Performance Data Reporting: Impact on Primary Care Practices (Text Ver

On September 16, 2009, Philip Sloane made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2 MB) (Plugin Software Help).

Slide 1

Performance Data Reporting: Impact on Primary Care Practices

Philip D. Sloane, MD, MPH,
Jacquie Halladay, MD, MPH, Sally Stearns, PhD,
Thomas Wroth, MD, MPH, Paul Bray, MA,
Lynn Spragens, MBA, & Sheryl Zimmerman, PhD

From the North Carolina Network Consortium and the Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill

Funded by the US Agency for HealthCare Research and Quality (AHRQ)
 

Slide 2

Disclosure

• I have no relationships to disclose, and
• I will not discuss off label or investigational use in my presentation

Slide 3

Background

• 2006 AHRQ publication: barriers and challenges to collecting and reporting healthcare data
• Barriers Identified:
  • Data system inefficiencies of data systems
  • Variation in indicators
  • Technological barriers
  • Competing priorities
  • Economic pressures
  • Organizational and cultural issues.

Slide 4

Objectives

• Detail the costs of implementation and maintenance of performance data reporting
• Gather information on how practices successfully overcome challenges to data reporting.

Slide 5

Programs Evaluated

• Physician Quality Reporting Initiative (PQRI)
• Bridges to Excellence
• Improving Performance in Practice (IPIP)
• Community Care of North Carolina (CCNC)

Slide 6

PQRI

• Medicare's reporting program.
• 74 quality measures (practices can choose).
• "G" codes are added to billing submissions.
• Must have 80% of cases reported on three quality measures.
• Incentive payment of ≤ 1.5% of Medicare allowable.

Slide 7

Bridges to Excellence

• Started in 2006 as a three-year pilot program by BC/BS.
• Incentive: $$, based on achieving quality thresholds and # of patients with BCBS insurance.
• Two programs studied:
  • Diabetes Care: HbA1c, BP, LDL, Eye exams, Foot exams, Nephropathy assessments, smoking status/cessation.
  • Physician Office Connections: Office systems and processes such as electronic prescribing, referral tracking, performance reporting (9 items total).

Slide 8

Improving Performance in Practice (IPIP)

• State-based, nationally led QI initiative
• Pilots in CO and NC.
• Uses quality improvement coaches (QICs) who go into physicians' offices and work with the practice on improvement efforts, including:
  • Data system assistance
  • Decision support and protocol development
  • Office team involvement in quality improvement and measurement

Slide 9

Community Care of North Carolina (CCNC)

• Statewide system of 14 regional Medicaid care networks
  • Each has a program director, medical director, steering committee, case managers
• Attention to chronic diseases (mainly diabetes and asthma)
• Guideline dissemination & case management
• Yearly statewide audits and reports with comparison data to local practices

Slide 10

Eight Practices Selected For Variety and Program Participation

Table of Practice Size by Total Number of Providers (MD and PA/NP's)

• Pvt-sm: 2/1
• Non-P-Med: 2/4
• Non-P-Med: 3/3
• Pvt-sm: 1/0
• Teaching: 8/18
• Pvt-LG: 6/9
• Pvt-sm: 1/1
• Non-P-Med: 3/3

Slide 11

Quality Data Reporting Programs Represented

Of the 8 practices in the COMP project, 4 participated in PQRI, 3 in IPIP, 6 in CCNC, 2 in BTE-Diabetes, 1 in BTE- PPC
 

Slide 12

Conditions Evaluated

Disease or Quality Measures
8 in Diebetes, 6 in Asthma, 3 in COPD, 2 in Falls Risk Assessment, and 2 in others

Slide 13

Medical Data Systems

Types of Electronic Medical Record Systems

• Paper record and Electronic registry: 3
• EMR e/o population functions: 2
• EMR with population queries: 3

Slide 14

Study Methodology

• Intensive site visits by economist, QI specialist & qualitative researcher
• Meticulous detailing of costs (see next slide)
• Interviews with:
  • quality champion,
  • care providers,
  • other practice staff
• Quantitative and qualitative analyses

Slide 15

Cost Categories - 1

Total Resource Costs points to Costs to Practice

• Total rather than marginal costs

• In-practice only

Slide 16

Cost Categories - 2

Total Practice Costs points to Staff Time: Measure-Specific (eye exam referrals, HbA1c)

Total Practice Costs points to Staff Time: Non-measure Specific (data entry, meetings)

Total Practice Costs points to Supplies, Equipment, Application Fees

Slide 17

Cost Phases

Total Practice Costs points to Start-Up Phase

Total Practice Costs points to Maintenance Phase

Slide 18

PQRI Implementation Costs in Four Practices

Total

• Practice A: $6,000
• Practice B: $0
• Practice D: $22,500
• Practice H: $6,000

• Practice A: $0
• Practice B: $0
• Practice D: $11,000
• Practice H: $0

Slide 19

PQRI Implementation in Practices A and H

Total

• Practice A: $6,000
• Practice H: $6,000

• Practice A: $500
• Practice H: $500

Slide 20

Cost Per FTE of Implementing CCNC vs IPIP

CCNC

• Practice B: $250
• Practice C: $500

• Practice B: $1,500
• Practice C: $2,600

Slide 21

Average Practice & Program Costs per FTE of CCNC*, IPIP**, and PQRI***

CCNC

• Practice Cost: $250
• In-Office Program Costs: $1,250
• Combined: $1,500

• Practice Cost: $2,750
• In-Office Program Costs: $500
• Combined: $3,100

• Practice Cost: $1,500
• In-Office Program Costs: $0
• Combined: $1,500

Slide 22

Estimated Costs and Reimbursement for Participation in B to E Diabetes

• Practice A Diabetes Cost: $800
• Practice A Diabetes Reimb: $1,600

• Practice G Diabetes Cost: $500
• Practice G Diabetes Reimb: $0

Estimates are per provider FTE
 

Slide 23

Estimated Costs and Reimbursement for Participation in B to E Medical Home

• Practice A Diabetes Cost: $750
• Practice A Diabetes Reimb: $1,250
• Practice A Med Home Cost: $750
• Practice A Med home Annual Reimb: $2,500

Estimates are per provider FTE
 

Slide 24

Lessons from Qualitative Interviews

• Methods:
  • Interviews with practice champion
  • Group interviews with practice staff
  • Medical director joined for lunch
  • Dedicated note taker present; case reports generated; research team reviewed for themes and lessons

Slide 25

Motivation to Participate is a Key to Success

• "Pay for performance seems inevitable, and we wanted to prepare our practice for it"
• "If we are providing quality of care, we want to separate ourselves out and be recognized"

Slide 26

Leadership is Crucial to Getting Started

• Leaders with quality improvement experience and an interest in participation; staff who then get motivated
• "The providers set the tone and empower the staff"

Slide 27

Three Major Logistical Challenges

• Staff time and effort
  • "The clinicians and staff are being driven to a frazzle"
• IT challenges
  • "I'm sure that the EHR vendor could develop a query to do this, if we paid them enough"
• Difficulties changing physician behavior
  • "Once you start to measure quality, the first thing the providers do is question the measures"

Slide 28

Going Through Hoops to Achieve Data Consistency

• One practice had to train the physicians to record "feet" instead of "extremity"
• Another had to create a report on smoking cessation counseling three times before it was in an acceptable format

Slide 29

Involving the Team

• Practices reported difficulty finding enough time to review and act on quality data reports
• "(The practice manager) presents the data in a fun way.she puts time into preparing it for you, in charts, so that we have clarity"
• "Initially providers are burdened by a new reporting activity. But after a while it takes less effort because they figure out how to give it to nursing"

Slide 30

Perceived Effects on Productivity & Finances

• Slowed down productivity initially, but overall productivity increase over time
• Positive: "Good income for good medicine"
• Negative: "They are taking money out of my pocket"

Slide 31

Theoretical Model: Factors Involved in Developing and Maintaining Quality Assessment, Improvement and Reporting in Primary Care

Infrastructure Development - Practice Preconditions - Catalyst - Program Initiation - Program Maturation - Sustainability

Preconditions
 

1. Exposure to QI
2. Leader with QI experience
3. Focus on quality > income

1. Committed leader or mandate
2. Collaborative atmosphere
3. Outside encouragement

1. Medical director support
2. Administrator support
3. Data entry & reporting resources
4. Staff meeting times

1. Tangible constructive change
2. Financial benefit
3. Enhanced practice reputation
4. Strategic partnerships that foster culture of quality

Slide 32

Image: Are we making an impact?