# Presentation: 747994

## Incentives for ICT Adoption:An Example from California

**Kristiana Raube, PhD and Cheryl L. Damberg, PhD**
**May 22, 2007**

**Financial support provided by the California Healthcare Foundation**

## RAND Study: Quality of Health Care Often Not Optimal

- Doctors provide appropriate health care only about half the time

- Source:  McGlynn, Asch, Adams, et al. “The Quality of Health Care Delivered to Adults in the United States,” *N Engl J Med*, 2003

## The Quality Gap*:Avoidable Deaths (per year) 

| Measure	 | Deaths per Year |
| --- | --- |
| Blood Pressure Control
Cholesterol Control	
Diabetes Care–HbA1c Control Smoking Cessation	
Flu Shots for Adults		
Colorectal Cancer Screening
Beta-Blocker Treatment	
Prenatal Care	
Breast Cancer Screening
Cervical Cancer Screening | 15,000 -26,000
  6,900 - 17,000
 4,300 - 9,600
 5,400 - 8,100
 3,500 - 7,300
 4,200 - 6,300
    900 - 1,900
    600 - 1,400
   600 - 	900
   600 - 	800 |
| 	National Total
	California Total | 42,000 – 80,000
 5,000 – 10,000 |

- *Based on if everyone could perform at the level of the top 10 percent Health Plans or Medical Groups.

- Source: NCQA, Washington, D.C., 2004.

##  Presentation Topics

**IHA Pay-for-Performance program design**
**IT measures**
**Financial incentives**
**Public report cards**
**What has happened?**
**Changes in IT adoption over time**
**Relationship of IT to Performance**
**Physician Leaders’ Opinions**
**Summary**

## Integrated Healthcare Association’s Pay-for-Performance Program

**The goal of  the IHA P4P program is to *****“create a compelling set of incentives that will drive breakthrough improvements in ******clinical quality****** and the ******patient experience****** through:***** **
***A common set of performance measures ***
***A public scorecard***
***Health plan payments based on performance***

## IHA P4P Program

**A California-wide collaborative effort among:**
**7 major health plans and 225 medical groups**
**6.2 million commercial Health Maintenance Organization and Point of Service enrollees****_x0010_**
**Measurement started in 2003 for 1****st**** payout in 2004**

| Design Elements |  |
| --- | --- |
| Unit of payment | Medical groups (n=225) |
| # of measures | 17 (clinical, patient experience, IT capability) |
| Data source | Administrative (plan or medical group self-report)
Minimum of 3.25 encounters Per Member Per Year |
| Earning potential | Avg. bonus of 2-3% of capitation (~$2.50 per member per month) |
| Scoring method | Most plans use relative rankings |
| Transparency | Full transparency |

## Performance Measures Measurement Year 2005, Payout 2006

**Clinical**
**Asthma management**
**Childhood immunization (MMR, VZV)**
**Cancer screening (breast, cervical)**
**Diabetes (HbA1c measure and control)**
**LDL (screening and control:  03 cardiac; 04 cardiac and diabetic)**
**Patient Experience**
**Timely access to care**
**Doctor-patient interaction/communication**
**Specialty care**
**Overall ratings of care**
**IT Capability**
_**Integrate clinical electronic data**_** for population management**
**Clinical decision making **_**support at point of care**_** through electronic tools**

##  Clinical IT Use in the Outpatient Care Setting is Especially Low

| Practice Setting | Administrative IT Systems | Clinical IT Systems |
| --- | --- | --- |
| Inpatient         Setting |        High |     Moderate |
| Outpatient
Setting |      Moderate |        Low |

## Clinical Information Technology

**Data Integration Technology (Population Management):**
** ****E-Patient Registry**
**Actionable reports from E-data collection**
**E-collection of HEDIS measures (Health Employer Data Information Set)**

**Point of Care Technology (Patient Care):**
**E-prescribing**
**E-drug interaction check**
**E-retrieval of lab results**
**E-access to clinical notes**
**E-retrieval of patient reminders**
**E-access to clinical findings**
**E-messaging**

## Weighting of Measures in Payout Formula

| Payout Year | 2004 | 2005 | 2006 | 2007 |
| --- | --- | --- | --- | --- |
| Clinical Measures | 50% | 40% | 50% | 50% |
| Patient Experience with Care | 40% | 40% | 30% | 30% |
| IT Capabilities | 10% | 20% | 20% | 20% |
| Total | 100% | 100% | 100% | 100% |
| Individual physician Feedback program (optional add on bonus) |  |  | x | x |
| Year-to-year improvement (optional in 06; begins 07 for all plans) |  |  |  | x |

## Incentive Payments--2006

**Aggregate Payment for all pay for performance measures, commercial HMO and POS**

**$53.7M**

**$83.4M**

**$144.6M**

## 2006 P4P Payments: AveragePer Member Per Month by Plan

## Incentive Payments

| Domain | 2004 | 2005 | 2006 |
| --- | --- | --- | --- |
| Clinical | $18.7 | $21.5 | $27.5 |
| Patient Experience | $15.0 | $21.5 | $16.5 |
| Information Technology | $3.7 | $10.7 | $11.0 |
| Total | $37.4 | $53.7 | $55.0 |

**Reported in Millions of Dollars**

## California Office of Public AdvocatePublic Report Card (www.opa.ca.gov)

## Print Copy Score Card

##  Presentation Topics

**IHA Pay-for-Performance program design**
**IT measures**
**Financial incentives**
**Public report cards**
**What has happened?**
**Changes in IT adoption over time**
**Relationship of IT to Performance**
**Physician Leaders’ Opinions**
**Summary**

## IT adoption increases each year

**By 2005, 33-44% of Groups and 68-76% of **
**Patients Had Data Integration Technology**

## More IT Functions are Adopted

**By 2005, 1-39% of Groups; 20-64% of **
**Patients had Point of Care Technology**

## 2004 Mean Information Technology Scores by Size of Group (max points=20)

|  | Total Physician Organization Enrollment |  |  |  | Pr>F |
| --- | --- | --- | --- | --- | --- |
|  | <15,000 | 15,000-25,000 | 25,000-50.000 | >50,000 |  |
| # Physician Orgs | 56 | 28 | 41 | 42 |  |
| Electronic Data for Care Management | 2.9 | 4.4 | 5.2 | 8.3 | *** |
| Tools at the Point of Care | 1.9 | 5 | 5.9 | 11.5 | *** |

***** <.0001 Significant difference in performance**

## IT Adoption May Be Related to Clinical Scores

## Physician Group Leaders Feel...

** ****IHA Program has compelled them to focus on quality**
**Has the attention of leadership**
**Allowed for resources to be targeted to these efforts**
** ****Believe they would have invested in IT without the incentive **
**However, incentives speeded the process up**
**Investments are costly and take years to implement**
**Smaller groups report worries of data capture and poor scores due to incomplete data**
** ****Return on investment is still negative**

## In Summary

** ****It is possible to incentivize adoption of IT ****	****	****through financial rewards**
** ****Better IT may be related to better clinical care **
** ****Physicians in CA acknowledge that IT is the ****	****	****way of the ****	****future**
**However, IT systems are expensive and difficult to implement**