  Pay up front, then ask for money back ú  effective to get attention, but negative assessment of funder ú  (Mehrotra et al. 2010 )

2)Close linking – time and causality perception ú  Incentives stronger when closely related in time to the behavior

rewarded. ú  For individuals – quarterly longest (not annually) ú  Less so for paying organisations 3

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Behavioural principles – cont.

3)Complexity reduces effectiveness §  ‘smaller practices in PHC P4P program, (no QI

staff with time to understand the 100 p doc) § Balance simplicity with comprehensiveness of

measure set and fairness 4) Threshold level to trigger payment Unachievable or Easily achieved goals do not motivate effort § Different starting points – need gradient of goals

to keep them motivated to improve. § Decaying over time? (Mehrotra et al. 2010)=

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Behavioural principles – cont.

§  5)Non cash incentives (esp peer recognition, scholarships to valued CME Event)

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Behavioural principles Helps §  Size of Incentive §  Leadership/peer dedication

to P4P §  Link between measure and

and outcomes §  Link between incentive

and front‐line staff §  Financial stability §  Operational strength §  Loss aversion §  Use of goal gradient §  Use of non‐cash incentives

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Hinders § Crowding out of

Intrinsic Rewards § Competing priorities § Work needed to raises

cores § Gameability § Bureaucratic

complexity

Resources

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Value based care & P4P

Scott, Ten clinician-driven strategies for maximising value of Australian health care, Australian Health Review, 2014, 38; §  http://www.publish.csiro.au/AH/pdf/AH13248Friebel R, Steventon A. 2016 The multiple aims of pay-for- performance and the risk of unintended consequences BMJ Qual Saf 2016;0:1–5. doi:10.1136/bmjqs-2016-005392 Hospitalcompare site for publically reported Q indicators: https://www.medicare.gov/hospitalcompare/search.html?4

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Resources

§  Sears, N. (2011), “Five strategies for physician engagement”, Healthcare Financial Management, Vol. 65 No. 1, pp. 78-82.

§  Spurgeon et al (2015),"Do we need medical leadership or medical engagement?", Leadership in Health Services, Vol. 28 Iss 3 pp. 173-184

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Resources

§ Reinertsen J, Gosfield A, Rupp W, Whittingdon J. Engaging Physicians In A Shared Quality Agenda. Ihi Innovation Series White Paper. Cambridge, MA: Institute for Health Care Improvement, 2007.

§ Ham C, Dickinson H. Engaging Doctors in Leadership: What Can We Learn from International Experience and Research Evidence? Birmingham, UK: University of Birmingham, 2008. 4

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Details

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Resources

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2) P4P Physician payments§  Extra payment for… e.g. over 65 screening PCP

preventative care§  UK

ú  146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. 40K$

ú  76 ClinQ indicators and 70 on org of care

§  USA ú  physicians in > 100+ group claims to Medicare subject to

“value modifier”, based on 2013. Reporting ú  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html

§  Issues ú  validity of measurements of improvement ú  Multiple providers for complex disorders

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