Performance Data Reporting: Impact on Primary Care Practices

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)

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

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.

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

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

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.

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).

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

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

10. Eight Practices Selected For Variety and Program Participation

11. Quality Data Reporting Programs Represented Of the 8 practices in the COMP project, 4 participated in PQRI, 3 in IPIP, 2 in BTE-Diabetes, 1 in BTE- PPC, 1 in a chronic disease collaborative

12. Conditions Evaluated

13. Medical Data Systems

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

15. Total Resource Costs • Costs to Practice • Total rather than marginal costs • Cost to QI program • In-practice only Cost Categories - 1

16. Cost Categories - 2 Total Practice Costs Staff Time: Measure-Specific (eye exam referrals, HbA1c) Supplies, Equipment, Application Fees Staff Time: Non-measure Specific (data entry, meetings) Cost Categories - 2

17. Total Practice Costs Start-Up Phase Maintenance Phase Cost Phases

18. PQRI Implementation Costs in Four Practices

19. PQRI Implementation in Practices A and H

20. Cost Per FTE of Implementing CCNC vs IPIP

21. Average Practice & Program Costs per FTE of CCNC*, IPIP**, and PQRI*** Maintenance Phase * 6 practices ** 3 practices *** 4 practices

22. Estimated Costs and Reimbursement for Participation in B to E Diabetes Estimates are per provider FTE

23. Estimated Costs and Reimbursement for Participation in B to E Medical Home Estimates are per provider FTE

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

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”

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”

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”

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

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"

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"

31. Catalyst Practice Precondi- tions Infrastructure Development Sustainability Program Initiation Program Maturation Infrastructure Development 1. Medical director support 2. Administrator support 3. Data entry & reporting resources 4. Staff meeting times Preconditions 1. Exposure to QI 2. Leader with QI experience 3. Focus on quality > income Sustainability 1. Tangible constructive change 2. Financial benefit 3. Enhanced practice reputation 4. Strategic partnerships that foster culture of quality Catalysts 1. Committed leader or mandate 2. Collaborative atmosphere 3. Outside encouragement Theoretical Model: Factors Involved in Developing and Maintaining Quality Assessment, Improvement, and Reporting in a Primary Care External and Internal Barriers and Facilitators

32. Image