- Email: [email protected]
Use of the Health Plan Employer Data and Information Set for measuring and improving the quality of asthma care
Review
Use of the Health Plan Employer Data and Information Set for measuring and improving the quality of asthma care Erwin W. Gelfand, MD*; Gene L. Colice, MD†; Leonard Fromer, MD, FAAFP‡; William B. Bunn III, MD, JD, MPH§; and Thomas J. Davies, JD, MPA¶
Objectives: To discuss the Health Plan Employer Data and Information Set (HEDIS) criteria for measuring performance in asthma care and to review new strategies to improve the quality of asthma care. Data Sources: Expert opinion from a roundtable on National Committee for Quality Assurance HEDIS and asthma care, supplemented with a MEDLINE database search to identify articles published between January 1, 1990, and May 31, 2005, with the following keywords in the title: asthma plus HEDIS, pay for performance, incentive programs, reimbursement, or employee education. Study Selection: Studies and review articles were selected for their relevance to measuring the quality of asthma care using HEDIS and improving care using newer trends, such as employee education and physician incentive programs. Results: Components of the HEDIS asthma measure have been found to correlate with outcomes, including risk of hospitalization and emergency department visits. However, refinements to the measure may be needed because it may misclassify a portion of patients as having persistent asthma who actually have intermittent asthma according to National Heart, Lung, and Blood Institute criteria. Physician incentive programs are increasingly being explored as a means of improving the quality of care while managing costs. Under current pay-for-performance programs, rewards are issued to providers who demonstrate highquality care based on the HEDIS asthma measure. Conclusions: The HEDIS asthma measure remains the most widely used performance tool for evaluating the quality of asthma care. Reimbursement models based on public reporting and pay for performance are expected to be a strong component of future health care payment systems. Ann Allergy Asthma Immunol. 2006;97:298–305.
INTRODUCTION Asthma continues to be a leading serious chronic disease among adults and children in the United States, accounting for 480,000 hospitalizations,1 1.9 million emergency department (ED) visits,1 and an estimated $14 billion in health care costs2 annually. The prevalence of asthma began increasing in 1980, with a nearly 74% increase occurring between 1980 and 1996.3 Asthma is now the most common chronic disease * Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado. † Department of Medicine, The George Washington University School of Medicine, and Pulmonary, Critical Care, and Respiratory Services, Washington Hospital Center, Washington, DC. ‡ Department of Family Medicine, University of California, Los Angeles, Los Angeles, California. § Health, Safety, Security, and Productivity, International Truck & Engine Corp, and Northwestern University School of Medicine, Chicago, Illinois. ¶ Integrated Healthcare Association, Oakland, California. This article was supported by an educational grant from Sanofi-Aventis Inc and ALTANA Pharma. Received for publication September 22, 2005. Accepted for publication in revised form March 20, 2006.
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of childhood, affecting an estimated 6.3 million children in the United States in 20012 and accounting for 14 million lost school days in 2002.1 Despite the availability of effective therapy and an improved understanding of asthma pathogenesis, physician visits, hospital outpatient visits, and ED visits for asthma have continued to increase during the past decade at alarming rates.3 Although hospitalization rates for asthma have declined since the mid-1980s,3 inpatient hospital services remain the largest single direct medical expenditure for asthma.2 Asthma has a profound impact in the workplace, accounting for 14.5 million workdays lost each year in the United States3 and a substantial, if unmeasured, effect on presenteeism. Presenteeism, or the problem of workers being on the job but not fully functioning because of illness or other medical conditions, is an important cause of loss of productivity because illnesses people take with them to work are so prevalent, frequently remain untreated, and typically occur during the peak working years.4 Loss of productivity results in high indirect costs, which may be largely invisible to employers. Studies have demonstrated that presenteeism
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costs to employers exceed those for direct medical care by 2to 3-fold.4 In response to the increase in asthma prevalence and mortality that occurred in the 1980s, national and international treatment guidelines were developed with the aim of improving asthma care.5–7 Despite the availability of these guidelines for more than a decade, they are not followed routinely in clinical practice in the United States, and many patients continue to receive suboptimal care for their asthma severity level.8 –10 Although emphasized as the preferred long-term control medication for patients with persistent asthma,6 inhaled corticosteroids (ICSs) continue to be underused, whereas short-acting 2-agonists are frequently overused.8,9 This is especially alarming in light of evidence that ICSs significantly improve asthma outcomes,6 with patients receiving ICSs having nearly half the risk of ED visit relapse and hospitalization as nonusers.11–13 Indeed, poor adherence to these agents has been reported to account for most hospitalizations for asthma.14 Furthermore, recent data suggest that most asthmatic patients are not receiving education regarding management of their disease, as recommended in the National Heart, Lung, and Blood Institute (NHLBI) guidelines, with most patients reporting failure to receive instruction on peak flow meter or inhaler use or a written treatment plan from their physician.9 Suboptimal care for asthma and its associated costs constitute an important public health problem that has captured the attention of clinical experts and government agencies.5,15 Furthermore, the significant impact of asthma in the workplace has captured the attention of payers and health plans, prompting them to explore new methods for measuring and improving the quality of asthma care. Although various disease management programs have demonstrated some efficacy in improving asthma outcomes,16,17 newer strategies for improving care while stabilizing costs are being studied. Offering disease management or education programs at the worksite is an increasingly popular strategy for enhancing patient participation in a cost-effective location.18 Incentive programs that reward physician groups for using performance measures that improve clinical processes are also increasing in number and are expected to produce fundamental changes in the way practicing physicians are compensated.19 Most of these pay-for-performance programs currently base their clinical standards on Health Plan Employer Data and Information Set (HEDIS) measures, which have become the most widely used criteria for measuring performance in the managed care industry. Although still evolving, reimbursement models based on public reporting and pay-for-performance concepts are now being used for asthma care and are anticipated to become prevalent in health care in the next 5 to 10 years.20 This article reviews use of the HEDIS criteria for measuring the quality of asthma care and the new trends in strategies being investigated to control costs and improve asthma care.
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MEASURING PERFORMANCE: THE HEDIS ASTHMA MEASURE Measuring the quality of asthma care is a critical component of improving patient outcomes.21 The HEDIS is the most frequently used set of performance measures in the managed care industry, with nearly 75% of the largest US employers using the measures to evaluate and set performance guarantees for health plans caring for their employees.22 The National Committee for Quality Assurance (NCQA) developed and maintains HEDIS as a tool to evaluate health plan performance across a range of criteria, to allow objective planto-plan comparisons, and to establish accountability in managed care.22 The HEDIS is an important industry standard and is viewed by regulators, consumers, and public purchasers of health care as an accepted “report card” for health plan performance.22 Currently, HEDIS assesses several measures, including effectiveness of care, access to or availability of care, satisfaction with the experience of care, health plan stability, use of services, cost of care, informed health care choices, and health plan descriptive information. In 1999, the NCQA added a specific quality evaluation measure to HEDIS, the Use of Appropriate Medications for People With Asthma. As depicted in Figure 1, the HEDIS asthma measure determines the percentage of health plan members with persistent asthma who were appropriately prescribed long-term control medication during the measurement year.23 The measure is reported for 3 age cohorts (5–9 years, 10 –17 years, and 18 –56 years) and as a combined rate.23 Although based on the NHLBI guidelines, the HEDIS asthma measure differs in that it uses medical claims data collected during the previous year rather than clinical evaluation of recent symptoms.21 Furthermore, the HEDIS asthma measure is pertinent to a continuously enrolled population of health plan members compared with individual patients.21 Consistent with the NHLBI guidelines, the HEDIS asthma measure considers the following medications to be acceptable therapy for long-term control of asthma: (1) ICSs (preferred therapy), (2) cromolyn sodium and nedocromil (alternative therapy for mild persistent asthma), (3) leukotriene modifiers (alternative therapy for mild persistent asthma), and (4) methylxanthines (alternative but not preferred therapy for mild persistent asthma). If prescribed alone without ICSs, longacting 2-agonists are not counted in the numerator because they are recommended in the National Asthma Education and Prevention Program guidelines as add-on rather than primary therapy for persistent asthma.23 To characterize the ability of the HEDIS criteria to evaluate asthma severity, Cabana et al21 conducted a cross-sectional study in which data from a nationwide sample of pediatric asthmatic patients were analyzed. An 86-item interview was conducted with the parents of 896 patients aged 2 to 12 years with an active clinical diagnosis of asthma. The HEDIS asthma criteria, as evaluated by parent report, were used to classify patients with persistent asthma. These criteria included any ED visit for asthma during the past year, any
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Figure 1. The 2005 Health Plan Employer Data and Information Set (HEDIS) measure for use of appropriate medications for people with asthma. *For HEDIS 2006, there is a proposal to change the denominator eligibility criteria from 1 year (the year before the measurement year) to 2 years (the year before plus the measurement year). **A dispensing event is 1 prescription of an amount lasting 30 days or less. Two different prescriptions dispensed on the same day are counted as 2 different dispensing events. To calculate dispensing events for prescriptions longer than for 30 days, managed care organizations should divide the days’ supply by 30 and round up to convert. ED indicates emergency department.23
hospitalization for asthma during the past year, 4 or more outpatient asthma visits and 2 or more asthma medication– dispensing events in the past year, and 4 or more asthma medication– dispensing events in the past year. By comparison, patients were classified as having persistent asthma according to the NHLBI criteria when their parents reported that they had nighttime asthma symptoms more than 2 nights per month or daytime symptoms more than 2 days per week.21 The sensitivity of each HEDIS criterion, alone and combined, was calculated using the NHLBI criteria as a reference. The proportion of patients classified as having persistent asthma was greater when based on the HEDIS criteria (656 [73%]) than on the NHLBI criteria (338 [38%]).21 When analyzed separately, a single hospitalization and a single ED visit had high specificity for persistent asthma (0.98 and 0.90, respectively), but both had low sensitivity. When the HEDIS criteria were combined, sensitivity increased to 0.89, but specificity declined to 0.70.21 Of the 346 patients without daily controller medication therapy, specificity remained fairly high (0.68), but sensitivity decreased to 0.45. These results suggest that many patients with intermittent asthma symptoms based on the NHLBI clinical criteria would be classified as having persistent asthma according to the HEDIS criteria.21 Limitations of this study include the use of parent recall rather than actual claims data, the assumption that “as-needed use” of a medication was equivalent to 1 medication-dispensing event, the lack of data from pulmonary function tests for NHLBI classification of severity, and the inclusion of only a pediatric population. Nevertheless, the authors emphasized that the HEDIS criteria for persistent asthma may include children who may not require daily controller medications and suggested that these criteria be
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used with caution when interpreting the quality of asthma care. Despite this concern, the ability of the HEDIS asthma measure to predict asthma-related outcomes has been demonstrated in several trials.22,24 In a retrospective study, Berger et al22 analyzed claims for 49,637 patients with persistent asthma for use of controller medications, ED visits, and hospitalization claims. Patients were stratified by use of controller medications and by adherence, which was measured as the total days’ supply of medication dispensed.22 Nearly 46% of the patients were not using long-term controller medications, whereas 36% and 18% were using 1 or more than 1 class of long-term controller medication, respectively.22 More than 25% of the patients did not receive any medication in the measurement year. When the subgroup of patients receiving ICSs was analyzed, it was observed that patients with low adherence to these agents had a higher risk of hospitalization or ED visits (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.79 –2.78) compared with those with moderate (OR, 0.81; 95% CI, 0.43–1.51) or high (OR, 0.37; 95% CI, 0.05– 2.69) adherence.22 Based on these data, the authors suggested that some refinements to the HEDIS asthma measure may be needed.22 Although data comparing outcomes in patients receiving ICSs vs alternative long-term control medications are needed, it was suggested that the equal weighting of ICSs to other long-term control therapies should be reevaluated in the current HEDIS definition of appropriate therapy.22 They further suggested that a measure of adherence be incorporated into the definition. Last, given that more than 25% of the patients identified as having persistent asthma in the study22 were not receiving any asthma medication, the authors cautioned that
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the HEDIS asthma measure, as written, may mislabel a proportion of people with intermittent asthma as having persistent asthma. Association of the HEDIS asthma measure with subsequent risk of ED asthma visits was examined in a crosssectional analysis24 of pharmacy and health care utilization data in children aged 3 to 15 years identified as having persistent asthma. A correlation between the HEDIS asthma measure and the risk of an ED visit was noted in patients with persistent asthma, with the dispensing of a controller medication lowering the risk of an ED visit by more than two thirds (OR, 0.3; 95% CI, 0.2– 0.4).24 The correlation depended on the underlying level of reliever dispensing, with greater protection conferred to children who received fewer than 4 reliever dispensings per person-year compared with those who received 4 or more reliever dispensings per personyear.24 The authors concluded that the HEDIS asthma measure as a performance measure can help stratify children with asthma based on their risk of future adverse events.24 IMPROVING PERFORMANCE: NEW STRATEGIES FOR IMPROVING ASTHMA CARE Employee Education Programs Asthma disease management programs have been used in a variety of health care settings,16 –18 but few studies have evaluated the value of such programs in the workplace. Burton et al18 reported the results of a worksite asthma education program offered to Bank One employees at no cost. Seventy-six employees of Bank One with nonoccupational asthma agreed to participate in the FirstAir Asthma Education Program, which consisted of 5 weekly 1-hour educational classes taught by an occupational health nurse during lunchtime.18 Free lunches and educational materials were provided as incentives to promote attendance. Participants completed the Asthma Therapy Assessment Questionnaire at the beginning of the program and 2, 4, and 12 months after the first session.18 Patient satisfaction questionnaires were also completed at the final educational session. Although the conclusions were limited by the small sample size, the program was found to have significantly improved asthma knowledge, patient perception, and medication use, immediately and 12 months after the first session.18 Results of the Asthma Therapy Assessment Questionnaire demonstrated significant reductions in communication barriers (P ⬍ .01), knowledge deficiency (P ⬍ .10), and self-efficacy barriers (P ⬍ .05) 12 months after initiation of the educational intervention.18 All asthma control measures were improved at 12 months, with significant improvements occurring in absenteeism (P ⬍ .05), overuse of reliever medications (P ⬍ .001), no written control plan (P ⬍ .10), medicine preference not known by the physician (P ⬍ .05), having a prescription for controller medicines (P ⬍ .001), and taking controller medicines every day (P ⬍ .001). In addition, the appropriate use of reliever and controller medications improved significantly (P ⬍ .001).18 More data are needed to determine the value of
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worksite interventions, but the improvements in asthma control demonstrated in this study would be expected to result in reduced direct and indirect costs to employers, enhanced quality of life, and reduced medical costs to employees. Pay-for-Performance Programs Limitations of traditional health care reimbursement models, along with greater public scrutiny and disclosure of clinical quality standards, have forced health plans and providers to explore new reimbursement models to improve quality of care while managing costs.20 Provider-focused initiatives are increasingly recognized and used as promising methods for achieving this goal. In 2001, the Institute of Medicine called for reform of the existing health care payment system to provide physicians with greater financial incentives for quality improvement.25 Although the philosophy of rewarding performance is standard in other industries, it remains somewhat foreign in the current health care environment.20,26 Nevertheless, at least 35 health plans representing 30 million members currently offer pay-for-performance programs, and it is anticipated that more than 80 plans will offer these programs by the end of 2006.27 The largest of the pay-for-performance programs include Bridges to Excellence, a not-for-profit organization that rewards providers for improved quality in diabetes and cardiac care; Rewarding Results, an initiative of the Robert Wood Johnson Foundation and the California HealthCare Foundation that aligns financial incentives with high-quality care, particularly for patients with chronic diseases; and the Payfor-Performance (P4P) program, a key initiative of the Integrated Healthcare Association (IHA) that rewards high-quality care in several clinical areas, including asthma. This program is 1 of 6 grantees of the Robert Wood Johnson– California HealthCare Foundation Rewarding Results initiative. Bridges to Excellence rewards physicians who have implemented information technology (IT) solutions (ie, electronic medical records, electronic prescribing software, and medical error–reduction systems) and who have demonstrated positive outcomes in diabetes or cardiac care.28 This program also provides products and tools to promote self-care of cardiac and diabetic patients and to identify local physicians who meet high performance standards. Similarly, Rewarding Results ties incentives to high-quality health care delivered by hospitals and physicians and offers monographs, toolkits, and various other publications to assist grantees in the implementation of incentive programs.20,29 To ensure that peer groups are comparable, some incentive programs match patients to providers based on patient demographics, comorbidities, and severity indices. The IHA P4P program was launched in January 2002 and is currently the nation’s largest and most ambitious physician incentive program.30 The IHA is a collaborative leadership group of California health plans, physician groups, health care systems, and academic, purchaser, consumer, and pharmaceutical representatives. The goals of P4P are to implement a common set of measures for physician groups (ie, a
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scorecard) and to publicly report those scores for California physician groups.31 Like other physician incentive programs, the P4P plan financially rewards physician groups that demonstrate good clinical performance and patient satisfaction and have qualifying investments in IT. Because multiple plans will offer incentive payments against the same criteria, it is possible for physician groups to earn substantial multiple rewards.32 Medical groups are eligible to receive bonuses of up to 3.5% of their annual capitation, with providers ranking in the top 25% receiving a portion of the payout.28 It has been projected that in the next 5 to 10 years, pay-for-performance– based compensation could account for up to 30% of the amount physicians are paid by the program.30 The P4P initiative is supported by the direct involvement of numerous purchasers, as represented by the Pacific Business Group on Health and CalPERS (California Public Employees’ Retirement System), the NCQA, the California Association of Physician Groups, the State of California (Department of Managed Health Care and Office of the Patient Advocate), and the California HealthCare Foundation.
In September 2001, 6 major California health plans, representing more than 7 million health maintenance organization enrollees, agreed to participate in the program.31 Data are being collected for 45,000 physicians, representing nearly 300 physician organizations. Participating physicians submitted data in early 2003, and the first bonuses, nearly $50 million, were paid out in the fall of 2004.26,28 The number of measures included in P4P and the funding available for rewards are expected to increase with time. Second-year (2004) incentive payments are being paid out as this publication goes to press. A central feature of the P4P program is the development of a single public scorecard that contains measures from 3 key areas: clinical quality, patient satisfaction, and investment in IT (Fig 2).31 The clinical measure descriptions used in the program are based on HEDIS measures and compose 40% of the total score.26 These clinical measures reflect performance on select areas of preventive care (mammograms, Papanicolaou smears, childhood immunizations, and Chlamydia screening) and the quality of management for 3 chronic conditions (asthma, diabetes, and coronary artery disease).
Figure 2. Data collection process in the Pay-for-Performance program. CCHRI indicates California Cooperative Healthcare Reporting Initiative; NCQA-DDD, National Committee for Quality Assurance–Diversified Data Design Corp. From Davies TJ. Pay for performance: a business case for quality for California physician groups. Manag Care. 2004;13(suppl 10):3– 8. Source: Integrated Healthcare Association.
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The Use of Appropriate Medications for People With Asthma is used to measure the quality of asthma care. The patient satisfaction score accounts for 40% of the total score and is derived from measures for specialty care, timely access to care, physician-patient communication, and overall ratings of care. The investment in IT is weighted at 20% of the total score and measures a plan’s use of integrative clinical electronic data sets at the group level and the ability to support clinical decision making at the point of care.26 Such technology includes building patient registries for patients with chronic diseases, use of electronic medical records, and using reminder systems at the point of care.28 Administrative results for clinical measures are collected and submitted to a data aggregator by either the participating plan or the physician group.31 The data aggregator combines these data with the patient experience and IT results to develop a single report card for each physician group. The resulting scorecards are published by the California Office of the Patient Advocate and are released in September of each year. Consumers can also access scorecards through the Office of the Patient Advocate Web site (http://www.opa.ca. gov). A sample scorecard is depicted in Figure 3. All clinical data submitted for P4P are audited according to HEDIS compliance audit standards to ensure that results are reported accurately.31 Although the impact of physician incentive programs on outcomes is currently unknown, all stakeholders in the health
care system are anticipated to benefit from P4P. Publicly reported scorecards empower consumers to make more informed choices and provide purchasers an objective measure to differentiate providers.32 Physician groups and individual physicians receive public recognition and financial rewards for their investments in quality and IT improvement, whereas health plans project a positive public image and benefit from system improvements and the improved health of plan members. Purchasers benefit from healthier employees and subsequent reductions in absenteeism and presenteeism. Finally, improved health for plan members should not only improve quality of life but also reduce long-term costs associated with urgent care and ED visits, hospitalizations, and absenteeism and presenteeism in the workplace. FUTURE STRATEGIES Efforts to enhance the quality of asthma care in the future are likely to focus on expanding physician incentive programs, such as P4P, Bridges to Excellence, and Rewarding Results. This model may also impact Medicare reimbursement, a possibility reflected in the April 2005 launch of the first public pay-for-performance program by the Centers for Medicare and Medicaid Services.34 Improvements in IT systems will continue to be emphasized, with anticipated increases in the use of electronic medical records, prescribing software, medical error–reduction systems, and reminder systems for point of care. Clinical toolkits, monographs, and
Figure 3. Sample quality-of-care report card generated from the Pay-for-Performance program. Adapted with permission from the Office of the Patient Advocate. Actual quality-of-care report cards are available at http://www.opa.ca.gov.33
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various education and diagnostic aids should become available to help physicians improve asthma care, to help asthmatic patients engage in their own care, and to encourage adherence to the NHLBI guidelines. Furthermore, new pharmacologic agents may become available that will improve adherence and safety or offer superior disease-modifying properties to existing therapies. CONCLUSIONS Despite effective treatment and the availability of national clinical practice guidelines, many patients with asthma continue to receive suboptimal care, resulting in escalating morbidity and associated costs. The disproportionate and rising costs of asthma demand efforts to measure and improve the effectiveness of asthma care. The most widely used asthma performance tool is the HEDIS measure, which has been demonstrated to predict asthma outcomes in several studies.22,24 Despite these results, the need for refinement of the HEDIS measure has been suggested because of a variety of limitations. Although still evolving, the era of public reporting and pay-for-performance in health care has arrived, and this model is believed to be a strong harbinger of the future health care payment system in the United States.35 The P4P program initiated by the IHA, the largest and most ambitious physician incentive program launched to date, rewards physician groups based on their performance in clinical quality, patient satisfaction, and investment in IT. The HEDIS asthma measure is used to determine performance in asthma care. Although few data regarding the effectiveness of physician incentive programs are currently available, it is hoped that these programs will offer solutions to the parallel problems of escalating costs and declining quality of asthma care. REFERENCES 1. Centers for Disease Control and Prevention. Asthma prevalence, health care use and mortality, 2002. Available at: http:// www.cdc.gov/nchs/data/asthmahealthestat1.pdf. Accessed July 7, 2005. 2. American Lung Association. Trends in asthma morbidity and mortality. Available at: http://www.lungusa.org/atf/cf/ %7B7A8D42C2-FCCA-4604 – 8ADE-7F5D5E762256%7D/ ASTHMA1.PDF. Accessed February 25, 2005. 3. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma—United States, 1980 –1999. MMWR Surveill Summ. 2002;51:1–13. 4. Hemp P. Presenteeism: at work— but out of it. Harv Bus Rev. 2004;82:49 –58. 5. National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1997. NIH publication 97-4051. 6. National Asthma Education and Prevention Program. Clinical Practice Guidelines: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics 2002. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 2002. NIH publication 02-5075.
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7. National Heart, Lung, and Blood Institute, Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Bethesda, MD: National Institutes of Health; 2004. NIH publication 02-3659. 8. Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled -agonists and underuse of inhaled corticosteroids. Arch Intern Med. 1999;159:2697–2704. 9. Asthma in America: Executive Summary. Available at: http:// www.asthmainamerica.com. Accessed February 23, 2005. 10. Hartert TV, Windom HH, Peebles RS Jr, Freidhoff LR, Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100: 386 –394. 11. Sin DD, Man SF. Low-dose inhaled corticosteroid therapy and risk of emergency department visits for asthma. Arch Intern Med. 2002;162:1591–1595. 12. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:887– 891. 13. Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma. Pediatrics. 2001;107:706 –711. 14. Williams LK, Pladevall M, Xi H, et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol. 2004;114: 1288 –1293. 15. Department of Health and Human Services. Action against asthma: a strategic plan for the Department of Health and Human Services. Available at: http://aspe.hhs.gov/sp/asthma. Accessed September 1, 2005. 16. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990;112: 864 – 871. 17. Zeiger RS, Heller S, Mellon MH, Wald J, Falkoff R, Schatz M. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991; 87:1160 –1168. 18. Burton WN, Connerty CM, Schultz AB, Chen C-Y, Edington DW. Bank One’s worksite-based asthma disease management program. J Occup Environ Med. 2001;43:75– 82. 19. Epstein AM, Lee TH, Hamel MB. Paying physicians for highquality care. N Engl J Med. 2004;350:406 – 410. 20. Corrigan K, Ryan RH. New reimbursement models reward clinical excellence. Healthc Financ Manage. 2004;58:88 –92. 21. Cabana MD, Slish KK, Nan B, Clark NM. Limits of the HEDIS criteria in determining asthma severity for children. Pediatrics. 2004;114:1049 –1055. 22. Berger WE, Legorreta AP, Blaiss MS, et al. The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes. Ann Allergy Asthma Immunol. 2004;93:538 –545. 23. National Committee for Quality Assurance. HEDIS 2004 Technical Specifications: Use of Appropriate Medications for People With Asthma. Washington, DC: National Committee for Quality Assurance; 2003. 24. Fuhlbrigge A, Carey VJ, Adams RJ, et al. Evaluation of asthma prescription measures and health system performance based on emergency department utilization. Med Care. 2004;42: 465– 471.
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25. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 26. Davies TJ. Pay for performance: a business case for quality for California physician groups. Manag Care. 2004;13(suppl 10): 3– 8. 27. Endsley S, Kirkegaard M, Baker G, Murcko AC. Getting rewards for your results: pay-for-performance programs. Fam Pract Manag. 2004;11:45–50. 28. Pay for performance. Health Manage Tech. 2004;8:56. 29. Rewarding Results Web site. Available at: http:// www.leapfroggroup.org/RewardingResults/about.htm. Accessed May 3, 2005. 30. Landro L. To get doctors to do better, health plans try cash bonuses. Wall Street Journal. September 17, 2004:A1. 31. National Committee for Quality Assurance. Integrated Healthcare Association Pay for Performance Program: 2004 Clinical Measure Specifications and Audit Review Guidelines. Washington, DC: National Committee for Quality Assurance; 2003. 32. Integrated Healthcare Association. Pay for performance: a business case for rewarding physician group excellence. Available
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at: http://www.iha.org/payfpov1.htm. Accessed February 25, 2005. 33. California Office of the Patient Advocate. Medical group quality. Available at: http://www.opa.ca.gov/report_card/med_groups/ rating_summary_report.asp. Accessed June 29, 2005. 34. Glendinning D. Medicare tests pay-for-performance: the AMA urges focus on quality improvement over cost control in the demonstration project. Available at: http://www.amednews.com. Accessed February 21, 2005. 35. Corrigan K, Ryan RH. Pay-for-performance is far from a certainty. Healthc Financ Manage. 2005;6.
Requests for reprints should be addressed to: Erwin W. Gelfand, MD Chairman, Department of Pediatrics National Jewish Medical and Research Center 1400 Jackson St Denver, CO 80206 E-mail: [email protected]
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Use of the Health Plan Employer Data and Information Set for measuring and improving the quality of asthma care Erwin W. Gelfand, MD*; Gene L. Colice, MD†; Leonard Fromer, MD, FAAFP‡; William B. Bunn III, MD, JD, MPH§; and Thomas J. Davies, JD, MPA¶
Objectives: To discuss the Health Plan Employer Data and Information Set (HEDIS) criteria for measuring performance in asthma care and to review new strategies to improve the quality of asthma care. Data Sources: Expert opinion from a roundtable on National Committee for Quality Assurance HEDIS and asthma care, supplemented with a MEDLINE database search to identify articles published between January 1, 1990, and May 31, 2005, with the following keywords in the title: asthma plus HEDIS, pay for performance, incentive programs, reimbursement, or employee education. Study Selection: Studies and review articles were selected for their relevance to measuring the quality of asthma care using HEDIS and improving care using newer trends, such as employee education and physician incentive programs. Results: Components of the HEDIS asthma measure have been found to correlate with outcomes, including risk of hospitalization and emergency department visits. However, refinements to the measure may be needed because it may misclassify a portion of patients as having persistent asthma who actually have intermittent asthma according to National Heart, Lung, and Blood Institute criteria. Physician incentive programs are increasingly being explored as a means of improving the quality of care while managing costs. Under current pay-for-performance programs, rewards are issued to providers who demonstrate highquality care based on the HEDIS asthma measure. Conclusions: The HEDIS asthma measure remains the most widely used performance tool for evaluating the quality of asthma care. Reimbursement models based on public reporting and pay for performance are expected to be a strong component of future health care payment systems. Ann Allergy Asthma Immunol. 2006;97:298–305.
INTRODUCTION Asthma continues to be a leading serious chronic disease among adults and children in the United States, accounting for 480,000 hospitalizations,1 1.9 million emergency department (ED) visits,1 and an estimated $14 billion in health care costs2 annually. The prevalence of asthma began increasing in 1980, with a nearly 74% increase occurring between 1980 and 1996.3 Asthma is now the most common chronic disease * Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado. † Department of Medicine, The George Washington University School of Medicine, and Pulmonary, Critical Care, and Respiratory Services, Washington Hospital Center, Washington, DC. ‡ Department of Family Medicine, University of California, Los Angeles, Los Angeles, California. § Health, Safety, Security, and Productivity, International Truck & Engine Corp, and Northwestern University School of Medicine, Chicago, Illinois. ¶ Integrated Healthcare Association, Oakland, California. This article was supported by an educational grant from Sanofi-Aventis Inc and ALTANA Pharma. Received for publication September 22, 2005. Accepted for publication in revised form March 20, 2006.
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of childhood, affecting an estimated 6.3 million children in the United States in 20012 and accounting for 14 million lost school days in 2002.1 Despite the availability of effective therapy and an improved understanding of asthma pathogenesis, physician visits, hospital outpatient visits, and ED visits for asthma have continued to increase during the past decade at alarming rates.3 Although hospitalization rates for asthma have declined since the mid-1980s,3 inpatient hospital services remain the largest single direct medical expenditure for asthma.2 Asthma has a profound impact in the workplace, accounting for 14.5 million workdays lost each year in the United States3 and a substantial, if unmeasured, effect on presenteeism. Presenteeism, or the problem of workers being on the job but not fully functioning because of illness or other medical conditions, is an important cause of loss of productivity because illnesses people take with them to work are so prevalent, frequently remain untreated, and typically occur during the peak working years.4 Loss of productivity results in high indirect costs, which may be largely invisible to employers. Studies have demonstrated that presenteeism
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costs to employers exceed those for direct medical care by 2to 3-fold.4 In response to the increase in asthma prevalence and mortality that occurred in the 1980s, national and international treatment guidelines were developed with the aim of improving asthma care.5–7 Despite the availability of these guidelines for more than a decade, they are not followed routinely in clinical practice in the United States, and many patients continue to receive suboptimal care for their asthma severity level.8 –10 Although emphasized as the preferred long-term control medication for patients with persistent asthma,6 inhaled corticosteroids (ICSs) continue to be underused, whereas short-acting 2-agonists are frequently overused.8,9 This is especially alarming in light of evidence that ICSs significantly improve asthma outcomes,6 with patients receiving ICSs having nearly half the risk of ED visit relapse and hospitalization as nonusers.11–13 Indeed, poor adherence to these agents has been reported to account for most hospitalizations for asthma.14 Furthermore, recent data suggest that most asthmatic patients are not receiving education regarding management of their disease, as recommended in the National Heart, Lung, and Blood Institute (NHLBI) guidelines, with most patients reporting failure to receive instruction on peak flow meter or inhaler use or a written treatment plan from their physician.9 Suboptimal care for asthma and its associated costs constitute an important public health problem that has captured the attention of clinical experts and government agencies.5,15 Furthermore, the significant impact of asthma in the workplace has captured the attention of payers and health plans, prompting them to explore new methods for measuring and improving the quality of asthma care. Although various disease management programs have demonstrated some efficacy in improving asthma outcomes,16,17 newer strategies for improving care while stabilizing costs are being studied. Offering disease management or education programs at the worksite is an increasingly popular strategy for enhancing patient participation in a cost-effective location.18 Incentive programs that reward physician groups for using performance measures that improve clinical processes are also increasing in number and are expected to produce fundamental changes in the way practicing physicians are compensated.19 Most of these pay-for-performance programs currently base their clinical standards on Health Plan Employer Data and Information Set (HEDIS) measures, which have become the most widely used criteria for measuring performance in the managed care industry. Although still evolving, reimbursement models based on public reporting and pay-for-performance concepts are now being used for asthma care and are anticipated to become prevalent in health care in the next 5 to 10 years.20 This article reviews use of the HEDIS criteria for measuring the quality of asthma care and the new trends in strategies being investigated to control costs and improve asthma care.
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MEASURING PERFORMANCE: THE HEDIS ASTHMA MEASURE Measuring the quality of asthma care is a critical component of improving patient outcomes.21 The HEDIS is the most frequently used set of performance measures in the managed care industry, with nearly 75% of the largest US employers using the measures to evaluate and set performance guarantees for health plans caring for their employees.22 The National Committee for Quality Assurance (NCQA) developed and maintains HEDIS as a tool to evaluate health plan performance across a range of criteria, to allow objective planto-plan comparisons, and to establish accountability in managed care.22 The HEDIS is an important industry standard and is viewed by regulators, consumers, and public purchasers of health care as an accepted “report card” for health plan performance.22 Currently, HEDIS assesses several measures, including effectiveness of care, access to or availability of care, satisfaction with the experience of care, health plan stability, use of services, cost of care, informed health care choices, and health plan descriptive information. In 1999, the NCQA added a specific quality evaluation measure to HEDIS, the Use of Appropriate Medications for People With Asthma. As depicted in Figure 1, the HEDIS asthma measure determines the percentage of health plan members with persistent asthma who were appropriately prescribed long-term control medication during the measurement year.23 The measure is reported for 3 age cohorts (5–9 years, 10 –17 years, and 18 –56 years) and as a combined rate.23 Although based on the NHLBI guidelines, the HEDIS asthma measure differs in that it uses medical claims data collected during the previous year rather than clinical evaluation of recent symptoms.21 Furthermore, the HEDIS asthma measure is pertinent to a continuously enrolled population of health plan members compared with individual patients.21 Consistent with the NHLBI guidelines, the HEDIS asthma measure considers the following medications to be acceptable therapy for long-term control of asthma: (1) ICSs (preferred therapy), (2) cromolyn sodium and nedocromil (alternative therapy for mild persistent asthma), (3) leukotriene modifiers (alternative therapy for mild persistent asthma), and (4) methylxanthines (alternative but not preferred therapy for mild persistent asthma). If prescribed alone without ICSs, longacting 2-agonists are not counted in the numerator because they are recommended in the National Asthma Education and Prevention Program guidelines as add-on rather than primary therapy for persistent asthma.23 To characterize the ability of the HEDIS criteria to evaluate asthma severity, Cabana et al21 conducted a cross-sectional study in which data from a nationwide sample of pediatric asthmatic patients were analyzed. An 86-item interview was conducted with the parents of 896 patients aged 2 to 12 years with an active clinical diagnosis of asthma. The HEDIS asthma criteria, as evaluated by parent report, were used to classify patients with persistent asthma. These criteria included any ED visit for asthma during the past year, any
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Figure 1. The 2005 Health Plan Employer Data and Information Set (HEDIS) measure for use of appropriate medications for people with asthma. *For HEDIS 2006, there is a proposal to change the denominator eligibility criteria from 1 year (the year before the measurement year) to 2 years (the year before plus the measurement year). **A dispensing event is 1 prescription of an amount lasting 30 days or less. Two different prescriptions dispensed on the same day are counted as 2 different dispensing events. To calculate dispensing events for prescriptions longer than for 30 days, managed care organizations should divide the days’ supply by 30 and round up to convert. ED indicates emergency department.23
hospitalization for asthma during the past year, 4 or more outpatient asthma visits and 2 or more asthma medication– dispensing events in the past year, and 4 or more asthma medication– dispensing events in the past year. By comparison, patients were classified as having persistent asthma according to the NHLBI criteria when their parents reported that they had nighttime asthma symptoms more than 2 nights per month or daytime symptoms more than 2 days per week.21 The sensitivity of each HEDIS criterion, alone and combined, was calculated using the NHLBI criteria as a reference. The proportion of patients classified as having persistent asthma was greater when based on the HEDIS criteria (656 [73%]) than on the NHLBI criteria (338 [38%]).21 When analyzed separately, a single hospitalization and a single ED visit had high specificity for persistent asthma (0.98 and 0.90, respectively), but both had low sensitivity. When the HEDIS criteria were combined, sensitivity increased to 0.89, but specificity declined to 0.70.21 Of the 346 patients without daily controller medication therapy, specificity remained fairly high (0.68), but sensitivity decreased to 0.45. These results suggest that many patients with intermittent asthma symptoms based on the NHLBI clinical criteria would be classified as having persistent asthma according to the HEDIS criteria.21 Limitations of this study include the use of parent recall rather than actual claims data, the assumption that “as-needed use” of a medication was equivalent to 1 medication-dispensing event, the lack of data from pulmonary function tests for NHLBI classification of severity, and the inclusion of only a pediatric population. Nevertheless, the authors emphasized that the HEDIS criteria for persistent asthma may include children who may not require daily controller medications and suggested that these criteria be
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used with caution when interpreting the quality of asthma care. Despite this concern, the ability of the HEDIS asthma measure to predict asthma-related outcomes has been demonstrated in several trials.22,24 In a retrospective study, Berger et al22 analyzed claims for 49,637 patients with persistent asthma for use of controller medications, ED visits, and hospitalization claims. Patients were stratified by use of controller medications and by adherence, which was measured as the total days’ supply of medication dispensed.22 Nearly 46% of the patients were not using long-term controller medications, whereas 36% and 18% were using 1 or more than 1 class of long-term controller medication, respectively.22 More than 25% of the patients did not receive any medication in the measurement year. When the subgroup of patients receiving ICSs was analyzed, it was observed that patients with low adherence to these agents had a higher risk of hospitalization or ED visits (odds ratio [OR], 2.23; 95% confidence interval [CI], 1.79 –2.78) compared with those with moderate (OR, 0.81; 95% CI, 0.43–1.51) or high (OR, 0.37; 95% CI, 0.05– 2.69) adherence.22 Based on these data, the authors suggested that some refinements to the HEDIS asthma measure may be needed.22 Although data comparing outcomes in patients receiving ICSs vs alternative long-term control medications are needed, it was suggested that the equal weighting of ICSs to other long-term control therapies should be reevaluated in the current HEDIS definition of appropriate therapy.22 They further suggested that a measure of adherence be incorporated into the definition. Last, given that more than 25% of the patients identified as having persistent asthma in the study22 were not receiving any asthma medication, the authors cautioned that
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the HEDIS asthma measure, as written, may mislabel a proportion of people with intermittent asthma as having persistent asthma. Association of the HEDIS asthma measure with subsequent risk of ED asthma visits was examined in a crosssectional analysis24 of pharmacy and health care utilization data in children aged 3 to 15 years identified as having persistent asthma. A correlation between the HEDIS asthma measure and the risk of an ED visit was noted in patients with persistent asthma, with the dispensing of a controller medication lowering the risk of an ED visit by more than two thirds (OR, 0.3; 95% CI, 0.2– 0.4).24 The correlation depended on the underlying level of reliever dispensing, with greater protection conferred to children who received fewer than 4 reliever dispensings per person-year compared with those who received 4 or more reliever dispensings per personyear.24 The authors concluded that the HEDIS asthma measure as a performance measure can help stratify children with asthma based on their risk of future adverse events.24 IMPROVING PERFORMANCE: NEW STRATEGIES FOR IMPROVING ASTHMA CARE Employee Education Programs Asthma disease management programs have been used in a variety of health care settings,16 –18 but few studies have evaluated the value of such programs in the workplace. Burton et al18 reported the results of a worksite asthma education program offered to Bank One employees at no cost. Seventy-six employees of Bank One with nonoccupational asthma agreed to participate in the FirstAir Asthma Education Program, which consisted of 5 weekly 1-hour educational classes taught by an occupational health nurse during lunchtime.18 Free lunches and educational materials were provided as incentives to promote attendance. Participants completed the Asthma Therapy Assessment Questionnaire at the beginning of the program and 2, 4, and 12 months after the first session.18 Patient satisfaction questionnaires were also completed at the final educational session. Although the conclusions were limited by the small sample size, the program was found to have significantly improved asthma knowledge, patient perception, and medication use, immediately and 12 months after the first session.18 Results of the Asthma Therapy Assessment Questionnaire demonstrated significant reductions in communication barriers (P ⬍ .01), knowledge deficiency (P ⬍ .10), and self-efficacy barriers (P ⬍ .05) 12 months after initiation of the educational intervention.18 All asthma control measures were improved at 12 months, with significant improvements occurring in absenteeism (P ⬍ .05), overuse of reliever medications (P ⬍ .001), no written control plan (P ⬍ .10), medicine preference not known by the physician (P ⬍ .05), having a prescription for controller medicines (P ⬍ .001), and taking controller medicines every day (P ⬍ .001). In addition, the appropriate use of reliever and controller medications improved significantly (P ⬍ .001).18 More data are needed to determine the value of
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worksite interventions, but the improvements in asthma control demonstrated in this study would be expected to result in reduced direct and indirect costs to employers, enhanced quality of life, and reduced medical costs to employees. Pay-for-Performance Programs Limitations of traditional health care reimbursement models, along with greater public scrutiny and disclosure of clinical quality standards, have forced health plans and providers to explore new reimbursement models to improve quality of care while managing costs.20 Provider-focused initiatives are increasingly recognized and used as promising methods for achieving this goal. In 2001, the Institute of Medicine called for reform of the existing health care payment system to provide physicians with greater financial incentives for quality improvement.25 Although the philosophy of rewarding performance is standard in other industries, it remains somewhat foreign in the current health care environment.20,26 Nevertheless, at least 35 health plans representing 30 million members currently offer pay-for-performance programs, and it is anticipated that more than 80 plans will offer these programs by the end of 2006.27 The largest of the pay-for-performance programs include Bridges to Excellence, a not-for-profit organization that rewards providers for improved quality in diabetes and cardiac care; Rewarding Results, an initiative of the Robert Wood Johnson Foundation and the California HealthCare Foundation that aligns financial incentives with high-quality care, particularly for patients with chronic diseases; and the Payfor-Performance (P4P) program, a key initiative of the Integrated Healthcare Association (IHA) that rewards high-quality care in several clinical areas, including asthma. This program is 1 of 6 grantees of the Robert Wood Johnson– California HealthCare Foundation Rewarding Results initiative. Bridges to Excellence rewards physicians who have implemented information technology (IT) solutions (ie, electronic medical records, electronic prescribing software, and medical error–reduction systems) and who have demonstrated positive outcomes in diabetes or cardiac care.28 This program also provides products and tools to promote self-care of cardiac and diabetic patients and to identify local physicians who meet high performance standards. Similarly, Rewarding Results ties incentives to high-quality health care delivered by hospitals and physicians and offers monographs, toolkits, and various other publications to assist grantees in the implementation of incentive programs.20,29 To ensure that peer groups are comparable, some incentive programs match patients to providers based on patient demographics, comorbidities, and severity indices. The IHA P4P program was launched in January 2002 and is currently the nation’s largest and most ambitious physician incentive program.30 The IHA is a collaborative leadership group of California health plans, physician groups, health care systems, and academic, purchaser, consumer, and pharmaceutical representatives. The goals of P4P are to implement a common set of measures for physician groups (ie, a
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scorecard) and to publicly report those scores for California physician groups.31 Like other physician incentive programs, the P4P plan financially rewards physician groups that demonstrate good clinical performance and patient satisfaction and have qualifying investments in IT. Because multiple plans will offer incentive payments against the same criteria, it is possible for physician groups to earn substantial multiple rewards.32 Medical groups are eligible to receive bonuses of up to 3.5% of their annual capitation, with providers ranking in the top 25% receiving a portion of the payout.28 It has been projected that in the next 5 to 10 years, pay-for-performance– based compensation could account for up to 30% of the amount physicians are paid by the program.30 The P4P initiative is supported by the direct involvement of numerous purchasers, as represented by the Pacific Business Group on Health and CalPERS (California Public Employees’ Retirement System), the NCQA, the California Association of Physician Groups, the State of California (Department of Managed Health Care and Office of the Patient Advocate), and the California HealthCare Foundation.
In September 2001, 6 major California health plans, representing more than 7 million health maintenance organization enrollees, agreed to participate in the program.31 Data are being collected for 45,000 physicians, representing nearly 300 physician organizations. Participating physicians submitted data in early 2003, and the first bonuses, nearly $50 million, were paid out in the fall of 2004.26,28 The number of measures included in P4P and the funding available for rewards are expected to increase with time. Second-year (2004) incentive payments are being paid out as this publication goes to press. A central feature of the P4P program is the development of a single public scorecard that contains measures from 3 key areas: clinical quality, patient satisfaction, and investment in IT (Fig 2).31 The clinical measure descriptions used in the program are based on HEDIS measures and compose 40% of the total score.26 These clinical measures reflect performance on select areas of preventive care (mammograms, Papanicolaou smears, childhood immunizations, and Chlamydia screening) and the quality of management for 3 chronic conditions (asthma, diabetes, and coronary artery disease).
Figure 2. Data collection process in the Pay-for-Performance program. CCHRI indicates California Cooperative Healthcare Reporting Initiative; NCQA-DDD, National Committee for Quality Assurance–Diversified Data Design Corp. From Davies TJ. Pay for performance: a business case for quality for California physician groups. Manag Care. 2004;13(suppl 10):3– 8. Source: Integrated Healthcare Association.
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The Use of Appropriate Medications for People With Asthma is used to measure the quality of asthma care. The patient satisfaction score accounts for 40% of the total score and is derived from measures for specialty care, timely access to care, physician-patient communication, and overall ratings of care. The investment in IT is weighted at 20% of the total score and measures a plan’s use of integrative clinical electronic data sets at the group level and the ability to support clinical decision making at the point of care.26 Such technology includes building patient registries for patients with chronic diseases, use of electronic medical records, and using reminder systems at the point of care.28 Administrative results for clinical measures are collected and submitted to a data aggregator by either the participating plan or the physician group.31 The data aggregator combines these data with the patient experience and IT results to develop a single report card for each physician group. The resulting scorecards are published by the California Office of the Patient Advocate and are released in September of each year. Consumers can also access scorecards through the Office of the Patient Advocate Web site (http://www.opa.ca. gov). A sample scorecard is depicted in Figure 3. All clinical data submitted for P4P are audited according to HEDIS compliance audit standards to ensure that results are reported accurately.31 Although the impact of physician incentive programs on outcomes is currently unknown, all stakeholders in the health
care system are anticipated to benefit from P4P. Publicly reported scorecards empower consumers to make more informed choices and provide purchasers an objective measure to differentiate providers.32 Physician groups and individual physicians receive public recognition and financial rewards for their investments in quality and IT improvement, whereas health plans project a positive public image and benefit from system improvements and the improved health of plan members. Purchasers benefit from healthier employees and subsequent reductions in absenteeism and presenteeism. Finally, improved health for plan members should not only improve quality of life but also reduce long-term costs associated with urgent care and ED visits, hospitalizations, and absenteeism and presenteeism in the workplace. FUTURE STRATEGIES Efforts to enhance the quality of asthma care in the future are likely to focus on expanding physician incentive programs, such as P4P, Bridges to Excellence, and Rewarding Results. This model may also impact Medicare reimbursement, a possibility reflected in the April 2005 launch of the first public pay-for-performance program by the Centers for Medicare and Medicaid Services.34 Improvements in IT systems will continue to be emphasized, with anticipated increases in the use of electronic medical records, prescribing software, medical error–reduction systems, and reminder systems for point of care. Clinical toolkits, monographs, and
Figure 3. Sample quality-of-care report card generated from the Pay-for-Performance program. Adapted with permission from the Office of the Patient Advocate. Actual quality-of-care report cards are available at http://www.opa.ca.gov.33
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various education and diagnostic aids should become available to help physicians improve asthma care, to help asthmatic patients engage in their own care, and to encourage adherence to the NHLBI guidelines. Furthermore, new pharmacologic agents may become available that will improve adherence and safety or offer superior disease-modifying properties to existing therapies. CONCLUSIONS Despite effective treatment and the availability of national clinical practice guidelines, many patients with asthma continue to receive suboptimal care, resulting in escalating morbidity and associated costs. The disproportionate and rising costs of asthma demand efforts to measure and improve the effectiveness of asthma care. The most widely used asthma performance tool is the HEDIS measure, which has been demonstrated to predict asthma outcomes in several studies.22,24 Despite these results, the need for refinement of the HEDIS measure has been suggested because of a variety of limitations. Although still evolving, the era of public reporting and pay-for-performance in health care has arrived, and this model is believed to be a strong harbinger of the future health care payment system in the United States.35 The P4P program initiated by the IHA, the largest and most ambitious physician incentive program launched to date, rewards physician groups based on their performance in clinical quality, patient satisfaction, and investment in IT. The HEDIS asthma measure is used to determine performance in asthma care. Although few data regarding the effectiveness of physician incentive programs are currently available, it is hoped that these programs will offer solutions to the parallel problems of escalating costs and declining quality of asthma care. REFERENCES 1. Centers for Disease Control and Prevention. Asthma prevalence, health care use and mortality, 2002. Available at: http:// www.cdc.gov/nchs/data/asthmahealthestat1.pdf. Accessed July 7, 2005. 2. American Lung Association. Trends in asthma morbidity and mortality. Available at: http://www.lungusa.org/atf/cf/ %7B7A8D42C2-FCCA-4604 – 8ADE-7F5D5E762256%7D/ ASTHMA1.PDF. Accessed February 25, 2005. 3. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma—United States, 1980 –1999. MMWR Surveill Summ. 2002;51:1–13. 4. Hemp P. Presenteeism: at work— but out of it. Harv Bus Rev. 2004;82:49 –58. 5. National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 1997. NIH publication 97-4051. 6. National Asthma Education and Prevention Program. Clinical Practice Guidelines: Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics 2002. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 2002. NIH publication 02-5075.
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7. National Heart, Lung, and Blood Institute, Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Bethesda, MD: National Institutes of Health; 2004. NIH publication 02-3659. 8. Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult patients with asthma: factors associated with overuse of inhaled -agonists and underuse of inhaled corticosteroids. Arch Intern Med. 1999;159:2697–2704. 9. Asthma in America: Executive Summary. Available at: http:// www.asthmainamerica.com. Accessed February 23, 2005. 10. Hartert TV, Windom HH, Peebles RS Jr, Freidhoff LR, Togias A. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100: 386 –394. 11. Sin DD, Man SF. Low-dose inhaled corticosteroid therapy and risk of emergency department visits for asthma. Arch Intern Med. 2002;162:1591–1595. 12. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277:887– 891. 13. Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma. Pediatrics. 2001;107:706 –711. 14. Williams LK, Pladevall M, Xi H, et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol. 2004;114: 1288 –1293. 15. Department of Health and Human Services. Action against asthma: a strategic plan for the Department of Health and Human Services. Available at: http://aspe.hhs.gov/sp/asthma. Accessed September 1, 2005. 16. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med. 1990;112: 864 – 871. 17. Zeiger RS, Heller S, Mellon MH, Wald J, Falkoff R, Schatz M. Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits. J Allergy Clin Immunol. 1991; 87:1160 –1168. 18. Burton WN, Connerty CM, Schultz AB, Chen C-Y, Edington DW. Bank One’s worksite-based asthma disease management program. J Occup Environ Med. 2001;43:75– 82. 19. Epstein AM, Lee TH, Hamel MB. Paying physicians for highquality care. N Engl J Med. 2004;350:406 – 410. 20. Corrigan K, Ryan RH. New reimbursement models reward clinical excellence. Healthc Financ Manage. 2004;58:88 –92. 21. Cabana MD, Slish KK, Nan B, Clark NM. Limits of the HEDIS criteria in determining asthma severity for children. Pediatrics. 2004;114:1049 –1055. 22. Berger WE, Legorreta AP, Blaiss MS, et al. The utility of the Health Plan Employer Data and Information Set (HEDIS) asthma measure to predict asthma-related outcomes. Ann Allergy Asthma Immunol. 2004;93:538 –545. 23. National Committee for Quality Assurance. HEDIS 2004 Technical Specifications: Use of Appropriate Medications for People With Asthma. Washington, DC: National Committee for Quality Assurance; 2003. 24. Fuhlbrigge A, Carey VJ, Adams RJ, et al. Evaluation of asthma prescription measures and health system performance based on emergency department utilization. Med Care. 2004;42: 465– 471.
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25. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 26. Davies TJ. Pay for performance: a business case for quality for California physician groups. Manag Care. 2004;13(suppl 10): 3– 8. 27. Endsley S, Kirkegaard M, Baker G, Murcko AC. Getting rewards for your results: pay-for-performance programs. Fam Pract Manag. 2004;11:45–50. 28. Pay for performance. Health Manage Tech. 2004;8:56. 29. Rewarding Results Web site. Available at: http:// www.leapfroggroup.org/RewardingResults/about.htm. Accessed May 3, 2005. 30. Landro L. To get doctors to do better, health plans try cash bonuses. Wall Street Journal. September 17, 2004:A1. 31. National Committee for Quality Assurance. Integrated Healthcare Association Pay for Performance Program: 2004 Clinical Measure Specifications and Audit Review Guidelines. Washington, DC: National Committee for Quality Assurance; 2003. 32. Integrated Healthcare Association. Pay for performance: a business case for rewarding physician group excellence. Available
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at: http://www.iha.org/payfpov1.htm. Accessed February 25, 2005. 33. California Office of the Patient Advocate. Medical group quality. Available at: http://www.opa.ca.gov/report_card/med_groups/ rating_summary_report.asp. Accessed June 29, 2005. 34. Glendinning D. Medicare tests pay-for-performance: the AMA urges focus on quality improvement over cost control in the demonstration project. Available at: http://www.amednews.com. Accessed February 21, 2005. 35. Corrigan K, Ryan RH. Pay-for-performance is far from a certainty. Healthc Financ Manage. 2005;6.
Requests for reprints should be addressed to: Erwin W. Gelfand, MD Chairman, Department of Pediatrics National Jewish Medical and Research Center 1400 Jackson St Denver, CO 80206 E-mail: [email protected]
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