Value Based Pay for Performance. Lindsay Erickson Pay for Performance Summit March 2, 2015

Transcription

1 Value Based Pay for Performance Lindsay Erickson Pay for Performance Summit March 2, 2015

2 Objectives IHA & California P4P Value Based P4P design and development Observations as we go live Copyright 2014 Integrated Healthcare Association. All rights reserved. 2

3 IHA & California P4P Program Copyright 2014 Integrated Healthcare Association. All rights reserved. 3

4 Pay for Performance Program in California $500m paid out 200 Medical Groups and IPAs 35,000 physicians 10 Plans 9 Million Californians Copyright 2014 Integrated Healthcare Association. All rights reserved. 4

5 Core Program Elements The California P4P program aims to create a compelling set of incentives that will drive improvements in clinical quality, resource use, and patient experience through: A Common Set of Measures Health Plan Incentive Payments A Public Report Card Public Recognition Awards Copyright 2014 Integrated Healthcare Association. All rights reserved. 5

6 Program Evolution First Measurement Year Quality only Appropriate Resource Use measures added Value Based P4P Quality and Resource Use integrated into single incentive program Payment for Improvement added Quality only Total Cost of Care measure added First payments for Value Based P4P Copyright 2014 Integrated Healthcare Association. All rights reserved. 6

7 Transition to Value Based P4P P4P Classic Value Based P4P Emphasis on quality improvement Separate incentives for quality and resource use Standardizes health plan quality measures and payment methodology Emphasis on affordability and value Combined incentive for quality and resource use Standardizes health plan resource use measures, as well as quality measures and payment methodology Copyright 2014 Integrated Healthcare Association. All rights reserved. 7

8 Value Based P4P design & development Copyright 2014 Integrated Healthcare Association. All rights reserved. 8

9 Value Based P4P Overview Does the PO qualify? Quality Gate Total Cost of Care Trend Gate Did the PO improve? Resource use compared to prior year Selected inpatient, outpatient, ED, and prescribing measures How much is the PO s incentive payment? Net savings for all ARU measures Quality determines share of savings Copyright 2014 Integrated Healthcare Association. All rights reserved. 9

10 Value Based P4P Overview Does the PO qualify? Quality Gate Total Cost of Care Trend Gate Did the PO improve? Resource use compared to prior year Selected inpatient, outpatient, ED, and prescribing measures How much is the PO s incentive payment? Net savings for all resource use measures Quality determines share of savings Copyright 2014 Integrated Healthcare Association. All rights reserved. 10

11 Value Based P4P Overview Does the PO qualify? Quality Gate Total Cost of Care Trend Gate Did the PO improve? Resource use compared to prior year Selected inpatient, outpatient, ED, and prescribing measures How much is the PO s incentive payment? Net savings for all ARU measures Quality determines share of savings Copyright 2014 Integrated Healthcare Association. All rights reserved. 11

12 Value Based P4P Design Performance gates Quality Total Cost of Care Trend Calculate share of savings based on resource use Adjust share of savings for Quality Sum adjusted shared savings Step 1a Quality Gate yes Step 1b Total Cost of Care Trend Gate yes no no PO does not qualify for value Based P4P incentive PO does not qualify for value Based P4P incentive Step 2 (repeat for each ARU measure) Calculate Base Incentive Amount using Appropriate Resource Use (ARU) Measures Step 3a Apply Quality Adjustment to base Incentive Amount Step 4 Sum Incentive Amounts across ARU Measures; negative amounts offset positive amounts Value Based P4P SHARED SAVINGS INCENTIVE Copyright 2014 Integrated Healthcare Association. All rights reserved. 12

13 Value Based P4P Drivers To earn ANY award: Meet minimum level of quality Below TCC trend gate Net improvement on resource use measures To MAXIMIZE award: Greater resource use improvement Complete diagnosis coding and risk capture Higher quality Step 1a Quality Gate yes Step 1b Total Cost of Care Trend Gate yes PO does not qualify for value Based P4P incentive PO does not qualify for value Based P4P incentive Step 2 (repeat for each ARU measure) Calculate Base Incentive Amount using Appropriate Resource Use (ARU) Measures Step 3a Apply Quality Adjustment to base Incentive Amount Step 4 Sum Incentive Amounts across ARU Measures; negative amounts offset positive amounts no no Value Based P4P SHARED SAVINGS INCENTIVE Copyright 2014 Integrated Healthcare Association. All rights reserved. 13

14 Modeling Shared with Stakeholders Copyright 2015 Integrated Healthcare Association. All rights reserved. 14

15 Observations as we go live Copyright 2014 Integrated Healthcare Association. All rights reserved. 15

16 Expect Most Will Meet Quality Gate Quality Score for Maximum Multiplier 70 Quality Composite Score Quality Gate 0 Ranked distribution of Physician Organization s Quality Composite Score Copyright 2014 Integrated Healthcare Association. All rights reserved 16

17 Expect Most Will Pass the Cost Trend Gate TCC Trend Gate = 5.2% Number of Plan-POs Total Cost of Care Trend, (%) Note: trends shown in the chart are the cost trend; performance at the TCC Trend Gate is assessed using the lower limit of the 85% confidence interval of the TCC trend. The 26.9 percent of plan-po dyads (158 of 588 total across five health plans) that missed the 5.3% cost trend gate are based on the confidence interval around trend; 46.1 percent (271 of 588 total) of plan-po dyads had trends above the 5.3% threshold. Copyright 2014 Integrated Healthcare Association. All rights reserved. 17

18 Expect Those That Pass Gates to Earn 40-50% of Any Savings 40% Percent of Plan-POs 35% 30% 25% 20% 15% 10% Passed Both Gates Missed Both Gates Missed Quality Only Missed TCC Trend Gate 5% 0% Quality Composite Score Did Not Pass Gates 32.5% 35% 40% 45% 50% 55% 60% 65% 67.5% Quality-Adjusted Share of Savings N/A Copyright 2014 Integrated Healthcare Association. All rights reserved. 18

19 Varied Resource Use Trends Decreases=Improvement Increases=Improvement Inpatient Bed Days Readmissions (IRN) ED Visits Generic Prescribing 6% % Change in P4P Population Rate 4% 2% 0% -2% -4% -1.3% 4.5% 1.7% 3.1% -6% Copyright 2014 Integrated Healthcare Association. All rights reserved. 19

20 Learnings Importance of stakeholder involvement and engagement Definition and understanding of value is constantly evolving Performance target not as clear with resource use and cost Balancing act between simplicity and methodological rigor Copyright 2014 Integrated Healthcare Association. All rights reserved. 20

21 It is good to have an end to journey toward; but it is the journey that matters, in the end. Ernest Hemingway Tangerine Falls Copyright 2014 Integrated Healthcare Association. All rights reserved. 21

22 Thank you! Lindsay Erickson Copyright 2014 Integrated Healthcare Association. All rights reserved. 22