Pay for Performance: Why You Should Care (Part 2 of 3)

by Gillian Hubble

categories: Doctors and Nurses, Hospitals and Health Systems, public health

Published October 20, 2009 @ 06:00AM PT

Part 2: Empowered Patients

Last time we dug into what P4P actually is. Today we'll give you the P4P tools to become an empowered patient, and introduce you to their quality metrics basis. This will allow you to pay for quality versus average or sub-par care.

Ready? Quick! You’re having a heart attack. Your family called 911, and now the paramedics are asking which hospital you want to go to. How do you know? Your life may depend on it.

All right, hold that thought. Now would be a good time to divulge how quality is actually measured. Believe it or not, health plans and their contracted doctors and hospitals have been routinely collecting quality data since 1991.

That's when National Committee for Quality Assurance came out with HEDIS (Healthcare Data and Information Set) performance measures. They assess preventive care, like immunizations and cancer screenings, and disease management (for example, asthma, diabetes, hypertension – high blood pressure, heart disease and depression.) HEDIS scores are now a requirement to participate in Medicare Advantage, a privatized Medicare health plan. US News & World Report uses them for its annual America’s Best Health Plans report.

Hospitals have also had to collect core measures on care quality and safety since 1997, if they want Joint Commission accreditation (the brainchild of a doctor in 1910, to improve standards of care.) The focus in 2001 honed to heart attack, heart failure, pneumonia, and pregnancy-related conditions. Two years later surgical infection prevention measures were added. So what exactly do they measure? For heart attack, things like:

• Giving patients aspirin at hospital arrival and prescribing it at discharge,
• Giving patients anti-hypertensive (blood pressure lowering) medications and prescribing them at discharge,
• Time until patients are given clot-busting medications,
• Time until artery-opening surgery (percutaneous intervention, otherwise known as angioplasty or “the balloon procedure”)
• Smoking cessation counseling (if needed),
• And, of course, all-important inpatient mortality.

So what, you say? The Centers For Medicare and Medicaid Services (CMS) began collecting quality and patient satisfaction data in 2001. CMS bases quality bonuses on them in pilot areas. For the last 4 years, the Hospital Quality Demonstration Project involved 230 hospitals and 1.5 million patients. According to results released in August, during that time 4,700 heart attack deaths were prevented and overall quality in 5 areas (heart attack, heart failure, coronary artery bypass graft, pneumonia, and hip and knee replacements) increased by 17%. Yes, this stuff matters: this year, CMS will distribute $12 million in bonuses to top performers.

CMS also runs a Physician Group Demonstration project with 10 large providers that has yielded significant improvements in 32 clinical measurements for diabetes, heart failure, hypertension (high blood pressure) and other conditions. In its third year, the program saved Medicare $32 million, a portion of which will be shared with 5 top-performing physician groups. Among those are Geisinger Clinic in Pennsylvania and Park Nicollet Health Services in Minnesota, which hit benchmarks on all 32 measures. CMS also has a new pilot measuring care improvements in 26 areas due to healthcare information technology.

So back to that life or death question of where to get help for your heart attack. Yes, there is helpful information out there, and being prepared is key. Unless you’re really proactive, you can’t control the state you live in – unfortunate, according to the Commonwealth Fund’s state rankings, which reveal wide disparities in care. But you can go to the Joint Commission’s public website, Quality Check, to view facilities and services both accredited and certified in your area.

Also check out NCQA’s report cards to choose high-quality health plans and doctors. Health plans are given starred ratings on 5 care aspects, and physicians are given recognition for patient-centered medical homes, heart and stroke treatment, diabetes treatment, and back pain treatment. And if you want hard-core, detailed data on how well hospitals care for patients with certain conditions, head to Medicare’s Hospital Compare tool. For instance, for hospitals within 25 miles of my zip code, I found that Tucson Medical Center actually provides better care for heart attack patients than University Medical Center, based on 7 very specific care measures and including the exact number of patients cared for.

More generalized quality information on doctors is harder to come by. We’ll tackle that in another post. But meanwhile, you’ve got some long-standing care-enhancing tools at your disposal and the promise of more widespread P4P in the future. Some providers are putting up a big fuss about that though. Find out why next time.

Update: Ezra Klein just posted an interview with Peggy O'Kane, NCQA President, on its latest State of Healthcare Quality report, to be released Thursday. It's worth a read.

Photo Cliff1066 // CC BY 2.0