Addressing Issues

Aligning Payment Policies with Care: Fixing the Quality Care Problem

Institute of Medicine (IOM) Recommendations 5,6

The IOM recommends that private and public purchasers examine their current payment methods to remove barriers that currently impede quality improvement, and to build in stronger incentives for quality enhancement. Payment methods should:

• Provide fair payment for good clinical management of patients seen. Clinicians should be adequately compensated for taking good care of all types of patients, including caring for sicker patients or those with more complicated conditions.
• Promote patient centered, effective, efficient, and timely care in a safe environment.
• Provide an opportunity for health care professionals to share in the benefits of quality improvement, such as malpractice risk reduction.
• Provide the opportunity for consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly. For example, an online report card could compare ratings on HMO services for people with diabetes.
• Align financial incentives with the implementation of care processes based on best practices and the achievement of better patient outcomes.
• Reduce fragmentation of care and not be a barrier to coordination of care for patients across settings.
  

IOM Report Brief September 2006

Advising the Nation. Improving Health. Rewarding Provider Performance: Aligning Incentives In Medicare. www.acme-assn.org/home/11723_report_brief.pdf

The health care organization and health care professional role

To promote quality improvement, health care organizations can implement clinical quality improvement programs and the use of outcomes measurement, diabetes management programs, practice guidelines, automated information systems, electronic medical records, and computerized decision-support tools. Aids for health care professionals include reminder systems (e.g., charts, computerized reminders, checklists, or medical record flags) or standing orders for effective treatments or services, such as preventive exams of eyes, kidney and feet for patients with diabetes. Systems that provide real-time prompts to caregivers are effective in reducing under use.3 Quality improvement may not necessarily lower health costs but can contribute to improved health care and clinical outcomes. Of the existing technologies, diabetes registries offer potential benefit both for improving care delivery and reducing costs.18

Examples of quality improvement efforts:

• With an emphasis on "eHealth," the Veterans Administration offers a secure patient portal known as "My HealtheVet" to provide access to a personal health record, on-line health assessment tools, mechanisms for prescription refills and making appointments, and to evidence-based health information to help patients advocate more effectively for their own health need. www.healthtransformation.net/cs/
  veterans_administration_healthcare_system_my_healthevet

• National Committee for Quality Assurance (NCQA)/ American Diabetes Association (ADA) Diabetes Physician Recognition Program
  web.ncqa.org/tabid/139/Default.aspx
  The program recognizes physicians who demonstrate that they provide excellent diabetes care and provides critical information to purchasers and consumers of health care and support quality improvement efforts by health care providers. To earn diabetes recognition, a physician or physician groups collect and submit treatment data for people with diabetes, such as the percentage of patients whose cholesterol, blood pressure and blood sugar levels are under control. Those that meet or exceed national performance thresholds are promoted online and added to a referral list, to which NCQA and ADA direct interested consumers.

• Application of The Health Plan Employer Data and Information Set (HEDIS®)
  A study in a large health maintenance organization (HMO) compared health care costs for patients who fulfilled HEDIS criteria for diabetes and were in an HMO-sponsored disease management program with costs for those not in disease management. The program interventions, given over 1 year, promoted diabetes clinical guidelines by nurses in their day-to-day interaction with primary care physicians and patients, HMO-sponsored continuing medical education for primary care providers, early and appropriate specialty clinic referral, and primary care site-based patient education and case management by the HMO nurses. Patients volunteered for the program and were seen by the nurse one to four times from the date of referral. Per member per month paid claims were lower for program patients compared with non-program patients. This difference was accompanied by lower inpatient health care use, fewer emergency room visits and a higher number of primary care visits for program participants than in non-program participants. Program patients also achieved higher HEDIS scores for A1C testing and lipid, eye, and kidney screenings, and lower A1C values.19

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