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Worcester Medicine Pay for
Performance - So Now What Do We Do? From The Editor
A Message from the President
P4P - A
Harbinger of the Future or the Fad du Jour?
Pay for Performance
The Business Case for Quality Aligning Incentives through Pay for
Performance Initiatives
Central Massachusetts & P4P - What is CMIPA Doing About It? Why We Need an
Alliance
The
Harvard Pilgrim Health Care Quality Advance Program LEGAL CONSULT WDMS
Remembers its Colleagues
Pay for Performance -
So Now What Do We Do? Dr. Lindblad, Associate Editor for this issue of Worcester Medicine, is a founding partner of Primary Physician Partners, St. Vincent Hospital, Worcester. With Pay for Performance, we are trying to make changes in a system of care that hasn’t really changed the way we do business in over 50 years. Most physicians and health care leaders agree that the systems at work in the health care industry are outmoded and in need of major change. But most disagree on what approach will work best. According to the Institute of Medicine’s report “Crossing the Quality Chasm,” in order to improve physicians and health care leaders must: •Redesign care processes Pay for Performance is trying to push the system toward these goals, but are organizations and physician behaviors fundamentally changing? I am reminded of Benjamin Franklin’s definition of insanity: “Doing the same thing over and over and expecting different results.” So are we doing the same things over and over again only with different packaging on the outside? Some important questions about Pay for Performance are raised: Do only physician behaviors need to change? Will there be standardization of measures and
incentives by payor? Are local health care organizations working together to
eliminate duplication of resources? Are they coordinating care and
collaborating to deliver the best possible care to the populations they
serve? None of these articles mentions collaboration amongst organizations, but in reality we all are dependent on each other to deliver good quality of care to our collective population of patients. Where is the forum for all organizations supplying healthcare to our communities, a forum for collaborating on and coordinating technology and care, for advancing the effectiveness of teams, redesigning care processes, and managing the growing knowledge base? The way the Pay for Performance movement stands now, each group will get paid for its own individual performance and for using different methods and working on different HEDIS (Health Plan Employer Data and Information Set) measures, and each will receive different payment by the payors ~ all the while expecting different results. Maybe Ben Franklin was right. From The Editor At this early point in my editorial career, I have come to agree with Ogden Nash, who said that “Progress might have been all right once, but it has gone on too long.” This issue continues our transition into the new Worcester Medicine. For starters, it is the last of our three month production cycles and the first of our two month cycles. We will release the magazine in November, January, March, May, July and September. This increased frequency will allow us to discuss “hot” issues in a timelier manner. In addition, we will increase the size of the issues to accommodate fuller coverage of the chosen topics. From hereon in, most issues will have an Associate Editor in charge of obtaining articles and overseeing the creation and release process. I’d like to thank Peter Lindblad, M.D. for taking on this issue’s topic of Pay for Performance and for instituting the model for future Associate Editors. We plan to establish a regular list of features in order to expand our coverage and several of those columns are already in place: Legal Consult, As I See It, Letters to the Editor and Society Snippets. Creative Writing, Science Corner, Healthcare Controversies in Worcester and Off Call (focusing on the non-business side of our lives) are all under consideration for inclusion starting with the next issue of Worcester Medicine. To assist us in designing the Off Call feature, we have sent a survey out to our membership to determine the scope of our hobbies, sports, interests, etc. As always, I invite feedback from our readership on current articles and suggestions for future articles and features.
A Message from the President Pay for Performance is the featured topic for this issue of Worcester Medicine. Our intention is to examine how P4P will affect medicine in Central MA. As a district medical society, let’s consider the effectiveness and ethical appropriateness of providing physicians with financial incentives when they demonstrate improvements in clinical performance. While I understand that financial incentives for physicians have been in place for several years, I think ongoing surveillance of their impact on the quality of patient care is required. Questions that come to mind include: What kind of behavior should be the focus of the incentives? Should it be evidence- based practice patterns, patient satisfaction with regard to interaction with the physician, or clinical outcomes over time? What instruments and methods are going to be used to assess performance? Will surveys be sent out, will assessors observe patient-physician interactions or will retrospective chart revenues be conducted by specialty-trained personnel? Can the assessment tools be manipulated by a payer or licensing body to mandate shortened visit times, discourage the use of diagnostic tests or expensive treatment modalities, or ~ in the worst scenario ~ discipline physicians unjustly. As physicians, we must always remember that we are our patients’ advocates. Every patient is unique in genetic makeup, the presence of co-morbid medical conditions, and psychosocial conditioning. The patient’s physician must make risk-benefit assessments when considering the approach to each new complaint in the context of what is known about the patient and his or her family. The extent to which financial incentives can avoid interfering with these assessments while encouraging deliverance of compassionate, high-quality care will determine whether such incentives will lead to improved patient outcomes.
P4P - A
Harbinger of the Future or the Fad du Jour? Pay for Performance is the latest spin on physician rewards. The concept is an admission that the fee-for-service system does not require doctors to measure their performance. We all know we can’t manage what we don’t measure. Further, while some HMOs and physicians do measure, the HMOs are not large enough to control physicians’ behavior in the medical marketplace by requiring electronic medical record keeping (including electronic management and measurement software), convincing physicians to adopt performance goals, and changing physicians’ focus on their patients from episodes of care to “health.” The basic premise of pay for performance is that health plans (whether Medicare or private) pay doctors extra for outcomes. You and I both know that Six-Sigma in a manufacturing process guarantees a better product. Physicians argue that even though they do everything properly, such as treat cholesterol to goal, it does not ensure that patients won’t have heart attacks or strokes. However, Health Partners in Minneapolis was a pioneer in paying doctors bonuses for treating diabetics’ blood sugars and cholesterol levels to goal, getting them to stop smoking, and getting them to take aspirin daily. Over six years (1997- 2003), the percentage of patients who met all criteria more than tripled, rising from 5% to 17%. The Centers for Medicare and Medicaid Services (CMS) have started a 3-year pilot project with 10 medical groups to test paying physicians based on their results “rather than just their time.”1 The federal government will pay standard fee-for-service (FFS) rates and will determine bonus payments for the physician groups based on their meeting 32 quality benchmarks (like managing diabetic patients’ blood sugars) and reducing the cost of caring for an assigned patient population, many of whom have chronic diseases.2 This is good – we’re after quality. However, 70% of payments in the first year are linked to “efficiency” (read cost savings), dropping to 60% the second year and to 50% the third year of the project. Here’s where it gets interesting. The driving force behind this project is David Cutler, best known as the key author of Hillary Clinton’s aborted attempt at a health care bill about 11 years ago. That attempt to limit spending by mandatory caps had to result in limiting service – unacceptable. HMOs succeeded for a while, but Americans “did not want health-maintenance organizations to limit their choices any more than they wanted the government to.”3 Now Cutler urges us to improve the quality of care. Rather than reduce the amount of care or the cost, he wants to use the money to persuade us to do “everything the patient needs and nothing the patient doesn’t need.” Kaiser Permanente and General Electric are already doing this; they’re focusing on quality. Cutler showed how Medicare’s changes in hospital compensation resulted in shorter patient stays, simultaneously demonstrating physicians’ and hospitals’ responsiveness to incentives. Yet those changes have not resulted in deterioration of care. To the contrary, myocardial infarction survival has improved significantly over the last 10 years. The cost has gone up, but that increase is related to significant benefits. Likewise, the cost of treating congestive heart failure with a complex pharmacopoeia of targeted drugs and implanted devices has gone up, but survival and the quality of survival have improved as a result. So the solution sounds intuitive and easy! Yet a study by the RAND Corporation showed that people get only 55% of the care recommended for them. Doctors prescribe pills people don’t take, blood sugar monitoring they don’t perform, and physicians themselves don’t consistently prescribe beta blockers and aspirin after myocardial infarction. A study I did (in a former life) showed that about 85% of eligible MI patients got aspirin and about 75% got beta blockers on discharge. Those percentages might sound good, but think about this: How many of you would get on a Boeing 737 to travel to Chicago from Boston if there was a 75% chance the pilot would check the oil pressure in the port engine? I used that analogy as my team worked to improve the results. Then, in March 2004, in the New Orleans airport, I sat in that plane at the gate. Twenty minutes past pushback time, the pilot came on the overhead and announced there was a problem with the oil pressure reading from the port engine and the mechanic was on his way. The problem was fixed and we were on our way 40 minutes later. Anyone want to take off without checking? Anyone with a myocardial infarction want to be discharged without a proven life-saving medicine being ordered? Donald Berwick (who runs the Institute for Healthcare) conducted a trial for six hospitals and one HMO that resulted in halving MI mortality in two years at Tallahassee Memorial Hospital and in other measurable benefits. I measured time to antibiotics for patients being admitted with pneumonia in 2003. It was seven hours, despite evidence that there is survival benefit to giving the drugs within four hours. Within six months of measuring this data, we had the time down to under two hours average, with no one waiting more than four. Measurement, benchmarks, and a process yielded results. Are health care firms implementing pay for- performance systems? P4P has been around for over ten years according to Geoffrey Baker, CEO and founder of Med-Vantage, Inc., a software and research company that helps build performance scorecards and P4P programs. He estimates that close to half of insurers operate P4P programs, and locally FCHP, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim, and Tufts have some pay-for-performance arrangements. Their arrangements include the simple (HEDIS measures, generic prescribing) and the complex (using computer information technology, meeting complex formulas for outcomes and resource use). Blue Cross Blue Shield of Massachusetts claims that providers who participate in its P4P programs will earn $18.7 million in incentives this year. Then why are more plans not offering them? First, let’s go back to the Park Nicollet example. Health Partners’ investment was only marginally worthwhile. It recouped some of its investment, but since people change jobs and insurers, many financial benefits went to another organization. Ultimately, if managed long-term, the benefits go to Medicare, not Health Partners (or any other insurer willing to invest.) Health Net Inc.’s subsidiary in Connecticut is launching a P4P program for primary care physicians and specialists measuring diabetes treatment, breast cancer screening, and immunization rates, with the first payout due next year. MVP distributed P4P payments in Vermont – up to 8% of the usual reimbursement. The Blue Cross Blue Shield Association claims BCBS plans have implemented P4P in 32 states with 14 more on the near horizon.4 Kaiser Permanente pays its physicians a fixed salary with a bonus tied to performance measures. Data suggests improvement in patients’ health. G.E. is splitting with physicians the savings from better management of diabetes and heart disease. The amount of money is small, but measurable. On the other hand, The Wall Street Journal on September 17, 2004 reported that the top rated doctors out of the 45,000 participating in 6 California health plans would split a bonus pool of $40 - $60 million, roughly $1000 per participating physician. The actual bonus would depend on what percentage of those physicians wound up getting bonuses. On July 7, 2005, Blue Cross of California announced it was paying out $72 million to 196 participating physician groups in the state (sorry – not physicians, but groups). That’s about $370,000 per group. If Fallon Clinic got that, it would equate to about $1500 per physician for the year – not an overwhelming financial incentive. And by the way… according to Scott Smith in Minnesota Medicine, Park Nicollet “does not plan to disburse payments directly to physicians.” The AMA has approved principles and guidelines for pay-for-performance programs. The committee was insistent that “the patient remains the focus and the outcome is quality, using relevant quality-improvement measurements.”5 The AMA’s main reservations involve its opposition to CMS’s physician payment formula, especially the formula for calculating “sustainable growth rate.” This compensates for increases in utilization of services by forcing a reduction in physician payments. Since P4P programs ought to increase the volume of appropriate services, the payment formula would penalize the appropriately motivated and performing physicians more than the P4P incentives would pay them! Still, I haven’t yet met the physician who feels he/she’s overpaid for his/her work, and P4P is a way to augment current payment schedules. Now we’re set: We’ve got performance goals, participating insurers, and money to pay physicians for good practice. Is this too good to be true? Some people have advocated caution. Roy M. Poses, M.D., of Brown University Center for Primary Care and Prevention, noted that while “physicians must engage with the proponents of pay-for-performance…there are a number of important issues they will have to bring up if this movement is to have any net benefit for patients, and at least not heap further misery on physicians.”6 Sicker patients have worse outcomes. Will P4P programs guard against the moral hazard to create incentives for physicians to select healthier patients and avoid the sicker ones? Dr. Poses and his colleagues noted that the “Results of Report Cards for Patients with Congestive Heart Failure Depend on the Method Used to Adjust for Severity.”7 They compared survival in congestive heart failure in a community hospital, a VA medical center, and a university center – and the outcome of simulated report cards depended on the method used to adjust for severity; in other words, they could choose their results based on the measurement tool! If physicians focus on a few measures (OK, not always a few, sometimes many) will they lose sight of other variables that might impact their patients more? As I questioned earlier, is P4P really about quality or is it about saving money for commercial insurers? United Health rates efficiency as high as quality. “Efficiency” may mean funding its own internal goals rather than funding patient care. Please note that, with a few exceptions, the focus is on ambulatory care, especially primary care. Haven’t we put enough burden on “PCPs?” I agree it’s important for primary care physicians to provide quality care, but how does the American College of Physicians and participating commercial managed care companies – in their partnership in the Ambulatory Care Quality Alliance on Guidant Corporations – producing defective implantable cardiac defibrillators at over $25,000 each and then covering up their risk of failing fit in? Someone please explain the “quality” and “efficiency” in that process, and then explain why we haven’t heard from the health plans about it. Medicare and many health plans have been paying millions for vertebroplasties8, the effectiveness of which has not been proven (and in fact has been called into question by University of Virginia Health Systems researchers whose preliminary study showed equally good results with placebo treatment), yet Medicare wants to further reduce how much it gives primary care physicians in compensation. A weakness in this entire process is the failure to consistently define “performance.” Performance should be quality. If you agree with me that quality is a combination of access, clinical performance, patient service, and the Institute of Medicine’s goal of “efficiency,” and that clinical quality consists of consistent reproducible evidence-based prevention, detection, evaluation, and management of disease, then payors need to expand the process. I suggest that the expansion include measurement of all of the above, with P4P for access goals and patient satisfaction scores, fulfillment of clinical quality goals, and utilization of electronic health records to facilitate measurement and compliance. Finally, Medical Rants (online) noted from the American College of Physicians that “the quality train has left the station.” I think experts had similar comments about B2B (remember that one from 5 years ago?), dot coms, fiber optics, telecommunications, and, closer to home, large integrated delivery systems (like Allegheny Health Education and Research Foundation, which not only went belly up, but also saw its CEO, Sherif Abdelhak, put in jail) and physician management corporations (citing “successes” such as MedPartners and Phycor). My questions then are: Should we participate in the process? Should we compare goals to evidence-based medicine? Should we be skeptical and critical every step of the way? Should we provide a reality check when the insurance industry runs amuck? Should we accept P4P money for doing what we all should be doing anyway? Yes. Caution! Pay-for-performance is “in,” but there is no guarantee that it has legs. We have accountability as physicians to contribute to the discussion, ask probing questions, compare goals to our best medical evidence, and provide the best possible care for our patients without diluting our already stretched ability to provide high quality care and access and without selling our principles for the appeal of P4P dollars. Marc Greenwald, M.D., is Chief Medical Officer at Fallon Clinic, an internist, and a former critical care internist.
1Minnesota Medicine, v88, July 2005 Pay for Performance “Payment for Performance” (P4P) is a new phrase that refers to the concept of providing financial incentives for improving clinical performance. While the phrase itself may be new, the practice of payment for performance is not. Fee for service pays for performance where performance is measured primarily by productivity ~ the amount of service provided. The newly enhanced concept of P4P seeks to reward other aspects of performance such as evidence-based practice, efficiency in resource utilization, patient experience, and investment in information technologies. In theory, better quality services provide more benefit to patients, are worth more, and should therefore be more highly reimbursed. Improving clinical performance requires investments that can sometimes lead to reductions in revenue for the providers of service. As such, traditional reimbursement models have been blamed for perpetuating incentives contradictory to investment and innovation. The current P4P movement is designed to shift incentive to the newly valued aspects of performance (as above). How is it
going to effect your organization? What are you
doing about it? Measurement of performance can be labor intensive and very costly. However, recent improvements in the measurement of evidence-based practice, using claims data, has made such measurement feasible despite acknowledged limitations of this data source. These data can also be used to identify patients due for services and to facilitate population-based interventions. UMass Memorial Health Care has recently contracted with MedVentive, a leading medical informatics company, for the use of their sophisticated information systems. These systems will give us the ability to provide performance feedback to physicians at multiple levels of analysis and to identify patients due for services so that practices can efficiently intervene. These interventions will result in better patient care, better performance on P4P measures, and better reimbursement. We are also in the process of negotiating new contracts with payers of which P4P is an important component. We expect that the Centers for Medicare and Medicaid Services (CMS) will expand existing P4P features in the near future at the direction of Congress. We are preparing for this scenario. How is it
going to affect medicine in Worcester?
The Business Case for Quality Aligning Incentives through Pay for
Performance Initiatives Health care providers and organizations agree that providing high quality care is our highest priority and most significant responsibility to our patients. Historically, though, adherence to those ideals has been difficult to prove. The Pay for Performance movement is creating a demand to do just that - prove that we provide our patients with the best possible care. What is Pay
for Performance Although the Pay for Performance train is moving rapidly now, it has been evolving over the past couple of years through a number of phases. Development
of Measures and “Voluntary” Public Reporting Survival of
the Fittest As practicing physicians, your clinical decisions and actions have a significant impact on the performance reported by each hospital with or at which you work. Are your patients screened and immunized for pneumonia and influenza? Do your heart failure patients receive written educational instructions on diet, activity, and weight monitoring? Do you counsel your patients not to smoke? The clinical actions you take, as well as your documentation, are critical to the hospital’s ability to demonstrate quality of care. From a Quality Management perspective, the pay for performance movement is a helpful motivator. The combination of public reporting, competition, and financial incentives has captured the attention of clinicians and hospital administrators who want to know what our current performance is, if we are improving, and if not, what needs to be done. This level of leadership support is critical for aligning resources within the hospital to focus on improving clinical care. An equally important factor for successful improvement is the ability to engage physicians as champions for change. While the influence of Pay for Performance is making an impact, there are significant challenges associated with it. CMS is not the only payer on this bandwagon; in fact, it’s starting to get a little crowded. Each payer’s plan includes its own set of requirements, performance measures, incentives and timelines. The impact is that hospitals are challenged to keep up with the requirements for data collection and reporting. The subsequent ability to drive clinical care improvements is made even more difficult since resources to do so are diluted amongst many priorities. Hospitals are not the only ones who need to be concerned with this new movement. The Physician Pay for Performance train is leaving the gate and will certainly have its own share of challenges to overcome. The American Medical Association has been actively involved in efforts to promote guidelines for implementation to ensure that a fair process is applied. The good news is that all of this attention has validated quality as the most critical priority in health care. All eyes are on the numbers to make sure that positive changes in clinical care are the net result. When that happens, everyone wins. Worcester District Medical Society: I have been a colleague of Marjorie Clay, PhD’s for the approximately 14 years that she has been at University of Massachusetts Medical School. I greatly admire the knowledge and skill she displays in her capacity of Ethicist for the Medical Center. I have had the privilege and pleasure of teaching with her many times. Therefore, I quickly turned to her article on stem cell research in the current [July] issue of Worcester Medicine. As usual, Marjorie had done a spectacular job articulating the conflict and smoothing the rough edges of the polarizing arguments that have been getting media attention over the past few years. I believe this article has a thoughtful and rational basis for bringing the opposing sides closer together. I also believe that the article needs and deserves a much more widespread distribution. Is this possible? Sincerely,
I thought the article on stem cell research by Dr. Clay in the recent Worcester Medicine was very illuminating. She managed to take a highly emotionally- charged and misunderstood issue and explain it clearly and simply! We should all look for ways to share her insight with the larger public. Sincerely,
Central Massachusetts & P4P - What is CMIPA Doing About It? Introduction Every decade, the healthcare industry develops a new paradigm for reducing costs. During the 1980s, cost containment focused on utilization. Utilization review agents, lacking appropriate knowledge, would overturn the attending physician’s clinical decisions. This intrusion infuriated physicians and consumers alike while doing little to control health care costs. The utilization review world soon morphed into managed care. Managed care promised to reduce costs and improve quality through high performing, tightly managed networks. Primary care physicians (PCPs) were paid a “gate keeper” fee and physician groups shared in financial risk. While the physician fees were put at risk through withholds and/or capitation payments, physicians could earn surplus money if they performed well against a global budget. After several physician groups filed for bankruptcy as a result of poorly devised financial risk sharing arrangements and a few high profile managed care lawsuits made headline news, a backlash against “managed care” erupted. Smart HMOs shifted their strategies from regulating physician performance to incentivizing physicians to invest in information technology. Most insurance companies have diverted their efforts to advanced quality measurement, disease management, and pay-for performance programs. While advanced quality measurement and disease management programs have not been fully introduced in the marketplace, pay-for-performance (P4P) programs have taken center stage as the new panacea for reigning in costs. What is P4P? The proponents of P4P argue that these incentive payments and improved information systems will lead to improved population management. Physician
Concerns with P4P Programs One hurdle is the lack of standardization of payment incentives among the insurance companies. It would be easier for an Independent Physician Organization (IPA) to implement 5 HEDIS measures for their entire patient population than to implement several different incentives which vary by payor. Furthermore, the data provided by the payors are woefully inadequate because they do not measure content of care and report on the previous (rather than current) year’s performance. Finally, payments are not frequent enough to capture the physician’s interest. If P4P programs are to survive, payors will need to pay physicians bonuses more frequently, provide the IPAs with more timely data, and cooperate in developing a common set of measures and incentives. It is critically important that payors identify the right number and type of meaningful measures to actually improve care. The number of patients at the group and individual level, even with pooled data, must be statistically significant and the measures must be equally relevant to PCPs and specialists (SCPs). Many surgical organizations have argued that the measures at the primary care level are not easily transferable. They claim that surgery is more episodic and less focused on chronic disease management, preventative services and screening. Specifically, they argue that current disease management strategies are not relevant to surgery because, unlike primary care, surgery requires incentives that focus on short term results — the right procedures, at the right time, for the right patient — rather than on a broad quality measurement. Equaling challenging is that individual physicians and specialties are in different stages of preparedness for participation in meaningful P4P programs. Some individuals do not have access to sophisticated information technology. Finally, there are the financing issues — will additional money be made available for positive incentives, or will there be a revenue-neutral system in which some providers get more money while others less? Physicians have requested that insurers allocate additional monies for P4P initiatives (funding above and beyond what would normally be budgeted). How is P4P
going to affect medicine in Central Massachusetts? More information will be shared with consumers regarding a physician’s performance or costs attributed to his/her panel. This disclosure can be frightening, particularly if the data is skewed, inaccurate or misleading. Consumers may switch physicians who have higher costs assigned to them, especially if they are being charged higher co-payments or increased premiums for continued access. This switch may cause PCPs to become more selective about specialty referrals, perhaps allowing cost to be a major deciding factor in to whom they refer cases. What is
CMIPA doing about it? At CMIPA, we are helping our members track their patients through a number of initiatives. We have encouraged them to purchase EMRs – and have reviewed EMR systems on their behalf — and have developed standards to evaluate the existing programs. To date, CMIPA has achieved the following: 1) Instituted grant programs to fund internet access and EMR purchases (a program partially sponsored with support from Fallon Community Health Plan) 2) Entered into an agreement with eClinicalWorks to create a Web-Based Patient Registry to allow for data analysis to support outcomes and P4P objectives 3) Built a website to facilitate communications and reporting 4) Developed a claims-based data warehouse with disease registries for asthma and diabetes By the end of this year, we will launch a Mammography ordering & tracking center. We are also working with the MassPRO to connect raw data from a member’s EMR to CMIPA’s data warehouse and then to transmit the aggregate or patient identifying data to CMS. Through the MassPRO, we have enrolled some of our physician practices in the Bridges to Excellence program, which pays physicians’ offices up to $50 per year for each patient covered by a participating employer or plan. In addition, CMIPA is working with the insurers to promote principles for profiling and to ensure that reporting is clear and fair. We have also created an internal mechanism to define common measures for CMIPA members at the individual physician group or POD level. To succeed under P4P programs, physicians will need to be part of organizations that will provide them with the tools and data so that they can practice with the best available technology and most up-to-date clinical information. Why We Need an
Alliance As the new President of the Worcester District Medical Society Alliance, I have been trying to articulate just why the Alliance has any relevance in today’s world, a world in which many organizations are experiencing a decrease in their memberships while only some are flourishing. What makes an organization healthy and dynamic? Short of providing airline miles and discounts on purchases, I think any organization that wants to stay relevant has to fulfill a need for its members. When the Alliance was formed over fifty years ago, its mission was defined as: “To promote the health of the citizens of Massachusetts and to advance the health and wellbeing of the medical family.” Promoting the health of the community is the easier task since the problems are so clearly outlined for us; television, newspapers, and magazines tell us all what the health issue of the moment is. Promoting the health of the medical family, however, is a little more complex. First of all, identifying the problems of the medical family can be difficult since we do not see ourselves objectively and therefore sometimes do not see the changes and problems that are occurring. Because everyone ~ no matter what their age or profession ~ is affected by health care, there are many forces affecting medicine other than just the day to day practice of dispensing care. State governments make laws about the practice of medicine and the federal government makes laws about medicine. Insurance companies make decisions about “worth” and reimbursement. Ethicists make decisions about the moral aspect of medical practice and research. Lawyers and juries make decisions about the standards and practice of medicine. The Alliance then needs to be an educational and support group because all these entities affect the “health and wellbeing” of the entire medical family. Arming ourselves with knowledge of the current laws and issues affecting medicine has never been more important. Not only is the Medical Society Alliance the vehicle for getting information, it also can be a vehicle for educating and affecting the direction of medicine. As I see it, the medical family is responsible for staying abreast of medical progress and changes and the Alliance is the organization that should facilitate the honoring of that responsibility. I have been married to a physician for 25 years and it is amazing at this juncture to have children and nieces and nephews who are considering medicine as a career. What they may face over the next 25 years could be incredible. Gene therapy and robots might be commonplace. But one truth probably will not change ~ when there is a physician or 2 or 3 in the family, the whole family will somehow be affected.
The
Harvard Pilgrim Health Care Quality Advance Program As managed care contracts have moved away from traditional risk-sharing or capitation models, Harvard Pilgrim has turned toward other payment incentives. Our incentives, tailored for local care units (LCU), include pay for performance programs that are focused on rewarding an LCU and its physicians for factors within their control, including quality of care and efficiency around specific areas of care. Pay-for-performance is nothing new to Harvard Pilgrim. We’re already well into planning for the fourth year of our Quality Advance Program which we’re committed to fostering and improving for the long term. One way we’ve ensured the success of the program is by streamlining our contracting model and adding a quality component. We made this modification in response to the need for a program that was simpler and more effective ~ one that recognizes and rewards physicians’ performance while at the same time allowing them more control over the care that they provide to our members. The Quality Advance Program includes several incentive-based components available to LCUs of varying current provider contracts and of varying practice size and type, such as adult or pediatric. The current Quality Advance Program includes incentives for adult clinical improvement practice measures such as radiology and laboratory services management, asthma management, diabetes testing, and antidepressant management, all of which reflect ongoing Harvard Pilgrim quality initiatives. For pediatric practices, measures include asthma management, chlamydia testing, and improvement of care for antibiotic use and patients with Attention- Deficit/Hyperactivity Disorder. Other incentives offered to clinicians and LCUs as part of Quality Advance this year include investments in Clinical Information Technology (CIT) like basic registry, electronic registry and electronic record functions. Future versions of QAP will build on the success of the current model. We will attempt to include more outcome- based measures and will continue to reward high-quality care.
The Legal Perils of "Pay
for Performance" The effort to encourage physicians to render more effective and efficient care, reflected in various “pay for performance” initiatives by payers, has also taken the form of hospital-sponsored “gainsharing” programs. While there are important legal differences between the two concepts, the legal analysis applied to gainsharing programs sheds light on issues raised by “pay for performance” arrangements. In particular, recent government approvals of gainsharing programs impose important requirements that address concerns expressed about “pay for performance” arrangements. Typical “pay for performance” programs adopted by health plans seek to reward physicians for such actions as timely screenings and immunizations, for ensuring that patients have positive experiences with aspects of their care like wait times and physician-patient communication, and for making investments in available information technology like electronic decision-making tools. Much discussion has taken place regarding how to write guidelines with appropriate flexibility while fairly tying them to financial incentive programs, how to assign credit for compliance with such guidelines where multiple caregivers are involved in the care of a single patient, and whether the performance standards are selected more for ease of measurement than for value. The legal analysis of “pay for performance” arrangements turns on whether they reward physicians for reducing or limiting medically necessary services to patients. For example, Massachusetts law prohibits any health insurance contract provision calling for a “specific payment made to a health care professional as an inducement to reduce, delay or limit specific, medically necessary services covered by the health care contract.” Gainsharing programs usually refer to arrangements between hospitals and physicians in which changes in the physicians’ clinical practices lead to lowered hospital costs which are then enjoyed by the other physicians. For example, in one gainsharing program involving cardiac surgeons the hospital and physicians share the savings resulting from such practices as opening packaged items only when they’re actually needed, the substitution of less expensive clinically insignificant supplies, and the standardization of certain cardiac heart valves. As with “pay for performance” schemes, the legal analysis of gainsharing arrangements focuses on inducements to physicians to limit patient care. Federal law imposes a maximum civil monetary penalty of $2,000 per patient on a hospital making, and a physician receiving, any payment as an inducement to reduce or limit services to any Medicare or Medicaid fee-for-service patient under the physician’s direct care. Over the past year, the Office of Inspector General of the Federal Department of Health and Human Services has expressed concern over not only whether gainsharing arrangements cause stinting on patient care, but also over whether such programs lead to “cherry picking” healthy patients, payments for patient referrals, unfair hospital competition and violation of the private inurement and private benefit prohibitions applicable to tax-exempt hospitals. Despite these issues, the OIG has recently approved a number of gainsharing arrangements that feature safeguards to minimize liability under the civil monetary penalty statute. The same types of safeguards also relate to concerns expressed about “pay for performance” programs. One safeguard imposed on gainsharing arrangements is that the cost-saving actions and resulting savings are clearly and separately identified. One purpose of this requirement is to ensure individual physician accountability for any adverse effects of the arrangement. One criticism of “pay for performance” programs is that they assign credit to individual physicians for improvements in clinical performance. Another set of gainsharing safeguards requires both credible medical support, periodically reviewed, that the arrangement will not adversely affect patient care and the use of objective historical and clinical measures that establish baseline thresholds below which savings are not counted. In other words, the program would be monitored continuously to ensure that no medically necessary services are denied patients. The implementation of these safeguards would respond to federal and state prohibitions against denying or limiting such services applicable to “pay for performance” programs. With respect to the product standardization aspect of the approved gainsharing programs, another safeguard imposed by the OIG is that physicians are able to make patient-specific determinations as to the most appropriate device to use, and that the full range of devices will still be available despite the product standardization. The goal is to produce savings through inherent clinical and fiscal value and not by restricting physicians’ choices. In this way, the gainsharing legal analysis seeks to accommodate the difficulty of establishing flexible yet meaningful clinical measures, an issue encountered in “pay for performance” arrangements. The OIG’s recent approval of various gainsharing programs noted that each program violated the civil monetary penalty statute prohibiting payments for limiting medical care to certain Medicare and Medicaid patients. Nevertheless, each program contained safeguards that increased the transparency of the program, both through specifying clinical actions and by requiring verifiable cost savings attributable to those actions. These safeguards are relevant to concerns surrounding “pay for performance” arrangements. WDMS
Remembers its Colleagues Philippe W.
Ouellette, MD On a sunny morning in May, family, friends, colleagues and one-time patients gathered in Our Lady of the Assumption church in Millbury to celebrate the passing into eternal life of Dr. Philippe W. Ouellette. The liturgy was presided over by Dr. Ouellette’s nephew, Monsignor Robert G. Lavoie. In song and story, three generations ~ children, grandchildren and great-grandchildren ~ paid tribute to a beloved and loving paterfamilias. In addition to seven children, six grandchildren and two great grandchildren, Dr. Ouellette’s survivors include several nieces and nephews. Denise, Philippe’s wife of fifty-nine years, predeceased him in 2003. The youngest of ten children, Phil was born and grew up in Lewiston, Maine. He knew Worcester first as a student at the former Assumption Preparatory School. Four years at Assumption College, culminating in a Bachelor’s Degree, provided the basis for a lifetime interest in, and commitment to, Assumptionist philosophy and all things French. After an internship at Worcester City Hospital (still remembered as a much sought-after appointment at the time), and three years of military service, Phil completed a residency in Obstetrics and Gynecology at the University of Loyola Medical School Hospitals. Returning to Worcester in 1950, right in the midst of the “Baby Boom,” Phil opened a solo practice in that most demanding of specialties, Obstetrics and Gynecology. In addition to meeting the demands his practice and the needs of a growing family, Phil made time for his church, his community and his profession, serving as Chief of Obstetrics and Gynecology at St. Vincent Hospital, Associate Clinical Professor of Obstetrics and Gynecology at the University of Massachusetts Medical School, President of the New England and Worcester OB/GYN Societies, Medical Director of Catholic Charities Services for Unwed Mothers, President of the Assumption College Alumni Association, and as a member of The Boards of Marillac Manor and Catholic Charities, the Parish Council of his church, and the Council of the Millbury Boy Scouts of America, among others. In these days of well-regarded residencies in obstetrics and gynecology going unfilled, we look back with wonder on the careers of Phil Ouellette and his contemporaries who, without regard for clock or calendar, gave of themselves in the service of others, both born and unborn. May a peaceful rest be granted our dedicated colleague. John A. Duggan,
MD Daniel
Kaplan, MD Dr. “Danny” Kaplan died on March 6, 2005. His death marked the end of an era in Worcester, in medicine, and in the history of our times in general. Of Danny it may be truly said, “They don’t make them like that anymore.” Dan was born in New York City in 1911. As a child, he saw the events of World War I unfold and leave their mark on our country. He lived through the Roaring Twenties and the days of Prohibition. During his adolescence, his family moved to Fitchburg, MA, where Dan excelled as a basketball player at Fitchburg High School. He continued his education at Clark University, where he was a good student and again a star basketball player. Things were tough in those days for students, especially for the many who came from working class or poorer families. Tuition, although reasonable by our current standards, was hard to come by for the son of a poor family. But Danny put together enough for the payments through a combination of scholarships, loans, and part-time as well as summer jobs. There still remained room and board, a problem that had to be solved. Danny moved in with the Malkiel family on the East Side of Worcester and traded doing household chores, including stoking the coal furnace three floors below in the basement, for a room and his meals. As fate would have it, the Malkiels had a daughter named Celia and it was also part of Dan’s duties to tutor this young high-school student and escort her to school events at night. Of course, the expected happened and the friendship between these two matured into love and Celia and Dan were married after graduation. After making it through medical school days and internship, which were as difficult then as they always have been and always will be, Dan started planning his general practice of medicine. Celia soon gave birth to first child Myrna, and then came World War II. Dr. Kaplan became Captain Kaplan and served for three and a half years in the Pacific Theater before returning to Worcester in 1946 to open his practice of General and Family Medicine. Then son Richard was born and medical life and family life were under way. Danny Kaplan was a physician in the old-fashioned sense of the word. He accepted his patients as they came ~ rich or poor, young or old, he took them in their turn. In those days, general practitioners practiced obstetrics, pediatrics, and geriatrics (before it had a name) in the office, in the home, and sometimes in the hospitals. Dr. Kaplan was always available, medical bag in hand, ready to climb the stairs to reach a patient on the top floor of a three-decker. Throughout the years, his office waiting room was always teeming with patients of every ethnicity, race, nationality and financial status. Dr. Dan saw them all. As time passed, Dan moved his office from Franklin St. to the Vernon Medical Building. He stopped his house-call practice and limited his in-patient work to St. Vincent Hospital, where he remained a proud staff member until the end of his career. This physician was a loving husband and proud and loving father to Myrna and Richard. His oldest grandson chose Dan to be the best man at his wedding. Dan was a wonderful physician, superb spouse, and a beloved grandfather, truly a man who was “all that he could be.” We as his colleagues will miss him and we join his family and patients in sharing both the loss and our memories of Dr. Dan. Edward Mason, MD |