# Presentation: 461288

## AHIC EHR WorkgroupOctober 13, 2006Can P4P and P4PI Help Overcome Some Financial Barriers to EHR Development?

- Ronald Bangasser, MD, FAAFP
- Chair, Technical Advisory Committee
- IHA’s CA Pay for Performance Program
- Past President, California Medical Association

## California P4P History

- 2000:  Stakeholder discussions started
- 2002:  Testing year
- IHA received CHCF Rewarding Results Grant
- 2003:  First measurement year
- 2004:  First reporting and payment year
- 2007:  Fifth measurement year;
-                fourth reporting and payment year

## California P4P’s Reach

- Health Plans:			            7
- Physician Organizations:	        228
- Physicians:				   40,000
- HMO Commercial Members:
- Payout:				  6 million
- Public Reporting		12 million

## Program Results

- _Clinical_:  continued improvement across all measures
- 1.9 to 4.8 percentage point increases from MY 2004 to MY 2005
- 4.0 to 14.5 percentage point increases from MY 2003 to MY 2005
- _Patient experience_:  modest improvement on all measures
- 0.5 to 2.2 percentage point increases from MY 2003 to MY 2004
- _IT_:  Expansion of capacity
- 11 percentage point increase in the number of Physician Organizations earning full credit from MY 2004 to MY 2005

## Correlation Between IT and Other P4P Domains

## P4P Payouts 2003-2005

**Dollars **
**(in millions)**

## Response to Stakeholders’ Needs

- IT-Enabled Systemness Domain proposed for MY 2007
- Efficiency Domain proposed for MY 2007
- 10 new clinical measures proposed for testing in 2007

## Public Reporting

- Medicare Advantage
- Steering Committee approved public reporting for MY 2006 using the seven clinical measures tested
- OPA 2006 Report Card
- Includes patient experience results from CCHRI
- Provides link to clinical results on IHA’s website
- MY 2005 Transparency Report
- To be posted on IHA’s website in December 2006

## New Populations

- Working with Managed Medi-Cal plans to design expansion to Managed Medi-Cal
- Developing proposal to CMS to facilitate expansion to Medicare Advantage

## Is IHA’s P4P program THE answer?

- NO
- It certainly is one way to improve quality and it has shown positive results
- BUT

## What did Beaver Get?.... and How Did We Spend It?

- For 2005, based on 2004 data, both self-reported and from Health Plans, Beaver Medical Group got $1.2 Million in P4P Quality Improvement Bonuses
- 1⁄2 went for IT improvements
- 1⁄2 went to physician bonuses – to those who did the work
- Beaver LEFT over $400,000 on the table, mostly in low Patient Sat Scores

## Medical Groups and EHR’s

- Everyone thinks that many Medical Groups from size 50 and up have a robust EMR
- My 150 multi-specialty group has spent over $140,000 per physician over the last 8 years and we are still improving ours
- Others have spent far more – many failed to meet expectations or failed completely

## What about the Solo and Small Group Physicians?

- 50% of Physicians in CA are in Solo and Small Group offices, 70% in the rest of the US.
- Some may be connected with one or more IPA’s.  The IPA’s may be collecting data and sending it in.  Sometimes there is good feedback to the physician....
- Some solo physicians get some money for performance....
- Many do not know about P4P or feel threatened by it

## The Solo and Small Groups

- An EHR seems like a dream to most, often a very bad dream
- Cost is the biggest barrier, even if other barriers are overcome
- Most have a billing system.  Some may use e-mails, even with patients.  Fewer may transmit some data to their IPA.
- Going the next full step will be a challenge financially, but it will may require new office staff and a new office system.

## So how can we engage the Solo and Smalls?

- At least to create a starter incentive, you can use a P4P and P4PI program
- The office can start with a simple registry of patients that have a certain disease (Diabetes), using a simple Excel spreadsheet
- Then, they can add which patient had a HgbA1C.  Next column, when did they have it.
- Since most would see their diabetic patients at least once within any 3-month period, they would have a pretty complete list in 120 days.

## Can this generate $$$?

- By repeating this with disease processes that are P4P measures, there could be more money generated by the IPA who could send that down to the physician.
- This will not be enough to fund a new EHR, but it could be a start.

## Specialty Solo’s will have an easier time

- Many specialties have a high dollar, low volume of patient practice
- Many specialties deal with only a few   ICD-9 codes, compared to Primary Care Specialties
- Now, the AMA Physician Consortium on Performance Measures has developed over 80 measures, many specialty with national specialty organizations, with another 90 in the works.

## Other Barriers – Beyond “Can I Afford It?”

- I want the best system that will do everything I need, never breakdown, require no upkeep, cost me less staff, and bring in money.
- Updates – how often, how much hassle?
- Flexibility – Will my system be able to keep up new requirements?  How long will it or the company last?
- Is this time to take the risk, bite the bullet?
- Who can I turn to for help?...trusted help

## Other Sources for Physician Funding

- Who get the benefits of a physician EHR?
- There is a small chance for savings in physician office – maybe 10%
- Most of the benefit and savings will go to the Businesses and the Health Plans, and the Government.
- Little benefit in dollars will go to the patients. and safer health care.
- So those who get the savings should help in funding....

- Patients will benefit in better

## Chronic Disease Management?

- Only 27% of high blood pressure patients are under control
- Only 42% of diabetics have cholesterol control
- Only 66% of diabetics have blood pressure
- Only 35% of A. Fib patients get anti-coagulation
- Only 25% of depressed patients get enough care
- 50% of discharged CHF patients are readmitted within 90 days

## Does Disease Management Work?

- ONE Example:  Diabetes
- 44% of conventionally treated patients reached the CVD endpoint in 7.8 years
- Only 24% of intensively treated patients reached same endpoint in same number of years
- = 17 Heart attacks versus 5
- = 20 Strokes versus 3
- IT MAKES A DIFFERENCE

## MUST HAVES in Chronic Disease Management

- Access to most effective prevention and treatment
- Primary care infrastructure to administer #1 – Systems, especially Registries
- Self-Management
- Specialized services when needed
- Supportive Communities

## Challenge:  Can we do it?

- Can we afford not to do it?

## Thank you

- Dr Ron Bangasser
- rbangass@epiclp.com