p4p: developments and acceptance in medicaid and medicare disease mgmt. gus geraci, md senior...

P4P: Developments and AcceptanceIn Medicaid and Medicare Disease Mgmt.

Gus Geraci, MDSenior Product Manager for Provider Facing ProgramsMcKesson Health Solutions

May 8, 2007 Disease Management Colloquium 2

Agenda

Science and Design of P4P

Success and Failures

Progress to Date

Questions


Agenda



Progress to Date

Questions


Science of P4P

Defects Exist in Current Payment Systems Incentive for Volume Quality May Suffer

Do $$$ Work to Change Behavior?

Mixed Literature and Emotion


Science of P4P (2)

Evidence is Accruing that Programs Do Work

Many Naysayers

Every Program is Different

How To Avoid “Gaming”


P4P and Disease ManagementIn Medicaid/MedicareChallenges:

FFS Environment No Direct Contractual Relationship With Providers

DM Programs Perceived As Interfering

Misperception of Funding Source for DM Programs Not From MY Pocket

“Too much paper” Concerns About Potential Liability


P4P in Disease Management

We Have Hard Evidence that P4P Achieves Better Results Within a DM program by: Engaging Providers Providing an Incentive for Specific Evidence Based

Activities Thereby Improving Clinical and Financial Results


McKesson’s P4P Approach

Incorporate P4P Market Feedback into Design

Tie P4P Payments to Key DM Program Success Factors Influenced By Providers

Involve National/State Professional Organizations in Design

Publicize P4P Program Well


Helps ensure quality of care Yes: based on nationally accepted guidelinesFoster the patient-provider relationship Yes: provider is key in recruitment and goal-settingOffers voluntary participation Yes: no penalty or reduction in fees for non-participationUses accurate data and fair reporting Yes: payments based on information received directly from

providers, patients or claimsProvides fair and equitable incentives Yes: providers are paid a fair amount as compensation for

the work done

Design Follows AMA P4P Guidelines


Market FeedbackProgram Design

Data Validity

Mod

el C

ompl

exity

Long Lag times between physician behavior, data collection and reporting, and bonus payments

Confusing to physicians

Difficult to administer

Low pt volume per physician

• Not statistically significant

•Case mix issues

P4P

Design

Flaws

• Payments designed like FFS system

•Start with simple participation metrics

•Use widely accepted claims-based metrics (HEDIS-like)

Frequent payments: First payment within 6 months after program launch; quarterly payments thereafter


Agenda



Progress to Date

Questions


MS MHS Program Experience – Stormy!

MS MHS Program launched August 22, 2005

Hurricane Katrina struck MS Gulf Coast August 29th

Practitioners focused on meeting refugee needs

P4P introductory mailing delayed


Medicare Health Support (MS)

Development of an individualized, goal oriented care management plan in consultation with each targeted pt, to include: Point of contact responsible for communications Self-care education and education for primary caregivers

and family members Education for physicians and other providers as well as

collaboration to enhance communication of relevant information

CMS-Mandated Services


MS Design Similar to PA

Enroll

Information Exchange Clinical and Administrative

Evidence Based Clinical Metrics


How the P4P Program Works

Time

Physician responsibilities:


Mississippi - Terminated

Results Not Tracking With Design


PA Medicaid P4P Program

PA Practitioners More Familiar With P4P Programs (Commercial and Medicaid MCO)

FFS Managed Care Program – EPCCM

Program Continues to Grow in Enrollment

“I actually got a check…”


Survey of ParticipatingProviders

56% Agree/Strongly Agree P4P is Useful to Practice

42% Unsure

2% Strongly Disagree

60% Agree Strongly Agree Helps Improve Quality

38% Unsure

2% Strongly Disagree


Clinical Results

P4P participation is shown to increase the average monthly rate of occurrence for a blood test for cholesterol within the diabetes population

P4P participation is shown to increase the average monthly rate of occurrence for a prescription for controller medication within the asthma population

P4P participation is shown to increase the average monthly rate of occurrence for a prescription for cholesterol lowering medication within the CAD population

P4P participation is shown to increase the average monthly rate of occurrence for a prescription for beta-blocker within the heart failure population


Financial Results

P4P Participation Resulted in Greater Savings in Inpatient Costs Than Non-P4P


Agenda



Progress to Date

Questions


Progress to Date

We’ve Learned a LOT

Getting Out of Medicare in MS

Continuing Strong in PA

Designing Next Two Years for PA Non-Disease Management P4P

−Quality Incentives Aligned with State Initiatives


Redesigning the Program

Realigning the Program

Reinforcing Success of P4P in Medical Home Model for Primary Care

Success Exists in Specialty and Primary Care P4P

Requests for P4P in New And Current Programs


Stay Tuned for Next Year!

More Detailed Analysis

More Non-DM Data

P4P Works Clinical Financial Greatest Barriers Are:

−Supporting Program

−Distrust


Agenda



Progress to Date

Questions


Questions?

[email protected]

p4p: developments and acceptance in medicaid and medicare disease mgmt. gus geraci, md senior...

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