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The Better Quality Information to Improve Care for Medicare Beneficiaries Project: Exploring Approaches to Physician Performance Measurement By Aucha Prachanronarong, MHS On August 22, 2006, President Bush issued an Executive Order calling on all federal agencies and those who do healthcare business with the government to engage in collaborative efforts to incorporate the 4 cornerstones of value-driven healthcare: health information technology standards, quality standards, price standards, and incentives. The Department of Health and Human Services has embarked on a campaign to make these 4 cornerstones a reality by encouraging the public and private sectors to work collaboratively at the local level. In support of this campaign, the Centers for Medicare & Medicaid Services launched a project in late 2006 that leverages local collaboratives as a means to explore a national approach to physician performance measurement. This project, which is known as the Better Quality Information to Improve Care for Medicare Beneficiaries Project, aims to test methods to aggregate Medicare administrative data with data from commercial health plans and, in some cases, Medicaid, in 6 local collaboratives to calculate and report quality measures for physician groups and for some individual physicians. [AHDB. 2008;1(7):22-26.]
O
n August 22, 2006, President Bush issued an Executive Order—Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs— calling on all federal agencies and those who do healthcare business with the government to engage in collaborative efforts to incorporate the cornerstones of valuedriven healthcare (Table 1). The 4 cornerstones of value-driven healthcare are1: 1. Interoperable health information technology 2. Measure and publish quality information 3. Measure and publish price information 4. Promote quality and efficiency of care.
Local Collaboration Key to Value-Driven Healthcare Department of Health and Human Services Secretary Michael O. Leavitt has embarked on a campaign to make these 4 cornerstones a reality. A key piece of this campaign, known as the Value-Driven Ms Aucha is a Health Insurance Specialist, Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services, Baltimore, MD.
22
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September 2008
Health Care Initiative, is encouraging the public and private sectors to work collaboratively at the local level. Regional or local public–private collaboration among payers, health plans, providers, and consumers is essential to the success of this initiative. Healthcare systems are local. The different environments for healthcare delivery differ in the range of populations served, resources available, and in the characteristics of the local marketplace. Thus, broad-based efforts to improve quality of care need to be driven by local leaders who represent the various stakeholders and who are willing to pool their resources toward achieving common goals. In addition, quality initiatives need to allow for local input so that local market conditions can be taken into consideration. Although fostering the growth of locally led collaboratives is crucial to the success of the Value-Driven Health Care Initiative, national coordination is also needed. Patients should expect and be able to receive good quality care regardless of where they live. Similarly, all providers should be able to meet certain basic, agreed on standards of care regardless of where they practice. The need for national coordination is
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Table 1 The 4 Cornerstones of Value-Driven Healthcare Interoperable HIT • Interoperable HIT is the development and implementation of standards and health information systems that allow various parts of the healthcare delivery system to communicate and exchange data quickly and securely • Interoperable HIT holds the potential to create greater efficiency in the healthcare delivery system Measure and publish quality information • Consumers need quality-of-care information to be able to make confident and informed decisions about their healthcare providers and treatment options • Quality-of-care information is also important for providers to have to be able to improve the quality of care they provide • The quality information consumers and providers receive should be based on measures that are developed through consensus-based processes that involve all stakeholders, such as the processes used by the National Quality Forum, the AQA Alliance, and the Hospital Quality Alliance Measure and publish price information • To be able to make confident and informed decisions
about their healthcare providers and treatment options, consumers also need to have price information that is measured and reported in a uniform manner • Efforts are currently under way to develop uniform approaches to measuring and reporting price information, including strategies for measuring the overall cost of services for common episodes of care and the treatment of common chronic diseases Promote quality and efficiency of care • The healthcare delivery system should be structured
in a manner to reward those who offer and those who purchase high-quality, cost-effective care • All stakeholders—providers, consumers, health plans, and payers—should participate in arrangements that reward high-quality, cost-effective care HIT indicates health information technology. Source: Reference 1.
particularly salient for the Medicare program, which provides health insurance coverage for approximately 43.9 million beneficiaries across the United States.2 Because of Medicare’s national scope, the Centers for Medicare & Medicaid Services (CMS) needs to ensure that Medicare beneficiaries residing in Florida can
VOL. 1
NO. 7
KEY POINTS ▲ In 2006, the Department of Health and Human Services
embarked on a campaign to promote the transparency of health information in the United States following the president’s call for value-driven healthcare. ▲ In accordance with this effort, CMS has launched a pilot for
Medicare beneficiaries, known as the Better Quality Information Project. ▲ Because the delivery of care differs by local demographic and
market characteristics, a major concern for CMS is to ensure that Medicare beneficiaries receive comparable information on healthcare quality throughout the country. ▲ The Better Quality Information Project focuses on testing
methods for measuring physician performance using 6 local collaborative efforts. ▲ The lessons collected from this project could offer useful
information for CMS’ future efforts at measuring the performance of physicians who treat Medicare beneficiaries.
receive information on quality of care that is consistent with the quality-of-care information provided to Medicare beneficiaries residing in California.
A National Approach to Physician Performance Measurement A key piece to measuring and reporting quality information is measuring and reporting information on physician performance. Typically, efforts to measure and report on physician performance have been done in a piecemeal manner.3 Physicians, who usually see patients covered by a variety of public and private insurers, often receive information about their performance only as it relates to patients covered by a single insurer. Since physicians typically receive information on only a subpopulation of their entire patient population, physicians typically have no idea how their practice, as a whole, is performing against various quality measures. As a result, consumers looking for information on physician performance to help them select a physician or to review treatment options typically do not have a comprehensive picture of a physician’s performance either. Often, the insurance plans measure the physicians on a different group of measures as well. For example, a physician could potentially receive a report from one entity that only looked at the preventive services provided by the physician, while a second report from a different entity looked at the services the physician provided to his or her patients with diabetes. Even if the quality measures on the 2 reports appeared to be the
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Table 2 The 6 BQI Pilot Sites The 6 local collaboratives working with Delmarva are: 1. Arizona State University Center for Health Information & Research, Phoenix, AZ 2. California Cooperative Health Care Reporting Initiative, San Francisco, CA 3. Indiana Health Information Exchange, Indianapolis, IN 4. Massachusetts Health Quality Partners, Watertown, MA 5. MN Community Measurement, Minneapolis/St. Paul, MN 6. Wisconsin Collaborative for Healthcare Quality, Madison, WI
same, it is possible that the methods used by the 2 entities to generate the physician’s performance rate may have differed. For example, a physician receives 2 reports from 2 entities notifying the physician of the percentage of his or her patients with diabetes whose hemoglobin A1C levels are under control. However, the threshold used for determining whether a patient’s hemoglobin A1C level is under control may differ between the 2 entities. Consequently, the information that the physician received from the 2 entities would not be comparable. Since the various reports provide the physician with inconsistent information that may even be conflicting at times, it becomes difficult for the physician to act on the information provided in these various reports to improve the quality of care he or she provides.
CMS’ BQI Project In an attempt to explore how to provide physicians who treat Medicare beneficiaries with more meaningful, comprehensive information of their performance, CMS launched a new project in late 2006. In keeping with the central principles of the Value-Driven Health Care Initiative, this project, known as the Better Quality Information (BQI) to Improve Care for Medicare Beneficiaries Project, also leverages the experience of local multistakeholder collaboratives to explore a national, coordinated approach to physician performance measurement. CMS contracted with the Delmarva Foundation for Medical Care (CMS’s Quality Improvement Organization for Maryland) to provide overall project administration and management for the BQI Project and to conduct analyses on the Medicare administrative data. Delmarva awarded subcontracts to 6 local collaboratives, or pilot sites (Table 2), to receive, aggregate, and analyze Medicare administrative data along with their existing datasets. Delmarva and the 6 BQI pilot sites were tasked with testing:
24
AMERICAN HEALTH & DRUG BENEFITS
September 2008
1. Methods to aggregate Medicare administrative data with data from commercial health plans and, in some cases, Medicaid 2. The use of the aggregated data to calculate and report on quality measures for physician groups and, in some cases, for individual physicians practicing in each of the pilot sites’ local communities. The BQI Project will be completed at the end of October 2008. The following criteria were used to select the pilot sites: • Strong physician leadership engaged in creating the coalition • Multiple employer participation • Experience in measuring and aggregating physician level data • Experience providing feedback reports to physicians • Presence of a public website for consumers to access relevant information • Demonstrated capacity and interest to accept additional tasks • Willingness to work with a viable health information network if available • Capability and infrastructure to begin data collection within a short time frame. The 6 local collaboratives selected to participate in the BQI Project each brings a unique set of characteristics and experiences that have resulted in some differences in approach to implementation. One pilot site, for example, receives all payer data (including Medicare and Medicaid) directly from its member physician practices, while another pilot site relies solely on administrative data received from participating health plans. Similarly, some pilots have access to clinical data, including laboratory results, whereas other pilots only have access to administrative data, such as claims. Some pilots have a wealth of experience in publicly reporting healthcare performance information. Other pilots have no experience with public reporting. Some pilot sites are statewide in terms of population covered and scope, whereas others cover specific areas within the state in which they operate. We believe, however, that the uniqueness of each pilot site will prove beneficial for gathering lessons for the development of a national strategy for physician performance measurement.
Goals for the BQI Project The BQI pilot sites all have had some previous experience linking data from different sources together. In some cases, a pilot site may even have previous experience using the linked, or aggregated, data to produce healthcare performance information on the providers
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in their respective communities. Before their participation in the BQI Project, however, few of the pilot sites had the ability to incorporate Medicare data with the pilot sites’ other data sources. In seeking to test methods for aggregating Medicare administrative data with other data sources to produce a more comprehensive picture of the quality of care provided by physicians to Medicare beneficiaries through the BQI Project, CMS has provided many of the BQI pilot sites the opportunity to incorporate the experiences of Medicare beneficiaries into their local efforts for the first time. For many BQI pilot sites, the BQI Project represents the first time that Medicare data have been combined with other data sources for the purpose of generating meaningful information on physician performance. In most cases, the addition of Medicare data represents a significant addition of information about a physician’s practice that many of these local collaboratives had been missing. In 2005 alone, approximately 33 million people received a reimbursed service under Medicare fee-for-service, including roughly 32.7 million people who received reimbursable physician services.4 The BQI pilot sites will be working until the end of October 2008 to aggregate Medicare administrative data (eg, Medicare inpatient claims, outpatient claims, carrier claims, enrollment databases, and provider databases) with data from other payers to produce quality measure results. Since the BQI pilot sites will be using data from multiple payers, including Medicare, to produce these measurement results, they will be able to provide a more comprehensive picture of the quality of services being provided by physicians in their communities who treat Medicare beneficiaries. Each BQI pilot site will be reporting on 12 measures. The measures selected by each BQI pilot site are derived from the AQA Alliance (formerly the Ambulatory Care Quality Alliance) starter set of measures for physician performance (Table 3)5 and other quality measures endorsed by the National Quality Forum. In selecting measures for the BQI Project, a number of considerations were taken into account, including the data sources available to each BQI pilot site, to calculate the measure as well as the measure’s relevance to the Medicare population, and the local community.
Methodological Questions Before CMS can develop a strategy for measuring the performance of physicians around the country using Medicare administrative data, a number of methodological questions need to be answered. Each BQI pilot site will be aggregating the Medicare data with their own data sources to generate multipayer physician level
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Table 3 AQA Alliance Measures for Physician Performance Preventive measures 1. Breast cancer screening 2. Colorectal cancer screening 3. Cervical cancer screening 4. Tobacco use 5. Advising smokers to quit 6. Influenza vaccination 7. Pneumonia vaccination Disease-state measures 8. Drug therapy for elevated LDL cholesterol 9. Beta-blocker treatment after heart attack* 10. Beta-blocker therapy post–myocardial infarction* 11. Angiotensin-converting enzyme inhibitor/angiotensin
receptor blocker therapy 12. Left ventricular failure assessment 13. HbA1C management 14. HbA1C management control 15. Blood pressure management 16. Lipid measurement 17. LDL cholesterol level
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The Better Quality Information to Improve Care for Medicare Beneficiaries Project: Exploring Approaches to Physician Performance Measurement By Aucha Prachanronarong, MHS On August 22, 2006, President Bush issued an Executive Order calling on all federal agencies and those who do healthcare business with the government to engage in collaborative efforts to incorporate the 4 cornerstones of value-driven healthcare: health information technology standards, quality standards, price standards, and incentives. The Department of Health and Human Services has embarked on a campaign to make these 4 cornerstones a reality by encouraging the public and private sectors to work collaboratively at the local level. In support of this campaign, the Centers for Medicare & Medicaid Services launched a project in late 2006 that leverages local collaboratives as a means to explore a national approach to physician performance measurement. This project, which is known as the Better Quality Information to Improve Care for Medicare Beneficiaries Project, aims to test methods to aggregate Medicare administrative data with data from commercial health plans and, in some cases, Medicaid, in 6 local collaboratives to calculate and report quality measures for physician groups and for some individual physicians. [AHDB. 2008;1(7):22-26.]
O
n August 22, 2006, President Bush issued an Executive Order—Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs— calling on all federal agencies and those who do healthcare business with the government to engage in collaborative efforts to incorporate the cornerstones of valuedriven healthcare (Table 1). The 4 cornerstones of value-driven healthcare are1: 1. Interoperable health information technology 2. Measure and publish quality information 3. Measure and publish price information 4. Promote quality and efficiency of care.
Local Collaboration Key to Value-Driven Healthcare Department of Health and Human Services Secretary Michael O. Leavitt has embarked on a campaign to make these 4 cornerstones a reality. A key piece of this campaign, known as the Value-Driven Ms Aucha is a Health Insurance Specialist, Office of Clinical Standards and Quality, Centers for Medicare & Medicaid Services, Baltimore, MD.
22
AMERICAN HEALTH & DRUG BENEFITS
September 2008
Health Care Initiative, is encouraging the public and private sectors to work collaboratively at the local level. Regional or local public–private collaboration among payers, health plans, providers, and consumers is essential to the success of this initiative. Healthcare systems are local. The different environments for healthcare delivery differ in the range of populations served, resources available, and in the characteristics of the local marketplace. Thus, broad-based efforts to improve quality of care need to be driven by local leaders who represent the various stakeholders and who are willing to pool their resources toward achieving common goals. In addition, quality initiatives need to allow for local input so that local market conditions can be taken into consideration. Although fostering the growth of locally led collaboratives is crucial to the success of the Value-Driven Health Care Initiative, national coordination is also needed. Patients should expect and be able to receive good quality care regardless of where they live. Similarly, all providers should be able to meet certain basic, agreed on standards of care regardless of where they practice. The need for national coordination is
VOL. 1
NO. 7
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CMS’s Better Quality Information Initiative
Table 1 The 4 Cornerstones of Value-Driven Healthcare Interoperable HIT • Interoperable HIT is the development and implementation of standards and health information systems that allow various parts of the healthcare delivery system to communicate and exchange data quickly and securely • Interoperable HIT holds the potential to create greater efficiency in the healthcare delivery system Measure and publish quality information • Consumers need quality-of-care information to be able to make confident and informed decisions about their healthcare providers and treatment options • Quality-of-care information is also important for providers to have to be able to improve the quality of care they provide • The quality information consumers and providers receive should be based on measures that are developed through consensus-based processes that involve all stakeholders, such as the processes used by the National Quality Forum, the AQA Alliance, and the Hospital Quality Alliance Measure and publish price information • To be able to make confident and informed decisions
about their healthcare providers and treatment options, consumers also need to have price information that is measured and reported in a uniform manner • Efforts are currently under way to develop uniform approaches to measuring and reporting price information, including strategies for measuring the overall cost of services for common episodes of care and the treatment of common chronic diseases Promote quality and efficiency of care • The healthcare delivery system should be structured
in a manner to reward those who offer and those who purchase high-quality, cost-effective care • All stakeholders—providers, consumers, health plans, and payers—should participate in arrangements that reward high-quality, cost-effective care HIT indicates health information technology. Source: Reference 1.
particularly salient for the Medicare program, which provides health insurance coverage for approximately 43.9 million beneficiaries across the United States.2 Because of Medicare’s national scope, the Centers for Medicare & Medicaid Services (CMS) needs to ensure that Medicare beneficiaries residing in Florida can
VOL. 1
NO. 7
KEY POINTS ▲ In 2006, the Department of Health and Human Services
embarked on a campaign to promote the transparency of health information in the United States following the president’s call for value-driven healthcare. ▲ In accordance with this effort, CMS has launched a pilot for
Medicare beneficiaries, known as the Better Quality Information Project. ▲ Because the delivery of care differs by local demographic and
market characteristics, a major concern for CMS is to ensure that Medicare beneficiaries receive comparable information on healthcare quality throughout the country. ▲ The Better Quality Information Project focuses on testing
methods for measuring physician performance using 6 local collaborative efforts. ▲ The lessons collected from this project could offer useful
information for CMS’ future efforts at measuring the performance of physicians who treat Medicare beneficiaries.
receive information on quality of care that is consistent with the quality-of-care information provided to Medicare beneficiaries residing in California.
A National Approach to Physician Performance Measurement A key piece to measuring and reporting quality information is measuring and reporting information on physician performance. Typically, efforts to measure and report on physician performance have been done in a piecemeal manner.3 Physicians, who usually see patients covered by a variety of public and private insurers, often receive information about their performance only as it relates to patients covered by a single insurer. Since physicians typically receive information on only a subpopulation of their entire patient population, physicians typically have no idea how their practice, as a whole, is performing against various quality measures. As a result, consumers looking for information on physician performance to help them select a physician or to review treatment options typically do not have a comprehensive picture of a physician’s performance either. Often, the insurance plans measure the physicians on a different group of measures as well. For example, a physician could potentially receive a report from one entity that only looked at the preventive services provided by the physician, while a second report from a different entity looked at the services the physician provided to his or her patients with diabetes. Even if the quality measures on the 2 reports appeared to be the
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Table 2 The 6 BQI Pilot Sites The 6 local collaboratives working with Delmarva are: 1. Arizona State University Center for Health Information & Research, Phoenix, AZ 2. California Cooperative Health Care Reporting Initiative, San Francisco, CA 3. Indiana Health Information Exchange, Indianapolis, IN 4. Massachusetts Health Quality Partners, Watertown, MA 5. MN Community Measurement, Minneapolis/St. Paul, MN 6. Wisconsin Collaborative for Healthcare Quality, Madison, WI
same, it is possible that the methods used by the 2 entities to generate the physician’s performance rate may have differed. For example, a physician receives 2 reports from 2 entities notifying the physician of the percentage of his or her patients with diabetes whose hemoglobin A1C levels are under control. However, the threshold used for determining whether a patient’s hemoglobin A1C level is under control may differ between the 2 entities. Consequently, the information that the physician received from the 2 entities would not be comparable. Since the various reports provide the physician with inconsistent information that may even be conflicting at times, it becomes difficult for the physician to act on the information provided in these various reports to improve the quality of care he or she provides.
CMS’ BQI Project In an attempt to explore how to provide physicians who treat Medicare beneficiaries with more meaningful, comprehensive information of their performance, CMS launched a new project in late 2006. In keeping with the central principles of the Value-Driven Health Care Initiative, this project, known as the Better Quality Information (BQI) to Improve Care for Medicare Beneficiaries Project, also leverages the experience of local multistakeholder collaboratives to explore a national, coordinated approach to physician performance measurement. CMS contracted with the Delmarva Foundation for Medical Care (CMS’s Quality Improvement Organization for Maryland) to provide overall project administration and management for the BQI Project and to conduct analyses on the Medicare administrative data. Delmarva awarded subcontracts to 6 local collaboratives, or pilot sites (Table 2), to receive, aggregate, and analyze Medicare administrative data along with their existing datasets. Delmarva and the 6 BQI pilot sites were tasked with testing:
24
AMERICAN HEALTH & DRUG BENEFITS
September 2008
1. Methods to aggregate Medicare administrative data with data from commercial health plans and, in some cases, Medicaid 2. The use of the aggregated data to calculate and report on quality measures for physician groups and, in some cases, for individual physicians practicing in each of the pilot sites’ local communities. The BQI Project will be completed at the end of October 2008. The following criteria were used to select the pilot sites: • Strong physician leadership engaged in creating the coalition • Multiple employer participation • Experience in measuring and aggregating physician level data • Experience providing feedback reports to physicians • Presence of a public website for consumers to access relevant information • Demonstrated capacity and interest to accept additional tasks • Willingness to work with a viable health information network if available • Capability and infrastructure to begin data collection within a short time frame. The 6 local collaboratives selected to participate in the BQI Project each brings a unique set of characteristics and experiences that have resulted in some differences in approach to implementation. One pilot site, for example, receives all payer data (including Medicare and Medicaid) directly from its member physician practices, while another pilot site relies solely on administrative data received from participating health plans. Similarly, some pilots have access to clinical data, including laboratory results, whereas other pilots only have access to administrative data, such as claims. Some pilots have a wealth of experience in publicly reporting healthcare performance information. Other pilots have no experience with public reporting. Some pilot sites are statewide in terms of population covered and scope, whereas others cover specific areas within the state in which they operate. We believe, however, that the uniqueness of each pilot site will prove beneficial for gathering lessons for the development of a national strategy for physician performance measurement.
Goals for the BQI Project The BQI pilot sites all have had some previous experience linking data from different sources together. In some cases, a pilot site may even have previous experience using the linked, or aggregated, data to produce healthcare performance information on the providers
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in their respective communities. Before their participation in the BQI Project, however, few of the pilot sites had the ability to incorporate Medicare data with the pilot sites’ other data sources. In seeking to test methods for aggregating Medicare administrative data with other data sources to produce a more comprehensive picture of the quality of care provided by physicians to Medicare beneficiaries through the BQI Project, CMS has provided many of the BQI pilot sites the opportunity to incorporate the experiences of Medicare beneficiaries into their local efforts for the first time. For many BQI pilot sites, the BQI Project represents the first time that Medicare data have been combined with other data sources for the purpose of generating meaningful information on physician performance. In most cases, the addition of Medicare data represents a significant addition of information about a physician’s practice that many of these local collaboratives had been missing. In 2005 alone, approximately 33 million people received a reimbursed service under Medicare fee-for-service, including roughly 32.7 million people who received reimbursable physician services.4 The BQI pilot sites will be working until the end of October 2008 to aggregate Medicare administrative data (eg, Medicare inpatient claims, outpatient claims, carrier claims, enrollment databases, and provider databases) with data from other payers to produce quality measure results. Since the BQI pilot sites will be using data from multiple payers, including Medicare, to produce these measurement results, they will be able to provide a more comprehensive picture of the quality of services being provided by physicians in their communities who treat Medicare beneficiaries. Each BQI pilot site will be reporting on 12 measures. The measures selected by each BQI pilot site are derived from the AQA Alliance (formerly the Ambulatory Care Quality Alliance) starter set of measures for physician performance (Table 3)5 and other quality measures endorsed by the National Quality Forum. In selecting measures for the BQI Project, a number of considerations were taken into account, including the data sources available to each BQI pilot site, to calculate the measure as well as the measure’s relevance to the Medicare population, and the local community.
Methodological Questions Before CMS can develop a strategy for measuring the performance of physicians around the country using Medicare administrative data, a number of methodological questions need to be answered. Each BQI pilot site will be aggregating the Medicare data with their own data sources to generate multipayer physician level
VOL. 1
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Table 3 AQA Alliance Measures for Physician Performance Preventive measures 1. Breast cancer screening 2. Colorectal cancer screening 3. Cervical cancer screening 4. Tobacco use 5. Advising smokers to quit 6. Influenza vaccination 7. Pneumonia vaccination Disease-state measures 8. Drug therapy for elevated LDL cholesterol 9. Beta-blocker treatment after heart attack* 10. Beta-blocker therapy post–myocardial infarction* 11. Angiotensin-converting enzyme inhibitor/angiotensin
receptor blocker therapy 12. Left ventricular failure assessment 13. HbA1C management 14. HbA1C management control 15. Blood pressure management 16. Lipid measurement 17. LDL cholesterol level
