Bridges to Excellence

Monday, September 01, 2014 12:38 PM

Opportunity for physicians to be recognized for quality

by Robert J. Smith, MBA, Colorado Business Group on Health

As the Colorado Business Group on Health engages physicians on behalf of employers in an effort to improve the value of their health care spending, we find that many physicians resist two of the more common methods of payment reform: capitation and pay-for-performance. We think they do so with good reason. Capitation poses several problems, not the least of which is the large number of patients required to achieve statistical reliability and payment fairness. That number far exceeds what the vast majority of Colorado practices are likely to realize from any given purchaser. Pay-for-performance measures, meanwhile, are typically insurer-specific (and often insurer-centric) and seem to benefit the specific insurer rather than the individual physician. Even worse, because the measures are peculiar to each insurer, physician practices get pulled in multiple directions – further fragmenting efforts at performance improvement.

As an alternative to many of the current payment strategies, we propose that the nationally recognized Bridges to Excellence (BTE) program represents the best approach to focusing on what really matters in health care: intermediate measures of patient outcomes.

BTE recognizes physicians who perform well against a collection of nationally endorsed, standardized outcomes measures and/or guidelines adopted to delineate high quality care delivery for patients. These measures have the greatest clinical and financial impact. Perhaps most importantly, these guidelines were developed in collaboration with physician experts and leading health care organizations. Non-prescriptive in nature, BTE guidelines focus on quality accountability: the improvement of intermediate outcomes and better adherence to good processes as a means to measure the effects of proper management of patients and the delivery of good results.

BTE rests on principles developed and supported by the American Medical Association, such as:

• A focus on quality. BTE uses, and the AMA recommends, “evidence-based quality of care measures, created by physicians across appropriate specialties.” Rather than first focusing on cost, BTE standards represent those intermediate clinical outcomes that promote the best patient care. Costs actually end up being lower for BTE- recognized physicians because of the emphasis on quality and patient benefit.
• Fostering the physician-patient relationship. BTE respects that physicians are “ethically required to use sound medical judgment, holding the best interests of the patient as paramount.” Concerned only with the patient, and not the payer, BTE standards are designed to acknowledge outcomes limitations in the most severe patients. BTE asks the clinician to supply a statistically valid sample of patients or a full patient panel and then requires a proportion of these patients meet a criterion such as blood pressure or cholesterol levels.
• Fair reporting using accurate data. By including statistically valid data directly from the practice’s patient records, and NOT from the insurer’s claims, BTE ensures that the data accurately reflect patient results. And by including data across all payers, BTE reports fairly reflect physician practice patterns, regardless of payer source or type.

By seeking BTE recognition, clinicians endorse these physician-sponsored, transparent standards. But there are three more immediate and concrete reasons why a physician would seek recognition:

1. Network designation and performance rewards. Clinicians who join the BTE program can establish eligibility for pay-for-performance bonuses, differential reimbursement or other incentives from participating payers and health plans. In Colorado, selected health plans and employers use BTE recognition to provide annual incentives for each patient seen. Nationally, BTE recognitions are used by several major insurers as part of their network designations.
2. Demonstration of outcomes. Recognized clinicians demonstrate to the public, health plans and peers their dedication to delivering high quality patient care. Overall, patients who have diabetes and are being seen by BTE-recognized physicians have:
   • 49 fewer ED visits per thousand visits
   • 16 fewer inpatient admissions per thousand admissions, and
   • 356 days spent in a hospital, compared to 436 days as an inpatient per thousand patients, or 80 fewer hospital days
3. Performance benchmarking. Clinicians can identify aspects of their practice that vary from the performance requirements and take steps to improve quality of care. For HbA1c, blood pressure, LDL levels and other metrics, clinicians can see where they stand relative to threshold as well as minimum/maximum levels.

(It should be noted that in Colorado BTE recognitions are awarded only to individuals, not to practices.)

The CBGH has worked with member employers and various insurers to adopt BTE for diabetes and cardiac care – two of the chronic disease states that have the greatest impacts on Colorado employees’ health status and on employers’ costs – both in terms of direct medical costs and indirect costs due to increased absenteeism/presenteeism. For instance, with regard to diabetes, according the Colorado Department of Public Health and Environment (CDPHE):

• The adult prevalence of diagnosed diabetes increased 157% over the past decade, from 4.7% to 7.4%.
• One in four Coloradans with diabetes is undiagnosed.
• Even more alarming, an estimated one in three U.S. adults is pre-diabetic. Unfortunately, only 6% of adult Coloradans were aware of having pre-diabetes in 2012.
• Two in three people with prediabetes will likely develop diabetes within 6 years.

With regard to cardiovascular disease, CDPHE cites this diagnostic category as the leading cause of death in Colorado. On average one Coloradan dies every hour due to cardiovascular disease.

Nationally, BTE programs have also been developed for hypertension, coronary artery disease, congestive heart failure, spine, asthma, congestive-obstructive pulmonary disease, depression and medical home. Although these BTE programs have not been implemented in Colorado, some national carriers – including Aetna, Anthem, and UnitedHealthcare – either incorporate them into or use them as part of their national network contracts terms.

As noted above, pulling physicians in multiple directions compromises both practice efficiency and practitioner effectiveness. BTE measures and guidelines are designed to align with the Physician Quality Reporting System (PQRS), a Medicare reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals.

Clinicians can achieve BTE recognition in one of two ways:

• Electronic data submission. Depending upon the type of electronic medical record in place, clinicians can electronically submit data. Electronic submissions:
  • Are transmitted and reviewed quarterly.
  • Include all patients seen with diabetes during a period.
  
  In addition to ease of submission, this method provides access to reports that are available for real time population management and patient level management. Moreover, submitted data extends patient impact through all BTE chronic care programs.
• Manual chart review and extraction. Alternatively, data can be submitted manually through a point in time audit. Such chart audits must be completed at least once every two years. The submitted data will reflect care of 25 patients per clinician.

Data can be submitted either directly to BTE through CECity’s “MedConcert” protocol (see https://bte.medconcert.com) or through the National Committee for Quality Assurance (NCQA) (see www.ncqa.org/Programs/Recognition/BridgestoExcellence.aspx).

Data submitted electronically via your EMR is a very nominal cost, and many EMR vendors are already capable of interfacing at this time. Pricing is available on the respective websites.

Through the efforts of the Colorado Business Group on Health, BTE programs in Colorado bring key practical advantages to recognized physicians. CBGH promotes these physicians in their annual Health Matters Quality Report: Physicians, published annually. Other advantages include the opportunity to differentiate themselves, to benchmark their performance as part of their internal efforts at improvement, to attain health plan recognition and to achieve some financial remediation.

Physicians and practices seeking greater continuity across health plans’ standards as well as increased emphasis on clinical, rather than financial or simple, utilization measures can advance their own interest by first pursuing BTE recognition themselves and then by insisting during contract negotiations that nationally recognized BTE standards replace esoteric, plan-specific targets. No other programmatic opportunity exists for physicians to assert themselves and advocate for patient-centered targets.

In a time of increasing demands for transparency and accountability on the part of health care purchasers and consumers, Colorado physicians will be best served by endorsing the sort of outcomes-based measures of quality that the Bridges to Excellence program represents.

For more information about BTE in Colorado, visit the CBGH website at http://www.cbghealth.org/projects/improving-quality/bridges-to-excellence/ or call Donna Marshall or Robert Smith at 303.922-0939. For information about BTE nationally, go to http://www.hci3.org/node/1.