Integrated Healthcare Association Research Articles

5099 Capturing the Patient Voice for Diabetes Eye Exams

Abstract Disclosure: S. Du: None. S. Lambrechts: None. M. Freeby: None. M. Han: None. Background: Diabetic retinopathy (DR) is a leading cause of blindness among adults 20-74 years old. Ophthalmic exams are recommended every 1-2 years for type 2 diabetes patients with minimal to no DR. The 50th percentile Integrated Healthcare Association benchmark for DR screening is 49%, but at our academic medical center, the completion rate is 30%. Potential barriers to screening noted in the literature include lower levels of education, lack of knowledge about DR, and financial barriers. Objective: To understand motivating factors and barriers to DR screening among patients in our health system. Methods: We utilized the Patient Voice qualitative research method to uncover themes and identify interventions to improve care delivery. The literature was synthesized to develop a structured interview guide. From our urban academic health system, 15 patients were randomly selected for interview, six of whom had completed the “Diabetes Eye Exam” care gap and nine that had not. Interviews were transcribed and coded for thematic analysis. Results: Six opportunity areas were identified. 1) There are currently only six retinal cameras located across primary and specialty care clinics serving more than 38,000 diabetes patients. 67% of patients felt the current clinic locations were inconvenient, with distant locations and long travel times. 2) 20% of patients expressed that they would like increased flexibility of appointments offered, such as evening, weekend, and same day appointments. 3) Patients were motivated by automated diabetes eye exam specific reminder messages and appreciated the ability to self-schedule within the patient portal. 47% of patients wanted yearly reminder messages, while 40% had no preference. 4) 53% of patients expressed that they did not fully understand DR or were confused about the difference between an optometrist exam and diabetes eye exam. 5) 40% of patients completed their eye exam with their local optometrist and found this to be a more convenient option. One patient expressed that she wished her doctor had informed her that she could complete her diabetes eye exam at a local optometry clinic. 6) If patients do choose to complete their exam with their local optometrist, they would like reminders to send their records to their primary care physician or endocrinologist. A more streamlined processes to upload outside records through the patient portal would decrease this barrier. Conclusion: It is important to engage patient stakeholders and understand their needs to improve overall experience and close care gaps. Through the Patient Voice, we learned that factors such as driving distance, traffic, scheduling, and issues with uploading records are major barriers to care gap completion. Convenient clinic locations, education, and reminder messages are motivating factors. Future work will focus on developing and implementing solutions in each opportunity area. Presentation: 6/1/2024

Sample selection in the face of design constraints: Use of clustering to define sample strata for qualitative research.

To sample 40 physician organizations stratified on the basis of longitudinal cost of care measures for qualitative interviews in order to describe the range of care delivery structures and processes that are being deployed to influence the total costs of caring for patients. Three years of physician organization-level total cost of care data (n=156 in California) from the Integrated Healthcare Association's value-based pay-for-performance program. We fit total cost of care data using mixture and K-means clustering algorithms to segment the population of physician organizations into sampling strata based on 3-year cost trajectories (ie, cost curves). A mixture of multivariate normal distributions can classify physician organization cost curves into clusters defined by total cost level, shape, and within-cluster variation. K-means clustering does not accommodate differing levels of within-cluster variation and resulted in more clusters being allocated to unstable cost curves. A mixture of regressions approach focuses overly on anomalous trajectories and is sensitive to model coding. Statistical clustering can be used to form sampling strata when longitudinal measures are of primary interest. Many clustering algorithms are available; the choice of the clustering algorithm can strongly impact the resulting strata because various algorithms focus on different aspects of the observed data.

Bundle Up for Savings

Bundle Up for Savings

Linking commercial claims and state registry data to assess cancer care quality at the medical group level: Early lessons from California.

269 Background: The Integrated Healthcare Association (IHA) is a non-profit organization which runs the largest Pay for Performance program in California. We describe a feasibility study to apply NQF cancer quality measures to linked commercial claims and state registry data and calculate results at the physician organization level. We describe phase I of the study: identifying appropriate measures and securing access to the data. Methods: We requested technical specifications for 9 NQF breast and colon cancer quality measures from the measure stewards and 2009 –2012 claims data from 7 California health plans. Results: Two barriers were identified in phase I: First, California Cancer Registry (CCR) data policies, designed for public health surveillance and not quality measurement, caused delays and present hurdles to public reporting. CCR data is not available until it is at least 95% complete, so 2011 data was not available until October 2013. Moreover, CCR requires that they conduct the data linkage, which required new data use agreements between the data aggregator and each participating insurer – costly in both time and legal fees. Finally, obstacles to public reporting any of the CCR data at the provider level still exist. Barrier 2: NQF measure specifications for linked claims-registry data sets do not currently exist, so the project team developed them, adding to the problem of proliferating non-harmonized quality measures. Conclusions: While the application of NQF measures to claims-registry linkage appears feasible for measurement of cancer care quality at the medical group level, registry policies and the lack of standard technical specifications for linked claims-registry data sets adversely impact the timeliness, usability, and comparability of results using two widely available data sources. More flexible policies on the part of data registries and attention to measure harmonization could improve data quality and usability for cancer care quality assessment and public reporting, and should be considered. In phase 2, we will apply the measures at the physician group level, and assess the feasibility of public reporting at the physician group level.

Bundled payment fails to gain a foothold In California: the experience of the IHA bundled payment demonstration.

To determine whether bundled payment could be an effective payment model for California, the Integrated Healthcare Association convened a group of stakeholders (health plans, hospitals, ambulatory surgery centers, physician organizations, and vendors) to develop, through a consensus process, the methods and means of implementing bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed in its goal to implement bundled payment for orthopedic procedures across multiple payers and hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as administrative burden, state regulatory uncertainty, and disagreements about bundle definition and assumption of risk. Ultimately, few contracts were signed, which resulted in insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. Although bundled payment failed to gain a foothold in California, the evaluation provides lessons for future bundled payment initiatives.

Status, Challenges, and Opportunities of the Delegated Model in California

Calif. J. Politics Policy 2014; 6(2): 237–239 Commentary Jill M. Yegian* and Thomas R. Williams Status, Challenges, and Opportunities of the Delegated Model in California Keywords: commercial insurance; delegated model; fee-for-service; Health Main- tenance Organization; transparency. DOI 10.1515/cjpp-2014-0018 California has long been known as a national leader in integrated medical care and delegating financial risk to provider entities. In recent years, however, the delegated model has been experiencing gradual enrollment decline in Cali- fornia’s commercial HMO and Point-of-Service (POS) market. Although enroll- ment in risk-based Medicare Advantage has been holding steady and managed Medi-Cal enrollment has been growing, shrinking commercial enrollment in risk-based models raises the possibility that California could lose the benefits associated with investment in coordinated care that have been painstakingly gained over the last couple of decades. To illuminate the status and prospects for the delegated model, we review current data on risk-based commercial enroll- ment, reasons for the decline, and opportunities in the current environment. These issues must be addressed if the vision outlined in the Berkeley Forum Report is to be achieved. Data from the Department of Managed Health Care (DMHC) show a decline in the number of commercially-insured Californians enrolled in “risk-based organi- zations,” (physician organizations that contract with health plans) from approxi- mately 5.5 million to under 4 million between 2008 and 2012 (see Figure 1). Of note, DMHC’s definition of risk-based enrollment does not include integrated medical group enrollment, such as Kaiser. In contrast with the decline in com- mercial “risk-based organization” enrollment, Kaiser, which comprises approxi- mately 40% of California’s commercial market, has maintained steady enrollment over the last several years (California HealthCare Foundation 2013). *Corresponding author: Jill M. Yegian, Integrated Healthcare Association, Oakland, CA, USA, e-mail: jyegian@iha.org Thomas R. Williams: Integrated Healthcare Association, Oakland, CA, USA

Improving the value of healthcare delivery using publicly available performance data in Wisconsin and California

The healthcare industry must change in order to provide higher quality care and lower costs for patients; one method to improve both cost and quality used in Wisconsin and California is leveraging publicly reported claims and costs data. Wisconsin has been building comprehensive, publicly available clinical and administrative data sets: the Wisconsin Collaborative for Healthcare Quality (WCHQ) established in 2003 and the Wisconsin Health Information Organization (WHIO) established in 2009. The WCHQ and the WHIO allow physician groups to compare themselves with one another on cost and quality across 920 distinct episode treatment groups (ETGs). The ETGs include all components of care for a specific disease during a defined period. Since 2002 California has developed public reporting of quality data for physician groups and health plans through its Integrated Healthcare Association (IHA) and since 2008 its Right Care Initiative (RCI). In both states these data are used to identify best practices and opportunities for improvement, enhance care outcomes, and increase value for patients.

Do Physician Organizations Located in Lower Socioeconomic Status Areas Score Lower on Pay-for-Performance Measures?

Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs. To examine the association between PO location and P4P performance. Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S. 160 POs participating in 2009. We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use. The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001). Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.

Building a National Payment System

Integrated Healthcare Association, Oakland, California. Corresponding Author: Thomas R. Williams, MPH, MBA, Integrated Healthcare Association, 300 Lakeside Dr, Ste 1975, Oakland, CA 94612 ([email protected]).

Taking Stock Of Pay-For-Performance: A Candid Assessment From The Front Lines

Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician organizations involved in the California Integrated Healthcare Association's (IHA) P4P program reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened their organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. Continued monitoring is required to determine whether early investments made by physician organizations provide a basis for greater improvements in the future.

Assessment of Healthcare Utilization Associated with Integrated Healthcare Association's Pay For Performance (P4P) Asthma Measure, Appropriate Use of Rescue Inhalers

Using the 2005 HEDIS definition, patients who received appropriate asthma treatment had increased rates of asthma-related hospitalizations/emergency department (ED) visits compared to those who did not receive appropriate treatment. We assessed the association between IHA's P4P measure, Appropriate Use of Rescue Inhalers and asthma-related hospitalizations/ED visits.

Pay for Performance: Where's The Return?

BACKGROUND: Pay for performance (P4P) initiatives are designed to foster and reward improvement in health care delivery. These programs promote “value-based health care” by rewarding quality care that is characterized by a reduced amount of disproportionate spending. OBJECTIVE: To review the intent and design of P4P initiatives as well as the design and results of P4P programs in current practice. SUMMARY: Three key principles are fundamental to building a value-based health care system: measurement, transparency, and accountability. There are several levers currently driving P4P, each influencing the movement in its own way. Among these are employers, federal agencies such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, health plans, providers, accreditors, and Congress. One key player in the P4P movement, the National Committee for Quality Assurance (NCQA), is a private, independent nonprofit health care quality oversight organization that measures and reports on health care quality and unites diverse groups around a common goal: improving health care quality. NCQA, has demonstrated several successful provider-level measurement initiatives connected to P4P programs, notable among them Bridges to Excellence programs in several markets, physician recognition programs, the Integrated Healthcare Association’s P4P initiative in California, the National Forum on Performance Benchmarking of Physician Offices and Organizations, and health plan accreditation. CONCLUSIONS: The initial data from developmental P4P programs across the nation have indicated that both financial and nonfinancial incentives motivate significant change in health care delivery, but the return on investment of these initiatives is not yet known.

Performance-based measures: the early results are in.

Pay for performance (P4P) initiatives are designed to foster and reward improvement in health care delivery. These programs promote "value-based health care" by rewarding quality care that is characterized by a reduced amount of disproportionate spending. To review the intent and design of P4P initiatives as well as the design and results of P4P programs in current practice. Three key principles are fundamental to building a value-based health care system: measurement, transparency, and accountability. There are several levers currently driving P4P, each influencing the movement in its own way. Among these are employers, federal agencies such as the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, health plans, providers, accreditors, and Congress. One key player in the P4P movement, the National Committee for Quality Assurance (NCQA), is a private, independent nonprofit health care quality oversight organization that measures and reports on health care quality and unites diverse groups around a common goal: improving health care quality. NCQA, has demonstrated several successful provider-level measurement initiatives connected to P4P programs, notable among them Bridges to Excellence programs in several markets, physician recognition programs, the Integrated Healthcare Association's P4P initiative in California, the National Forum on Performance Benchmarking of Physician Offices and Organizations, and health plan accreditation. The initial data from developmental P4P programs across the nation have indicated that both financial and nonfinancial incentives motivate significant change in health care delivery, but the return on investment of these initiatives is not yet known.

Pay-for-Performance: At Last or Alas?

Pay-for-Performance: At Last or Alas?

Pay for Performance: At Last or Alas?

Pay for Performance: At Last or Alas?