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Quality of Care Measures Across Settings

November 15, 2010 in Medicare, Quality | No comments

How well does Medicare measure quality?  Not very well, especially across different treatment settings.  According to a RAND report:

“Only 10 clinical conditions are addressed by reporting programs for more than one setting. Three clinical conditions are included in programs for three settings: (1) acute myocardial infarction, (2) perioperative/surgical care, and (3) urinary incontinence. Seven conditions are included in programs for two settings: (1) back pain, (2) community acquired pneumonia, (3) depression, (4) end stage renal disease, (5) heart failure, (6) pain, and (7) prevention.”

By not tracking quality measures across providers or treatment settings, physician have less of an incentive to maintain quality across the patient’s full continuum of care.

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How has episode-based P4P worked in California?

November 30, 2009 in Health Insurance, Managed Care, P4P, Quality | No comments

Episodes of care are defined as the bundle of medical treatments used to treat an illness over  a specified time period.  Because all treatments are bundled together, these episodes have been thought to provide a superior unit of analysis in pay-for-performance (P4P) systems.  In fact, Oxford Health Plan pioneered episode payment in the 1990s.  [Later, the health plan abandoned episode payment due to data and computer system difficulties]

How has episode-based pay-for-performance worked in California?  A paper by Robinson, Williams and Yanagihara (2009) looks at Integrated Healthcare Association (IHA) initiative.  This association of health plans, hospital systems, and medical groups manages California’s P4P program.  The P4P program gives large physician groups a P4P score based on all of its commercial HMO patients. Using the Thomson Reuters Medical Episode Grouper (MEG), $264 million was spent on the California P4P between 2003 and 2007.  Although this is the largest P4P program in the nation, it amounts to less than 2% of California physician’s income.

Using medical groups rather than individual physicians has a number of advantages.  First, a larger number of patients are attributed at the medical group level compared to the individual provider.  Also, having multiple physicians within a single group treating a patient does not complicate the analysis.  Despite the use of medical groups rather than physicians, Robinson and co-authors found a number of problems with episode-based P4P:

  • Small Sample Size: The IHA technical committee stated that a physician organization must have a minimum of 30 episodes to be evaluated.  However, most physician organizations did not have enough episodes to be scored.  The main problem is that most enrollees are healthy during the year and thus do not generate as many episodes.  However, this may be less of a problem if P4P was to be applied to Medicare beneficiaries.
  • Data Completeness: “Prior to P4P, there was little incentive for the medical group to fully code what is done to the patient (procedures) and why it is done (diagnoses) on encounter forms.”  If P4P were applied to the Medicare population, procedure codes would likely be coded more accurately (because physicians are mostly paid by the procedure), but the diagnoses fields would likely suffer from similar problems.

Today in 2009, IHA has mostly abandoned episode-based P4P.  The metrics to be used going forward include: the percentage of prescriptions filled which are generic, the percentage of ambulatory surgery procedures that take place in freestanding centers compared to hospitals, ER visits per 1000 enrollees, non-maternity hospital visits per 1000 enrollees.

The authors note that episodes of care still may be appropriate for high-volume, high cost procedures in orthopedics and interventional cardiology, but California’s enthusiasms for episode-based P4P seems to be waning.

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Why it is difficult to evaluate physicians quality: No medical home

November 24, 2009 in Medicaid/Medicare, P4P | No comments

One laudable goal is to improve medical quality while reducing cost. One way members of Congress have proposed to accomplish this is to use episode groupers in order to provide feedback to doctors regarding their resource use. None other than Max Baucus has advocated this (see p. 45 of this white paper).

However, matching patient costs to individual physicians is difficult. A paper by Pham et al. (NEJM 2007) shows that Medicare beneficiaries see many physicians in the course of a year or even during the course of the treatment for one disease.  “Beneficiaries saw a median of two primary care physicians and five specialists working in four different practices.”

The authors explore 4 methods to attribute patient episodes to individual physicians:

  • Plurality provider algorithm.  Assigns a beneficiary to the physician (or practice) who billed for the greatest number of that beneficiary’s evaluation and management visits
  • Plurality primary care physician algorithm.  This method excludes specialist visits and assigns the beneficiary to the primary care physician billing for the most evaluation and management visits.
  • Majority provider algorithm. Assigns the beneficiary to the provider who billed for the plurality of evaluation and management visits, with the added criterion that the plurality must be at least 50% of those visits.
  • Multiple provider algorithm.  Assigns the beneficiary to all providers who billed for at least 25% of the beneficiary’s evaluation and management visits, thereby allowing the beneficiary’s care to be assigned to more than one provider.

Using these methodologies, Pham and co-authors found that “Between 2000 and 2001, and again between 2001 and 2002, an average of 33% of beneficiaries had a change in their assigned physician, with that assignment changing to a different practice for the vast majority (97%).”

Further, because a physician must account for the majority of the patient’s episode-level visits, many of the physician’s patient visits will be excluded from their score.  In the CTS data from the Pham study, only “39% of a primary care physician’s Medicare patients, and 6% of a medical specialist’s Medicare patients, were assigned to them.”  Patient with chronic illnesses are more likely to have multiple physicians and are less likely to have their care episodes assigned to a primary care physician.

This persistent instability “may decrease the motivation of physicians to invest in long-term improvements in care for patients with chronic conditions (e.g., hiring patient educators), or the ability to target interventions to specific patients, if they perceive that the benefits to patients will take years to accrue and that many of their patients are unlikely to remain assigned to them. Care dispersion may thus limit the motivation of physicians and their ability to improve the quality of care in multiple ways.”

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