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Quality Lessons from California

July 2, 2011
by Mark Hagland
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When it comes to contemplating ACO development, the leaders at IHA have strong recommendations

In the wake of the release of the proposed rule for accountable care organization (ACO) development on March 31, a variety of provider organizations and associations have submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding changes they would like to see in the final rule. Among the healthcare associations submitting comments on the proposed rule has been the Oakland, Calif.-based Integrated Healthcare Association (IHA), which submitted comments to CMS administrator Donald Berwick, M.D., in the first week of June.

The IHA, which describes itself as “a not-for-profit multi-stakeholder leadership group that promotes quality improvement, accountability, and affordability of healthcare in California,” represents provider and quality interests across that state, and sponsors and administers numerous quality improvement and other programs statewide. Among the IHA’s numerous concerns were the following (as summarized in a June 6 press release on the subject): IHA “strongly supports CMS efforts to promote value in healthcare through ACOs, but… the full set of 65 proposed measures would be too burdensome for newly formed ACOs. Instead, IHA recommends a first-year set of just 32 of those measures, consisting of ones that are already in use in existing performance measurement initiatives.”

The IHA urged Dr. Berwick to phase in some of the additional performance measures, and drop six of them. The association also recommended that CMS “provide more specifics on when an ACO’s performance data will be audited, and ensure that the process will not be an administrative burden on providers”; and recommended “that ACOs be rewarded not only for attaining high performance scores, but also for their rate of improvement.” All of these recommendations, IHA officials say, come out of their experience in working with pay for performance (P4P) programs over the past decade in California.

In that context, Dolores Yanagihara, program director, pay for performance, at IHA, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the comments that the association had submitted to CMS. Below are excerpts from that interview.

In deriving the substance of your comments from your numerous years of experience with pay for performance in California, you had said in the letter to Dr. Berwick that incorporating a full set of 65 outcomes measures at the very outset of the ACOs program would simply be too burdensome for providers. You’ve already had a decade’s worth of experience with P4P, correct?
Officially, we started measuring in 2003, but the program had been set up a couple of years before that. And yes, what everyone’s trying to do is to create systems of care, instead of looking at things measure by measure or case by case—so that you’ll have a process in place to address things. I don’t think we’re there yet, we have quite a ways to go. And starting step by step is key. And one of the things we built into our own program early on was trying to build on entities’ IT capabilities, in order to know what you’re doing early on, and measuring that over time.

We really see building IT as key to measuring and improving care. And anything that builds that kind of capability is very important. And we’ve seen that there have been, even within California, different ways of measuring. Seven health plans have been participating in our statewide collaborative; but in addition, most of them had had their own P4P plans before they started participating with us. And it’s just hard for providers to respond to so many different requirements. Even in building our own program, we were conscious of that. At that time, the most prominent measure set applicable was the HEDIS measures [the Healthcare Effectiveness Data and Information Set measures, from the Washington, D.C.-based National Committee for Quality Assurance]. And part of how we got health plan buy-in was by saying, OK, we’ll start at that physician group/health plan level and use HEDIS measures at first. But now there are so many more programs out there, so that that alignment becomes even more important. CMS recently put out a request for proposals, and the National Quality Forum was awarded that RFP; and the purpose was to try to identify a national set of measures to use, one that CMS can use; and all of us using performance measures are all looking to that initiative as we go forward.

Dolores Yanagihara

What is the timeframe for that initiative?
That work is just starting to kick off; I know there’s a report due to CMS sometime in early 2012, which would encompass some initial recommendations. So, we’re expecting medical groups and hospitals to try to be accountable and to measure the quality and costs of care; and the more that we can align and make it easier for groups and hospitals and health systems to be able to respond, and not be redundant in data collection efforts and measures, the more efficient they’ll be able to be in data collection and measurement.

You also feel the level of rigor is simply too high in the ACOs proposed rule, including all those measures at the outset?
Yes. And part of why we recommended phasing which measures in when, was based on the idea of using measures that are already being used, so that it’s not a burden to create another set of programming and testing, and adding new measures. So, starting there, and also building IT capability; because if more and more physicians and hospitals are using EHRs, the measuring process becomes easier.

In the context of ACO development, what do you foresee as the biggest hurdles you see in the next couple of years, for medical groups and for hospitals?
Even from the standpoint of forming an ACO, the relationship between groups and hospitals and health plans, the relationships between and among all the different players in healthcare, will have to become different from what they’ve been in the past; they need to become a team, and that hasn’t existed yet.

In other words, that relationship can no longer be adversarial?
Exactly. And strategically, working towards a common goal is going to be a huge cultural shift. So I think that’s a huge barrier, on the strategic level, even at the point of trying to decide whether to form one. And then once you’ve made that commitment and that shift, and then beyond that, there are multiple levels of challenges in making it a reality. And even when there’s a commitment there, you always have to be checking in in terms of trust and such. So it can be a little overwhelming even in getting it started.

What should CIOs and other senior healthcare IT leaders be doing right now?
First, they should be becoming stage 1-compliant with meaningful use; I think that’s really critical, just getting the proper infrastructure in place, and getting physicians and others to use EHRs.

The requirement that 50 percent of participating physicians will have to be stage 1-compliant with meaningful use sets a very high bar, don’t you think?
Absolutely. And so that’s critical, that’s a core requirement, a critical first step. And then, I think that the whole idea of how you incorporate, how you effectively then use all the data that will be at your fingertips once you put the structure into place, there will be huge requirements around training, around the kind of analysis and information being fed back to clinicians and the team, there will be huge requirements around all that. How do you train the people to be effective using the data they have to create more efficient, coordinated care?

Overall, do you believe that CMS has been too rigorous in the proposed rule?
It has definitely set a high bar. You need to be realistic, of course; but if you set the bar too low, no one’s going to tell you that you need to be more rigorous. So you set the bar fairly high, and then you seek input. So I think it’s good to come out strong, with guns blazing, and see how people respond, and then consider the comments. Were they ridiculously high in setting the bar on performance measures? Not really. But the rule is so complex and covers so many things, we focused on this area.

Do you think the field, particularly the physician field, is ready to turbo-charge activity in this area?
Even here in California, it remains a struggle for a lot of medical groups and hospitals. But I don’t know that we have a choice. Healthcare is lagging behind in many areas, and we have to move forward, we have to do it. I’m actually amazed that the one-physician practice you talked about in Alabama can even still exist. And it’s probably true with any major change: there will be those who will step up and figure out how to make the needed changes; and there will be those who won’t, and who won’t make it. And we have this big ongoing debate in P4P—and it’s, are we social democrats trying to raise all boats, or are we Darwinians? Here at IHA, we kind of started out as social democrats, trying to make sure everyone survived and thrived; but at some point, we had to kind of shift our attitude, in order to improve care.

Any other thoughts?
In our letter, we really were suggesting to CMS that they focus on sort of the middle-of-the-road performers, and what would stretch them towards greater capacity—and what it will take to move the bulk of the industry forward. So it’s that challenge to raise the bar and making it a stretch challenge, but not so difficult so that no one can make it. In conclusion, we’re very supportive of where CMS is trying to head, and hoping they’ll really listen to comments. So the question is, where is CMS trying to head? And I see CMS’s efforts as really good in terms of trying to align incentives. But it’s always more challenging than it seems at first glance, when you get into the weeds with things. And we’re really going in that same direction in terms of holding providers accountable for cost and quality. And this is one of CMS’s efforts in that area, and we support their moving in that direction.

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