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PROCEED WITH CAUTION performance incentive programs and racial disparities

PROCEED WITH CAUTION performance incentive programs and racial disparities. Alyna Chien MD MS Marshall Chin MD MPH Andrew Davis MD Lawrence Casalino MD PhD University of Chicago California Medical Association Foundation Ethnic Physician Leadership Summit

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PROCEED WITH CAUTION performance incentive programs and racial disparities

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  1. PROCEED WITH CAUTIONperformance incentive programs and racial disparities Alyna Chien MD MS Marshall Chin MD MPH Andrew Davis MD Lawrence Casalino MD PhD University of Chicago California Medical Association Foundation Ethnic Physician Leadership Summit Los Angeles Airport Marriott - September 30, 2006

  2. Outline • Background / Evidence • Impact on racial disparities • Leader perspectives on current programs (or at least not widening them) • Recommendations

  3. Performance incentive programs

  4. Performance incentive programs • Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes

  5. Performance incentive programs • Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes • “Pay-for-performance”  cash

  6. Performance incentive programs • Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes • “Pay-for-performance”  cash • “Public reporting”  reputation

  7. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  8. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  9. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  10. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  11. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  12. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  13. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  14. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  15. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  16. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  17. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ●Commercial health plans ● Private stakeholder coalitions ● Individual doctors● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  18. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  19. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  20. Not all programs are created equal ● Fee-for-service ● Capitation ● Commercial ● Un/Underinsured Context: Payors: Payees: Incentivized Measures: Incentive Triggers: ● Federal government ● State government ● Commercial health plans ● Private stakeholder coalitions ● Individual doctors ● Practices/groups ● Hospitals • ● Clinical process/outcome • ● Clinical access • ● Patient satisfaction • ● Use of formulary • ● Administrative efficiency • ● Achievement • ● Improvement • ● Tournament ● Risk adjustment Bokour, MCRR 2006; Rosenthal, Health Affairs 2004; The Leapfrog Compendium; Centers for Medicare & Medicaid Services

  21. Desired effect of programs Quality Time

  22. Evidence for desired effect Significant Mixed None • Beaulieu 2005 • Clark 1995 • Casalino 2003 • McMenamin 2003 • Rosenthal 2005 • Grady 1997 • Hillman 1998 * • Hillman 1999 * • Shen 2003 • Fairbrother 1998 * • Hibbard 2003 * • Hickson 1987 * • Kouides 1998 * • Norton 1992 • Pourat 2005 6 4 5 *Randomized design • Dudley, AHRQ Technical Paper 2004; • Peterson, Annals Int Med 2006

  23. ? Unknown effect on disparities Quality Time

  24. NARROWING NEUTRAL WIDENING One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  25. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  26. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  27. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  28. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  29. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  30. NARROWING NEUTRAL WIDENING Quality improvement literature One-size-fits-all ● ESRD patients ● ~40%  in adequate hemodialysis dosing ● White-black disparity persisted Seghal, JAMA 2003 Culturally sensitive ● Depression ● ~20%  in depression care ● White-minority disparity eliminated Arean, Medical 2005 One-size-fits all ? Induces cherry-picking ? Widens resource gaps / “rich get richer” ?

  31. NARROWING NEUTRAL WIDENING

  32. NARROWING NEUTRAL WIDENING

  33. NARROWING NEUTRAL WIDENING

  34. NARROWING NEUTRAL WIDENING

  35. Unintended consequences

  36. Evidence of desired effect Significant Mixed None • Beaulieu 2005 • Clark 1995 • Casalino 2003 • McMenamin 2003 • Rosenthal 2005 • Grady 1997 • Hillman 1998 * • Hillman 1999 * • Shen 2003 • Fairbrother 1998 * • Hibbard 2003 * • Hickson 1987 * • Kouides 1998 * • Norton 1992 • Pourat 2005 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design • Dudley, AHRQ Technical Paper 2004; • Peterson, Annals Int Med 2006

  37. Evidence of desired effect Significant Mixed None • Beaulieu 2005 • Clark 1995 • Casalino 2003 • McMenamin 2003 • Rosenthal 2005 • Grady 1997 • Hillman 1998 * • Hillman 1999 * • Shen 2003 • Fairbrother 1998 * • Hibbard 2003 * • Hickson 1987 * • Kouides 1998 * • Norton 1992 • Pourat 2005 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design • Dudley, AHRQ Technical Paper 2004; • Peterson, Annals Int Med 2006

  38. Evidence of desired effect Significant Mixed None • Beaulieu 2005 • Clark 1995 • Casalino 2003 • McMenamin 2003 • Rosenthal 2005 • Grady 1997 • Hillman 1998 * • Hillman 1999 * • Shen 2003 • Fairbrother 1998 * • Hibbard 2003 * • Hickson 1987 * • Kouides 1998 * • Norton 1992 • Pourat 2005 2 improved documentation only 2 noted cherry-picking 1 rewarded those already doing well *Randomized design • Dudley, AHRQ Technical Paper 2004; • Peterson, Annals Int Med 2006

  39. Impact of incentive programs on racial disparities

  40. Systematic review of MEDLINE® • 536 “hits”  1 empirical study • Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards • 1991 New York publicly reported risk-adjusted CABG mortality rates • Compared CABG rates • Hispanics and African Americans vs Whites • Before and after ‘report card’ instituted • NY versus 12 comparison states • Werner, Circulation 2005

  41. Systematic review of MEDLINE® • 536 “hits”  1 empirical study • Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards • 1991 New York publicly reported risk-adjusted CABG mortality rates • Compared CABG rates • Hispanics and African Americans vs Whites • Before and after ‘report card’ instituted • NY versus 12 comparison states • Werner, Circulation 2005

  42. Systematic review of MEDLINE® • 536 “hits”  1 empirical study • Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards • 1991 New York publicly reported risk-adjusted CABG mortality rates • Compared CABG rates • Hispanics and African Americans vs Whites • Before and after ‘report card’ instituted • NY versus 12 comparison states • Werner, Circulation 2005

  43. 1991 New York “CABG Report Cards”Werner, Circulation 2005

  44. 1991 New York “CABG Report Cards”Werner, Circulation 2005 0.7

  45. 1991 New York “CABG Report Cards”Werner, Circulation 2005 3.2 0.7

  46. 1991 New York “CABG Report Cards”Werner, Circulation 2005 3.2 0.7 2.7

  47. 1991 New York “CABG Report Cards”Werner, Circulation 2005 3.2 5.0 0.7 2.7

  48. Summary • Literature: • PIPs may not improve quality • Quality improvement does not necessarily narrow disparities • PIPs may widen racial/ethnic disparities • Programs as currently designed: • Do not necessarily have the needs of racial & ethnic groups or disparities in mind • Have features that may contribute to widening disparities

  49. Summary • Literature: • PIPs may not improve quality • Quality improvement does not necessarily narrow disparities • PIPs may widen racial/ethnic disparities • Programs as currently designed: • Do not necessarily have the needs of racial & ethnic groups or disparities in mind • Have features that may contribute to widening disparities

  50. Summary • Literature: • PIPs may not improve quality • Quality improvement does not necessarily narrow disparities • PIPs may widen racial/ethnic disparities • Programs as currently designed: • Do not necessarily have the needs of racial & ethnic groups or disparities in mind • Have features that may contribute to widening disparities

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