QUALITY: Sam Nussbaum saying the time is now for P4P

Sam Nussbaum is Wellpoint’s chief medical director (before that he was on the provider side). Improvement is too slow and variability is too great. Again it’s all been too slow. Cost and quality bear little relationship to each other. In fact it’s a negative correlation (Dartmouth)

We continually have a lack of excellence in quality but that there is employer and even consumer interest in improving it. He wants to promote the establishment of a national quality coordination board to turbo-charge P4P. He believes that P4P will incent investments in IT. But that we need to add clinical decision support into IT to reduce practice pattern variation (we need more than just EMRs)

So how to start?  Start with a foundation of trust (can this really come from Wellpoint? he doesn’t address that)  He thinks that they need to move from process measures to outcomes measures. He used the example of rich measures of quality process and outcomes in cardiology care, whereby they are rewarding for process and outcome. This is the Quality Insights Hospital Incentive Program (QHIP). In this program complications in PCI were 47% decreased in QHIP hosps vs 20% nationally. So how do they contract with hospitals to do that? They want to earmark a share of (increase in) payment to clinical quality measures. Similar success with OBGYNS in Ohio. They have lots and lots of programs in many states…and they want to move it to more places.

So how to translate that more generally. Within networks (and even within medical groups) there is practice variation, no correlation between cost and quality. Sam is true for hospitals And in the communities, the advertising billboards don’t reflect the real quality issue. But we need to raise the bar for everyone—can’t just send everyone to the top 30%.

And he wants to get consumers involved (so Wellpoint bought Lumenos and is using Subimo) to guide them to the best type of care. Plus roll that into many other programs, such as DM, specialty pharmacy, etc.

All good stuff but he never mentioned the dark side of HDHPs….and the avoidance of people at risk by insurance  firms. Ian Morrison is coming up later, and I’m sure he’ll talk about this.

But how do we pay for those programs via  PPO, or via ASO services? How does risk adjustment become very apparent? He believes that the key driver is CMS brining P4P to market. — but as anyone who reads the comments in THCB knows, that’ll still be a big fight. AND he admits that the unintended consequences of sharing information is that providers want more money, either to support improvement, or because they are already the best and want to be rewarded for it.

So we must close the quality chasm….P4P is one of the strategies. But there needs to be collaboration.

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