Physician Clinical Performance Physician Clinical Performance MeasurementMeasurement

Presentation to the Consumer-Purchaser Presentation to the Consumer-Purchaser Disclosure ProjectDisclosure Project

September 29, 2006September 29, 2006

Earl Steinberg, MD, MPPEarl Steinberg, MD, MPPPresident and CEO, Resolution Health Inc.President and CEO, Resolution Health Inc.

Adjunct Professor of Medicine and ofAdjunct Professor of Medicine and ofHealth Policy & Management, Health Policy & Management,

Johns Hopkins University Johns Hopkins University

© Resolution Health Inc., 2006© Resolution Health Inc., 2006All Rights ReservedAll Rights Reserved

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OutlineOutline

I. Concerns about the analysis of electronic “administrative” data

II. Key issues in physician clinical performance measurement A. Types of data that are available B. Measures C. Physician attribution D. Measurement Period E. Scoring F. Reporting G. How results are used H. PrivacyIII. Q&A

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution

• Measurement period

• Scoring

• Reporting

• Use of results

• Privacy

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Potential Data SourcesPotential Data Sources

• Electronic Medical Record

• Claims

• Claims + Other Electronic “Administrative” Data (e.g. enrollment, benefits, lab results)

• Chart Review

• Self-reported (by MD)

• Survey

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Inpatient Services Data?Inpatient Services Data?

• Discharge abstract vs UB92 vs Detailed bill?

• Detailed bill required to ID:

▪ Tests/Certain Procedures

- e.g. drug level; oxygen saturation; telemetry

▪ Medications (e.g. systemic steroids)

▪ Timing of provision of particular services relative to:

- date/time of admission

- initiation of treatment (e.g. was CT/MRI done

before anti-coagulation was started?)

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Outpatient Services Data?Outpatient Services Data?

• Behavioral health services

• DME

• Does each claim (e.g., each Rx claim) have a MD identifier? How specific is it?

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Claims Data vs Chart AbstractionClaims Data vs Chart Abstraction

Claims Data Chart Abstraction

Missing claims (e.g., OON utilization) Info. re care provided by other MDs often missing

Incomplete coding Incomplete documentation

Errors in coding (both inadvertent and deliberate)

NA

Variations in coding Variation in terminology, abbreviations, symbols and criteria

Limited breadth and depth of codes NA

NA Problems with legibility

Low cost High cost

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Pros/Cons of Various Data SourcesPros/Cons of Various Data Sources

PROs CONs

Claims Data Widespread Availability

Low Burden

Low Cost

Claim Lag (timeliness) Not a Problem for CPM

Limited Clinical Detail

Incomplete

Inaccuracies

Chart Abstraction Clinical Detail Incomplete

Variability

High Burden

High Cost

Patient Survey Data Can Address Non-Clinical Issues

High Burden/Cost

Uncertain Accuracy

Little Clinical Detail

Low Response Rates

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Things Not Detected in Claims DataThings Not Detected in Claims Data

• Patient symptoms

• Performance or results of a physical exam

• Family history

• Personal habits (e.g., smoking)

• Diseases not reliably inferred using claims (e.g. obesity)

• Procedures not reliably captured by claims data (e.g. influenza vaccine)

• Use of OTC meds (e.g. aspirin)

• Procedures/ tests performed on emergent v. elective basis

• Clinical disease stage or severity

• Documentation in patient chart

• Test results

• Alternative/ complimentary medical care

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Ways to Deal with ShortcomingsWays to Deal with Shortcomings of Claims Data of Claims Data

Shortcoming How to Address the Shortcoming

Certain tests and services are (may) not be reflected reliably in claims

data

Do not use measures that focus on use of those tests and services

(e.g. spirometry; influenza vaccine; smoking cessation programs)

Use of OTC drugs is not captured in claims data

Do not use measures that focus on use of meds that could be purchased OTC (e.g.

Use of aspirin post-MI)

Inaccuracies in diagnoses that are listed on claims

Require more than one indication that a member has a disease/condition

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Other Ways to Deal With Other Ways to Deal With Limitations of Claims DataLimitations of Claims Data

• Use a very conservative approach to identification of “newly diagnosed Disease X”

Example: Require a long “clean period” without

evidence of the diagnosis

• Make sure patients had insurance coverage for services that were being looked for

Example: If patient was supposed to be on a drug over

a particular time period, we only look at people with Rx benefits throughout entire time period

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data

• Measures

• Attribution

• Measurement period

• Scoring

• Reporting

• Use of results

• Privacy

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The “Geology” of Clinical Performance The “Geology” of Clinical Performance MeasurementMeasurement

Expert Opinion Evidence

Guidelines

Standards• Content of Care

• Outcomes of Care

PerformanceMeasures

• Cost of Care• Quality of Care

Performance Measurement

A Performance Assessment

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Components of Measures: 1. DenominatorComponents of Measures: 1. Denominator

• Defines the target population to whom the CPM applies• Things that should be considered for a process of care measure

are factors that should influence the care that should be delivered to a patient

• Things that should be considered for an outcome of care measure are factors that could influence the outcome of care

• Goal is to assure that “apples” are being compared to “apples”• Goal is typically accomplished through “patient sub-setting”• Sensitive to the technical specifications used to define the

denominator

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Components of Measures: 2. NumeratorComponents of Measures: 2. Numerator

• Quantifies whether a particular “event” of interest has occurred

- care consistent with a guideline or standard

- achievement of a normative outcome• Sensitive to the technical specifications used to define the

numerator

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Practice Guidelines Don’t = Quality MeasuresPractice Guidelines Don’t = Quality Measures

• Relationship between a practice guideline and a valid algorithmic representation of the guideline (i.e. a valid measure based on the guideline) is “1 to many”, not “1 to 1”

• Potential measures vary in terms of false negative vs false positive rate

• The devil’s in the details!

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Criteria for Assessing MeasuresCriteria for Assessing Measures

• Importance of the focus of the measure

• Variation in performance

• Potential for performance improvement

• Validity of the measure

• Reproducibility of the measure

• Feasibility of the measure - availability of data required for the measure - difficulty of collecting the data - cost of collecting the data

• Relevance to consumers and purchasers

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Measure Description: Complete TransparencyMeasure Description: Complete Transparency

Rule 114: Diabetics with HbA1c test in past 6 months Description

This rule identifies the percentage of members over 18 years old with a history of diabetes who have had a HbA1c test over the past 6 months

Technical Specification

Numerator =• Age over 18 years old AND• Meet RHI criteria for diabetes before measurement year (based on ICD-9 and NDC codes) AND• Eligible for benefits over the most recent 7 months during measurement year

Denominator = • At least 1 Procedure code (e.g. CPT-4) for HbA1c test over the most recent 7 months during

measurement year

Applicable Specialties

Internal Medicine

Family Practice

Endocrinology

References

American Diabetes Association. Diabetes Care. January 2006. 29 (suppl 1) s8-s11Edelman D, Maren K, Olsen K, et al. Utility of Hemoglobin A1c in Predicting Diabetes Risk. Gen Intern Med 2004;19(12):1175-1180

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution• Measurement period

• Scoring

• Reporting

• Use of results

• Privacy

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AttributionAttribution of Care to a Particular MDof Care to a Particular MD

• Should a patient or service be associated with only a single MD or with a group of MDs?

• Can a unique MD (group) ID be constructed?

• What information is available regarding MD specialty(ies)? How accurate is it?

• Does each claim (e.g., each Rx claim) have a MD identifier? How specific is it?

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution

• Measurement period • Scoring

• Reporting

• Use of results

• Privacy

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Measurement PeriodMeasurement Period

• Fixed - 2 yrs of historical data to ‘prime the pump’ - Single (consistent) measurement period - Easy to understand - Don’t use some potential observations

• Rolling, Variable - Once criteria for a denominator are satisfied, the following 12 mos. are used as the measurement period - Measurement year varies across MDs and across pts for a given MD - Could have >1 observation for a given pt for a given MD - Harder to do and harder to explain - Maximizes observations

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution• Measurement period

• Scoring• Reporting

• Use of results

• Privacy

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Construction of a Quality Construction of a Quality ScoreScore

• Types of scores - Single (aggregated) score per MD (or MD group) - A score for certain types of care (e.g. management of diabetes; cardiac

care) - Measure-specific scores• Weighting - unweighted sum of numerators and denominators across all pt-measures applicable to a given MD (implies all measures are equally important) - weighted sum (implies some measures are more important than others)• Sample size - Minimum number of observations for a given MD for a given measure for

that measure to be considered? - Minimum number of observations for a given MD for that MD to receive a score? - Confidence intervals around point estimates• Distinguishing between MDs - Numerical score vs %-ile vs quartile (or other group) - How big a difference in score is clinically meaningful?

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution• Measurement period

• Scoring

• Reporting • Use of results

• Privacy

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Making Reports RelevantMaking Reports Relevantto Consumers and Purchasersto Consumers and Purchasers

• Address issues that are important

• Address a spectrum of services

- within a specialty

- across specialties

• Provide information that is understandable/easy to interpret

• Provide information that is actionable

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution• Measurement period

• Scoring• Reporting

• Use of results• Privacy

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Potential Uses of Physician MeasuresPotential Uses of Physician Measures

• Inform patients and purchasers

• Quality improvement

• Payment adjustments (e.g. P4P)

• Financial incentives to patients (e.g., high performance networks/tiering

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Physician Measurement: Physician Measurement: Key TopicsKey Topics

• Data• Measures

• Attribution• Measurement period

• Scoring• Reporting

• Use of results

• Privacy

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Privacy IssuesPrivacy Issues

• Importance of security safeguards in connection with transfer, storage and use of data

- should have a security policy - use of passwords and encryption - de-identification of data (removal of personal identifiers) during transfer, storage and analysis - firewalls - monitor access - identification of patients to MDs?• Do physicians have a right to privacy re their clinical

performance?

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Data to Results OverviewData to Results Overview

Data Standardization and Integration

Enrollment Benefits Med Claims Rx Claims Lab Results Providers

Evidence-Based Rules Engine

Identify Apparent Deficiencies in Care

Data Management and Analysis

Attribution of Patient-Issue to Provider(s)

Provider-specific Clinical Performance Assessment

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Questions?Questions?