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N.E.W.T. Level

Measurement: Voldemort or Dumbledore?

Georgia Chapter Scientific Meeting

American College of Physicians

Savannah, Georgia

October 6, 2013

Nathan Spell, MD, FACP Chief Quality Officer, Emory University Hospital

Richard Gitomer, MD, FACP President, CQO and Director of Medical Svcs Emory Healthcare Network

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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

1. 2. 3. 4.

0% 0%0%0%

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

1. 2. 3. 4.

0% 0%0%0%

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

1. 2. 3. 4.

0% 0%0%0%

9

DO YOU PARTICIPATE IN A HEALTH

INFORMATION EXCHANGE?

1. Yes

2. No

3. Not sure

1. 2. 3.

0% 0%0%

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)

1. 2. 3. 4.

0% 0%0%0%

9

DO YOU HAVE MEDICAL HOME

CERTIFICATION?

1. Yes

2. No

3. Does not apply

1. 2. 3.

0% 0%0%

9

IN YOUR PRACTICE ARE YOU DOING

IMPROVEMENT WORK USING DATA OTHER

THAN FOR MOC?

1. True

2. False

True False

0%0%

9

18

CMS Medpar/PQRS

Administrative Data

Abstracted Data

Payors

Q-HIP

physiciancompare.hhs.gov (group practice performance data

coming 2014)

Hospitalcompare.hhs.gov

Clinically Enriched Data from EMR

(near future)

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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

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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

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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

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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

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ARE YOU CONSIDERED

MAGICAL OR MUGGLE?

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RANDOM VARIATION – EFFECTS OF

SAMPLE SIZE ON RATINGS

• Implications?

– Multiple insurers assessing only their covered patients

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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

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CAN WE SEE THE FUTURE OF PUBLIC

REPORTING?

The crystal ball is only

becoming more

transparent

– Performance

– Costs

– Patient experience

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APPROPRIATE USE OF

MEASURES

• Public reporting

• Public health/disease surveillance

• Payment program

• Regulatory and accreditation programs

• Professional certification or recognition programs

• Quality improvement with benchmarking(external

benchmarking to multiple organizations)

• Quality improvement (internal to specific organization)

www.qualityforum.org

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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

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NATIONAL INITIATIVES USING MEASURES

CMS HOSPITAL QUALITY • IP Quality • OP Quality • IP Rehab • Long-Term Care • Meaningful Use • Value-Based Purchasing

CMS MD QUALITY • Medicaid Adult • Meaningful Use • PQRS • Value-Based Modifier

OTHER HOSPITAL QUALITY • HHS Hospital Compare • Leapfrog Hospital

OTHER MD QUALITY • NCQA HEDIS Physician • ONC Beacon • Bridges to Excellence

HEALTHPLAN OR SYSTEM • NCQA HEDIS Health Plan • Shared Savings Program

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CMS PUBLIC REPORTING SITES

www.hospitalcompare.hhs.gov

Medicare Claims MedPAR (Medicare Provider

Analysis & Review)

www.medicare.gov/physiciancompare

CMS PQRS & ePrescribing

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HEALTHGRADES

www.healthgrades.com

Publically Available Demographics Future: PhysicianCompare

CMS MedPAR & Proprietary Algorithm HospitalCompare

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OTHER PUBLICALLY-AVAILABLE DATA

State-Level Reporting

STS Registry (Manual Abstraction)

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“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

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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

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SHARED SAVINGS MODEL OF

REIMBURSEMENT C

ost

per

pat

ien

t p

er

year

Time

Distributed based on quality performance

OTHER EXAMPLES: Shared Savings ACO (Pioneer & Shared-Savings ACO) IMPACT: • Larger returns can support substantive infrastructure change. • Diminishing returns over the years.

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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

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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

1. 2. 3. 4. 5.

0% 0% 0%0%0%

10

1. Poor

2. Fair

3. Average

4. Good

5. Excellent

Poor

Fair

Aver

age

Good

Excel

lent

0% 0% 0%0%0%

10

0%

0%

0%

10

1. Yes

2. No

3. N/A

1. Poor

2. Fair

3. Average

4. Good

5. Excellent

1. 2. 3. 4. 5.

0% 0% 0%0%0%

10

0%

0%

10

1. Yes

2. No