Michigan P4P program given high grades
Seven RWJF grantees honored
Since it’s one of the oldest incentive programs in the country, it might not come as a big surprise that Blue Cross Blue Shield of Michigan was among seven Robert Wood Johnson Foundation "Rewarding Results" grantees selected to highlight its successes in pay-for-performance programs during a National Press Club briefing on November 15 in Washington, DC., but the results it has have achieved to date are nonetheless impressive.
Consider the following:
- rates of patients receiving aspirin upon arrival were 95% at incentive hospitals, compared with 91% nationally and 90% for non-incentive hospitals;
- patients at discharge counseled to take aspirin were 96%, compared with 86% nationally and 85% non-incentive;
- patients receiving BETA blockers upon arrival were 93%, compared with 83% nationally and 80% non-incentive;
- patients prescribed BETA blockers at discharge were 96%, compared with 84% nationally and 80% for non-incentive;
- patients receiving a left ventricular function assessment (a determiner of blood flow through the heart) were 93% compared with 78% nationally and 75% at non-incentive hospitals;
- patients prescribed ACE inhibitors at discharge were 82%, compared with 74% nationally and 67% at non-incentive hospitals.
The program, which builds upon nationally recognized quality measures used by the Joint Commission on Accreditation of Health Care Organizations, currently focuses on three areas: quality of care indicators, patient safety, and a third component that rewards hospitals for programs that target the health of their local communities, particularly in reducing tobacco use and encouraging physical activity and nutrition.
"It was becoming increasingly apparent to everyone in the health care community that there was a gap between actual and optimal quality," explains David A. Share, MD, MPH, clinical director of the Center for Health Care Quality and Evaluative Studies at Blue Cross Blue Shield of Michigan. "Practices pertaining to medication known to achieve better outcomes were not being uniformly adopted, along with other practices known to improve patient experience and outcomes, so we decided to focus on these areas by selecting performance indicators generally accepted to be relevent, in hope of increasing the hospitals’ focus on those issues and developing resources for system changes for improve performance." Currently, he notes, 60% of a hospital’s score is based on quality, 30% on patient safety, and 10% on community programs.
The incentive program actually was initiated in 1989 — "Well ahead of the pack," notes Share. Its focus for the first 10 years, he says, was on rewarding hospitals for low-risk, non-acute cases and days. "But that eventually became a non-issue," he notes, and in 1999 the organization partnered with the Michigan Health & Hospital Association (MHHA) to develop a revised hospital incentive program, which was implemented in 2000.
How the program works
The program as currently structured includes a master contract called the "Participating Hospital Agreement," or PHA. The MHHA and Blue Cross Blue Shield partner on administering that contract, which includes explicit mention of the PHA incentive program. "One of its parameters is the potential to receive [an incentive of] up to 4% of hospital inpatient DRG payment in a given calendar year," says Share. "That’s based on performing at 100% on all of the indicators."
For example, the contract used JCAHO/CMS core indicators for heart attacks — i.e., the use of BETA blockers after an MI. "In 2000 when we began the program, the statewide average was 81%; in 2004, it had risen to 96%, and at that time the national average was 84%," Share notes. "Clearly, there was a pretty intense focus."
The program is not a static one, he adds. "For example, in patient safety, if a hospital had an ICU, we provided an incentive to be in the Keystone project," he relates. (The Keystone Intensive Care Unit Project is a joint effort of the MHHA and Johns Hopkins University.) "So at first, you were rewarded for just being in it. Once there was a baseline, however, we raised the bar by basically tying it to actual performance on measures like ventilator-associated pneumonia [VAP]."
Significant value for quality managers
Both VAP and catheter-related bloodstream infections dropped dramaticaly in the Keystone project, he adds, "And I’d like to think the incentive made them participate — because it was not cheap," he emphasizes.
Qualitative evaluations of the engagement of the hospital community also have been conducted, Share observes, which indicated a significant value in such programs for quality managers. "These involved everyone from CEOs to physician leaders to QA directors; we had independent folks interview them," he reports. "What we repeatedly heard was that QA directors and some of their staff told interviewers the PHA incentive program was responsible for the CFO getting to know their names and phone numbers, and to actually call them up and ask questions about performance. Many made sure they had the necessary resources to improve performance, because there were dollars on the line."
The boards of many participating hospitals now get regular reports on performance on quality indicators, says Share. "Some are even tying CEO incentive pay to performance on these measures — so, as you can see, they get quite engaged," he emphasizes.
Many challenges remain
Despite the success of his program, says Share, there are still a number of remaining challenges for P4P. "One challenge is defining the ROI (return on investment)," he says. "There is a whole science in evaluating these programs, like which influences are causal and which just happen at the same time in the marketplace. Generating valid, generally comprehensive evaluations is a newly emerging challenge."
Quality indicators, surprisingly, also offer a challenge. "Everyone agrees on indicators pertaining to areas of care where there is scientific certainty of optimal care, but that’s only 15%-20% of all care given," he claims. "Many other areas are highly technological, rapidly evolving, and the evidence base is not so clear. There are many areas of surgery, for example, with new technology, so how do you measure quality when you can’t define it properly?"
Issues such as these are being addressed in Michigan by creating collaborative quality initiatives. "We are getting hospitals together in consortia to pool comprehensive clinical information so we can do risk-adjusted studies for links between process and outcome, see what is a best practice, then implement them statewide," Share explains.
In other words he says, these erstwhile competitors must "Leave their guns at the door, stop competing on quality and start collaborating," Share asserts. "This pretty dramatically increases the rate of QI," he continues. "We’ve done it in angioplasty and shown a 27% decrease in mortality. This demonstrates that the process works, and now we are expanding into cardiac surgery, weight loss surgery, breast cancer care, general and vascular surgery."
The goal, he says, is to transform systems of care across a wider area. "Then, hopefully, we can incorporate what we learn into a more modernized incentive program," he concludes.
Since its one of the oldest incentive programs in the country, it might not come as a big surprise that Blue Cross Blue Shield of Michigan was among seven Robert Wood Johnson Foundation Rewarding Results grantees selected to highlight its successes in pay-for-performance programs during a National Press Club briefing on November 15 in Washington, DC., but the results it has have achieved to date are nonetheless impressive.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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