Tying Quality and Cost Measures to Reimbursement on Arkansas Medical News Inc.

Tying Quality and Cost Measures to Reimbursement

By: SHARON H. FITZGERALD

Anders Gilberg, MGMA Vice President for Public and Private Economic Affairs

When the Medical Group Management Association (MGMA) convened its 2008 annual conference in the sunny city of San Diego in October, several sessions covered a subject that didn’t make for sunny dispositions – moves by government and private payers toward pay for performance. Agreed upon by many presenters was the fact that measuring physicians on quality and cost is a precursor of P4P, thus the accuracy of that data will eventually be critical to physicians’ bottom lines.

One Practice’s Story

Catawba Women’s Center in Hickory, N.C., decided to take the bull by the horns and participate in a pilot program offered by its bigger payer, BlueCross and BlueShield of North Carolina. Using the National Committee for Quality Assurance (NCQA) Bridges to Excellence program, BCBS offered financial incentives to medical groups that would work toward certification in a performance assessment.

Amy Millsaps Guyer, the center’s practice administrator, said BCBS offered “a carrot,” a financial reward for practices that complete the survey and achieve a certain score. Catawba was eligible for more than $200,000 over a three-year period should it be ranked. The sum was based on the number of BCBS members as patients and the number of physicians in the practice. Catawba boasts nine physicians, three nurse midwives, three nurse practitioners and about 50 additional staff members. “We demonstrated what we thought to be the case already – our commitment to quality,” Guyer said. On its first try, the medical group was awarded Level 1 certification, with Level 3 being the top tier. “Although our goal was to achieve Level 3 certification, the lessons learned in our first attempt were priceless,” she said.

Guyer credits the practice’s success in part to its new electronic medical records system. The group went with SRSsoft’s Clinical Manager™, used to digitize all patient charts. She said, of all the software alternatives Catawba considered, the SRS program was “the least disruptive to the most highly productive – and most expensive – folks in our practice, the physicians.”

Does Guyer believe a practice can tackle cost and quality measurements by payers without an EMR? “You can do it, but it’s much more arduous,” she said. “It requires a lot more pulling of charts and abstraction. You can do it, but you cannot score as high. There are certain measures that you will not achieve a score on at all without electronic medical records.”

Guyer noted that the BCBS performance assessment wasn’t tied to reimbursement. “The fee-for-service contract that we’re under has not changed as a result of this designation. We feel like it’s a great marketing tool, though, and we had a financial reward outside of that contract,” she said, adding, “We appreciated the fact that the quality barometers were not abstractions from claims data, because claims data can be skewed very easily, and that’s one of the main arguments with a pay-for-performance program that might be developed by a payer. We liked that this was NCQA, a separate entity. That separate entity did our scoring, and it wasn’t that we were trying to jump through hoops for just one segment of our practice. Rather, the NCQA survey was based on our practice as a whole. So we were able to demonstrate that we’ve achieved success for our entire patient population.”

Asked if there is a connection between P4P and physician rankings by payers, Anders Gilberg responded, “Absolutely, and in the presentation I gave, we combined the two issues.” Gilberg is MGMA’s vice president for public and private economic affairs in Washington, D.C., and his conference presentation examined public and private P4P initiatives “and how medical group practices are increasingly caught in the middle, trying to determine where they stand against myriad measures and methods – often with cost, not quality, as the driving force,” he said.

While Medicare usually leads the way on payer initiatives, Gilberg said the federal giant is “a little bit behind” the quality and cost reporting initiatives of private health plans. Private payers’ measuring sticks may be as simple as reporting claims data or more comprehensive, using what’s called “administrative data,” which may also include prescription or laboratory data, for example. Some plans have even made the move toward sophisticated software designed to abstract data directly from physician charts and other medical records.

Gilberg said that “one of the frustrations” is the lack of standardization for both quality and cost measures. “The goal is to come up with a standardized set of clinical measures, because good quality care is not a proprietary thing to a health plan. What these measures should be based on is evidence in the literature developed by practicing physicians. But what we’re seeing, unfortunately, is multiple efforts – either pay for performance or public reporting on cost and quality – with little standardization,” he said.

There is hope, and on more than one front. One is the National Quality Forum (NQF), a not-for-profit membership organization founded to develop and implement a national strategy for healthcare quality measurement and reporting. Created a decade ago as a result of a presidential advisory, the NQF has broad participation from public and private healthcare stakeholders, including employers and labor unions. More good news is a standard measurement of physician and hospital quality hammered out by the New York attorney general’s office earlier this year between providers and seven private health plans. Those plans have committed to adopting the standards in other states they serve.

Gilberg has crafted six questions that he encourages physicians and other providers to ask payers launching quality and/or cost rankings. “Because each health plan is unique, it’s difficult to say that a one-size-fits-all strategy applies,” he acknowledged. Yet these questions are essential to ask, he said.

• What are the specifications for each measure, down to the procedure code or diagnostic code level? Gilberg said that, while the Medicare quality-reporting program has its problems, it is very transparent. Private payers should be, too. He also encouraged providers to ask about the source of the rating measures, which should be the scientific literature or specialty societies rather than the plans themselves.

• What are the attribution rules? In other words, plans shouldn’t hold individual physicians accountable for processes over which they have no control. Gilberg also encouraged physicians to ask how many patient visits may result in an assessment. Some plans use as few as five visits, whereas studies show that between 30 and 50 visits are necessary for accuracy, he said.

• Is it a tournament model? Does it create winners and losers? “In our mind, there’s a whole host of problems with that. It stifles innovation. It reduces the incentive for physicians who are in the top category to share best practices,” Gilberg said. A more appropriate reporting structure would establish “achievement thresholds,” encouraging physicians to improve their performance by increments, he said.

• Does the program provide actionable feedback to the practice in terms of quality of care?

• Is there an appeals process? Is there the ability to be reconsidered if the physician or practice provides additional data that would supplement faulty administrative data?

• How frequent would this appeals process be? Physicians can “get stuck” in a tier for a year or longer before the time rolls around to challenge the ranking, he said. In the meantime, the payer may — and some are — offer patients a lower copay to seek care from providers in the higher tiers.

Gilberg said electronic medical records are one way practices can stay abreast of their processes and their patient care — and how effectively payer rankings are measuring patient-care success. In fact, EMRs are, in and of themselves, one of the measures payers use to determine quality.