Rewarding Provider Performance Aligning Incentives in Medicare (2007) / Chapter Skim
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5 Implementation
5 Implementation
Pages 102-132
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From page 102... ...
5 Implementation CHAPTER SUMMARY Chapters 3 and 4 reviewed several alternative methods for cre ating and distributing a funding pool to reward performance by health care providers who serve Medicare beneficiaries. This chap ter addresses major implementation issues that must be consid ered when new payment schemes designed to create incentives for improved performance by multiple types of health care providers are introduced.
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From page 103... ...
The performance data must then be publicly reported before the final step of paying providers for their performance can be implemented. Data Collection and Auditing and Provider Feedback Following the development and testing of performance measures (which as noted was discussed in detail in the Performance Measurement report)
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From page 104... ...
Currently available at medicare.gov are Nursing Home Compare, Home Health Compare, Dialysis Facility Compare, Hospital Compare, Medicare Personal Plan Finder (for health plans) , and Medicare Prescription Drug Plan Finder.
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From page 105... ...
Beginning in 2006, CMS initiated voluntary reporting for physicians. Health plans, nursing homes, home health agencies,2 and dialysis facilities must all report on some services to CMS to receive payments.
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From page 106... ...
Recommendation 6: Because public reporting of performance mea sures should be an integral component of a pay-for-performance program for Medicare, the Secretary of DHHS should offer incen tives to providers for the submission of performance data, and en sure that information pertaining to provider performance is trans parent and made public in ways that are both meaningful and understandable to consumers. There are two views on how the burden of reporting should be treated.
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From page 107... ...
and other strategies. OVERALL TIMING OF PAY-FOR-PERFORMANCE IMPLEMENTATION As described in Chapter 4, the committee recommends rewarding providers in three domains -- clinical quality, patient-centeredness, and efficiency -- as an overarching principle.
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From page 108... ...
However, one option for rewarding on resource use during the intervening period would be to give physi cians meeting certain thresholds on both clinical quality and patient centeredness measures an additional reward if they, by some crude mea sures, were within the most efficient third of providers. The most efficient Option 2: Delayed Implementation The second option would be to delay implementation of pay for performance until a robust set of performance measures had been developed for all three domains.
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From page 109... ...
measures were being developed and the rewards for reporting were less than collected funds, a larger pool would accumulate for initial performance rewards. This delayed implementation approach would ensure that provider behavior did not overemphasize one domain over the others and that rewards would be distributed only for care that was of high clinical quality, patient-centered, and efficient.
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From page 110... ...
Home health agencies, followed by physicians, would be next to be expected to participate in pay for performance. For an implementation timeline, see Figure 5-2.
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From page 111... ...
Skilled nursing facilities, not among the institutional providers considered ready for pay for performance as listed in the previous section, deserve special mention. Medicare pays for a specific type of nursing home care provided by these facilities.
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From page 112... ...
"Participation" involves collecting and submitting to the payer the data needed to construct performance measures, which in turn makes providers eligible to receive financial rewards if they have performed well. With voluntary participation, the individual provider can decide whether to gather and submit performance data and be paid in part on the basis of performance.
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From page 113... ...
While such a stark mandate might be burdensome to CMS, the vast majority of hospitals, home health agencies, dialysis facilities, health plans, and skilled nursing facilities already report some data to CMS that are publicly disclosed. Mandatory participation for physicians and other small providers might be quite challenging if required in the next few years, however.
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From page 114... ...
Nonparticipants would argue that their base payments should not be reduced to provide the resources for a program from which they could not benefit. On the other hand, voluntary participation would reflect some of the underlying realities of the diverse provider community.
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From page 115... ...
The threshold size of organizations required to participate would be determined by the Secretary of DHHS. Voluntary participation by individual physicians and small physician organizations during the initial phase of pay for performance could improve the acceptance of performance-based rewards by allowing physicians time to develop both confidence in the measures and the structural supports necessary for participation.
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From page 116... ...
In establishing the size of the reward pools, CMS will need to strike a balance between providing financial incentives sizable enough to lead to near-universal participation and recognizing that initial measure sets are narrow, presenting an incomplete picture of a provider's performance. The transformational changes in the delivery system envisioned in the IOM's Pathways to Quality Health Care series of reports will depend upon both the adoption of longitudinal measures of quality that cut across settings and the provision of substantial payment rewards.
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From page 117... ...
While some small physician organizations and individual physicians are prepared to participate in public reporting and pay-for-performance initiatives, many others will require guidance, technical assistance, and additional infrastructure to make critical transitions in adopting quality procedures and information systems that can enable them to engage in these initiatives. CMS will need to monitor and evaluate the transition phase to identify and share lessons learned at the level of small and individual practices.
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From page 118... ...
As discussed in Chapter 4, the committee believes it to be unavoidable that rewards will be distributed initially by setting of care. In other words, rewards will be distributed to health plans, dialysis facilities, hospitals, home health agencies, skilled nursing facilities, and physician offices.
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From page 119... ...
Second, the ability to compare and discuss clinical quality and efficiency with a number of like-minded providers and possibly share information technology tools could serve to improve overall quality. Third, multispecialty virtual groups could encourage coordination and help overcome the quality deficiencies that arise from poor care coordination among the various physicians treating a single patient.
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From page 120... ...
One way to address this problem is to provide direct and indirect incentives for care coordination. To the extent that pay for performance rewards specific providers for performing at a desired level and care coordination contributes to high-quality care, pay for performance should indirectly encourage better care coordination.
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From page 121... ...
Another disadvantage of distributing rewards at the group level is that there is currently a disparity in clinical quality between care deliv ered by individual and small-practice physicians as compared with large physician groups (Bodenheimer et al., 2005)
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From page 122... ...
Quality would be assessed using the best currently available measures, includ ing, presumably, risk-adjusted 1-year survival and adherence to the Hos pital Quality Alliance and the Ambulatory care Quality Alliance technical quality measures. Resource use would be measured using price-stan dardized measures (e.g., relative value units, diagnosis-related groups, nursing home per diems)
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From page 123... ...
Example 3: Virtual Groups Convened by Health Plans Health plans could play a convening role in the formation of virtual groups, for example, by providing a common information technology plat form for gathering data across multiple solo or small group practices in return for a small fee. Practices would not have to be located in the same geographic area, as they would be linked by common financial and com munication systems.
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From page 124... ...
Nonetheless, the committee believes enhancing care coordination is essential to improving the overall quality of care and should be promoted through the use of incentives to the extent possible. THE ROLE OF HEALTH INFORMATION TECHNOLOGIES Potential Benefits Information technologies might be used as a transformative tool in systems change to enhance health care delivery.
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From page 125... ...
According to one study, smaller providers (i.e., home health agencies, skilled nursing facilities, and groups of fewer than five physicians) can be expected to have less well-developed electronic capabilities than larger groups (i.e., hospitals and groups of 20 or more physicians)
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From page 126... ...
; and · Partial or full funding in support of more than 100 Regional Health Information Organizations (RHIOs) -- regional collaborations throughout the country that facilitate the development, implementation, and application of secure health information systems across care settings (including those funded by AHRQ as noted above)
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From page 127... ...
IMPLEMENTATION 127 Barriers to Implementation The extent to which health information technologies can yield savings or better health outcomes is unclear. Gains have been proven only in large health systems and after long implementation processes.
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From page 128... ...
, Medicare (through its Quality Improvement Organizations) , professional organizations, trade associations, and industry websites -- are beginning to offer technical assistance to both hospitals and physicians.
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From page 129... ...
Such unintended adverse consequences should be compensated for and should not be neglected. These statistical issues are inherent in performance measurement, but can be adjusted for to better characterize the care that is delivered.
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From page 130... ...
2002. A user's manual for the IOM's "Quality Chasm" report.
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From page 131... ...
2006. Public reporting of provider performance: Can its impact be made greater?
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From page 132... ...
2006b. Medicare program; physicians referrals to health care entities with which they have financial relationships; exceptions for certain electronic prescribing and elec tronic health records arrangements.
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