Physician Practice Patterns

Transcription

1 This document is mde vilble electroniclly by the Minnesot Legisltive Reference Librry s prt of n ongoing digitl rchiving project. Physicin Prctice Ptterns Helth Services nd Medicl Mngement Division Februry, 2010 ~L.-..\ Minnesot Deprtment of Humcm Services Le_9 i_s_l_t_iv_e_r_e--=-p_o_f_t

2 Executive Summry Recent legisltion requires the Helth Services Advisory Council (HSAC) to develop methodology to notify physicins regrding their own prctice ptterns in services where there is high cost or high vribility cross providers. This monitoring nd trcking shll be regrding prctice ptterns ofphysicins providing services to medicl ssistnce, MinnesotCre, nd generl ssistnce medicl cre enrollees under fee-for-service, mnged cre, nd county-bsed purchsing. DHS is developing this cpcity while ensuring tht HSAC mintins its core function of evluting nd recommending to the Commissioner the most pproprite evidence bsed benefit policy for the Minnesot Helth Cre Progrm recipients. Introduction In the 2009 Minnesot legisltive session, the following lw ws pssed (Chpter 70, Article 5, Section 76): Physicin Prctice Ptterns: The Helth Services Policy Committee shll monitor nd trck the prctice ptterns of physicins providing services to medicl ssistnce, MinnesotCre, nd generl ssistnce medicl cre enrollees under fee-for-service, mnged cre, nd county-bsed purchsing. The committee shll focus on services or specilties for which there is high vrition in utiliztion cross physicins, or which re ssocited with high medicl costs. The commissioner, bsed upon the findings of the committee, shll regulrly notify physicins whose prctice ptterns indicte higher thn verge utiliztion or costs. Mnged cre nd county-bsed purchsing plns shll provide the committee with utiliztion nd cost dt necessry to implement this prgrph. Body of Report It is well documented tht vrition exists in utiliztion ofmedicl cre (Wennberg, 2003). To some extent, this vrition reflects differences in illness. According to some reserchers, however, most ofthe vrition reflects differences in the intensity ofprctice (Sirovich 2006). This utiliztion vrition cn be chrcterized s supply sensitive or preference sensitive (Drtmouth Atls, 2007). Preference sensitive cre indictes tht the ptient (nd fmily) choose one option over nother equivlent option bsed on dequte informtion. As n exmple, the decision oflumpectomy vs. mstectomy for erly stge brest cncer reflects preference sensitive choice. Finncil cost my be determinnt in this decision. Supply sensitive cre reflects the supply ofthe service in the community. It is well documented tht t community level, vrying levels of supply cn be ssocited with vrying levels of utiliztion (Wennberg, 2002). Vrition lso exists mong institutions nd individul providers. One study tht evluted the qulity nd outcomes ofcre for lmost one million Medicre enrollees found tht ptients in the highest-intensity regions spent more time in the hospitl nd hd more frequent physicin visits, specilist consulttions, tests, nd minor procedures, but their long-term mortlity rtes (fter djusting for bseline helth sttus) were 2% to 5% higher thn those in the lowest-intensity regions (Fisher 2003). Other ptient-level outcomes, such s qulity ofcre judged by clinicl performnce mesures, nd ptient stisfction with cre were no better (nd were sometimes worse) thn in the lowest intensity regions (Fisher 2003-). Over 600,000 Minnesotns, s monthly verge, receive helth cre through the stte's publicly funded helth cre progrms. Combined expenses for these progrms mount to nerly seven billion dollrs nnully in federl nd stte expenses. Fee-for-service helth cre (excluding long term cre nd mentl! chemicl helth), dministered by the Deprtment of Humn Services (DHS), ccounts for bout one qurter ofthe totl cost nd cover one third ofthe popultion during ny given month. Clims dt re collected for the fee-for-service popultion, while dministrtive dt (service encounters without ssocited fee structures) re obtined from the mnged cre orgniztions tht dminister cre for the remining two thirds ofthe popultion. Studies cn be crried out using dministrtive dtbses derived from dischrge coding informtion. Bsed on n bundnce ofpublished reports, use ofdministrtive dtbses hs become widely ccepted for reserch purposes. These dtbses re dvntgeous becuse they contin informtion regrding the cre for very lrge number ofptients. Utiliztion of provider-specific dt hs been shown to be effective t chnging professionl prctice, ccording to one systemtic review of the literture (Jmtvedt, 2006). According to the review, the effects re usully smll to moderte.

3 To fcilitte the mngement of its fee-for-service cre, DHS is currently developing more robust systems to trck the utiliztion ofhigh-cost, low-vlue, or highly-vrible cre in number ofres, including topics in rdiology utiliztion nd Cesren-section utiliztion. This informtion will be used by the Deprtment to ssist in the development ofevidence-bsed medicl policy for these services. DHS hs recently estblished collbortive Perintl Prctices Advisory Group (PPAG) s subcommittee of HSAC to improve perintl outcomes. This group ws formed following development of dt evluting vritions in fcility utiliztion of Cesren Sections. Although vritions were found mong fcility rtes of C-section use, the nlysis lso highlighted the need for I) collbortive discussion ofprctice ptterns, 2) synergistic shring to understnd the drivers ofsuccessful orgniztionl chnge mong stkeholders, nd 3) building momentum in the medicl community regrding the trnsformtion ofclinicl effectiveness knowledge into improved helth cre qulity nd vlue. This type ofctivity moves beyond mesurement nd ccountbility to the scling nd spred ofeffective interventions (Dougherty, 2009). Two significnt issues rise in the use ofdministrtive dtbses: one is technicl; the second reltes to policy. Technicl limittions in the qulity of the vilble clims dt include: Coding is, t times, inexct s complete coding is not needed (or in some cses possible) for clims billing. Since Medicid recipients tend to pss in nd out ofthe public progrm coverge, it my be difficult to ssure tht the totl cre received by ny recipient over given time period is cptured. Codes nd fields must be understood regrding their use, the chnge in their use over time, nd in how the dt is entered. As n exmple, the use of specific code my chnge over time in response to DHS instructions to providers. Understnding policy chnges such s this is essentil to the interprettion ofthe dt. Policy considertions re lso significnt. Dt on utiliztion, coupled with qulity mesures inferred from tht utiliztion, should be used to drive benefit policy. In this development, there re severl importnt considertions: Dt on physicin prctice ptterns my be used to drive pyment rtes,fcility sttus s Center of Excellence, recertifiction in the Helth Cre Home progrm, etc. Approprite qulity ofthe nlysis, s well s resonble expecttion ofthe ppliction ofsttisticl vlidity, should be chieved. As exmples, the Minnesot DHS my recommend volume crherion for procedure if there is scientific evidence tht higher volume centers hve improved outcomes compred to those institutions performing fewer procedures. The ppliction ofvlid evidence to coverge policy llows for refinement of DHS coverge decisions. Even s these decisions re mde, considertion to the level of evidence nd qulity ofthe reserch must be mde. This role is shred by the benefit policy stff, HSAC, nd the DHS medicl director with the support ofcontrcted services. In contrst, it my be inpproprite to segment providers by tiers without sttisticlly vlid nlysis ofdifferences. A provider orgniztion my rnk lower thn nother nd below defined cut offdue to rndom chnce. This difference, lthough not sttisticlly vlid, could cuse the orgniztion to be plced in lower pyment rte tier. This my disdvntge provider groups with higher proportion of complex ptients (where the complexity cnnot be cptured by existing dt sources); groups with one or more outliers (expensive ptients needing complex interventions); or groups with smller popultions ofenrollees (where smple size precludes sttisticlly vlid smples). Appliction ofevidence nd sttisticl modeling to prctice vrition in this public evlution should be prt of public converstion. Provider peer grouping being developed by the Minnesot Deprtment ofhelth (MDH) nd incentive pyments vi Bridges to Excellence re both exmples ofpublic discussions ofthe ppliction of tbese nlyses to benefit design. DHS hs been nd should continue to be driver ofthis work, performing the nlysis bsed on vilble dt nd pplying the nlysis to benefit design. The use of DHS clims dt should lso be used to drive provider qulity improvement processes. Developing "sfe" structures to shre comprtive results without rigorous sttisticl nlyses llows for robust qulity

4 improvement converstion. As n exmple, vritions in trum center use ofcomputerized tomogrphy (CT) to evlute emergency presenttion ofhed injury hve potentil, by the exposure ofvrition, to lter prctice. The continued development nd reporting ofprctice vrition for qulity improvement purposes my be considered seprtely from public reporting nd policy setting. DHS fces the chllenge of ppropritely plcing our work into one ofthese ctegories. Mjor issues rise, including: The development ofsttisticlly vlid (nd hence equitble) models for policy discussions is most often complex nd resource intensive. The effort nd detil devoted to the Provider Peer Grouping portions ofthe 2008 Helth Cre Refonn legisltion re testimony to this complexity. The use ofless rigorous nlyses ofqulity on selected topics should continue, but is hmpered by concerns bout misinterprettion oftrends, rtes, etc. tht re primrily designed to drive provider converstion nd qulity improvement ctivities. Unlike other qulity improvement rms ofthe helth cre system, DHS does not currently hve the uthority to hold nlyses confidentil s prt of qulity improvement process. (This is, in prt, becuse ofthe Deprtment's historicl role s clims pyer rther thn driver ofqulity.) The dependence on coding ccurcy to understnd services perfonned by providers nd to crete vlid nlysis in the Deprtment. Public interest in vrition should be weighed ginst the benefits tht rise from protected qulity improvement ctivities during project's life cycle. Neither option utomticlly chieves the best results in ll circumstnces. Creting n pproprite blnce, while driving to greter public trnsprncy, should be considered min gol ofthis effort. As utiliztion trcking systems re developed, the Deprtment will gin the cpcity to monitor utiliztion trends nd to trget services or specilties with high vrition for further nlysis. The Helth Services Advisory Council my serve s sounding bord s new topics for nlysis re generted, nd will provide forum for the public dissemintion ofreports summrizing vritions in provider prctice. The Deprtment will lso develop mechnism to notify individul physicins regrding their prctice ptterns for qulity improvement purposes. Conclusions nd Recommendtions DHS will continue to develop its cpcity to trck utiliztion ofhigh-cost, low vlue, nd/or highly-vrible cre. Topics for considertion will be brought to HSAC on semi-nnul bsis, nd summry results ofthese nlyses will be shred with the Council t public HSAC meeting before they re disseminted to the provider community for qulity improvement purposes. As the gol remins improvement in qulity nd vlue, considertion must be given to the qulity ofdt nd the effect of dt relese on the provider community. These topics will be revisited periodiclly to ssess the degree to which provider behvior chnges over time. It is recommended tht the Legislture provide the Deprtment ofhumn Services with the uthority to hold selected nlyses s prt of qulity improvement process nd hence protected from public disclosure. Public reporting in ggregte during the process or with identified results upon completion could be seen s steps to encourge collbortion nd insure trnsprency. The Deprtment hs the opportunity, s mjor pyer ofhelth cre services in Minnesot, to leverge its reltionships with the helth cre community to promote meningful, collbortive dilogues regrding identified prctice vrition nd trnslte them into improved helth qulity nd vlue. These qulity improvement results could be relized for ptients ofthe Minnesot Helth Cre Progrms (MHCP). Additionlly, they would hve the potentil to be successfully integrted s new stndrd ofcre throughout the helth cre delivery system in MN. Bibliogrphy Drtmouth Atls Project Topic Brief, "Preference-Sensitive Cre." The Drtmouth Atls Project Dougherty D, Conwy PH, "The "3T's" Rod Mp to Trnsfonn US Helth Cre." JAMA,2008:299(19).

5 Fisher ES, Wennberg DE, Stukel TA, et i, "The implictions ofregionl vrition in Medicre spending. Prt I: The content, qulity nd ccessibility ofcre." Annls 0/Internl Medicine 2003; 138: Fisher ES-, Wennberg DE, Stukel TA, et i, "The implictions ofregionl vrition in Medicre spending. Prt 2: Helth outcomes nd stisfction with cre." Annls /Internl Medicine 2003; 138: Jmtvedt G, Young JM, Kristoffersen DT, et l. "Audit nd feedbck: effects on professionl prctice nd helth cre outcomes." Cochrne Dtbse /Systemtic Reviews 2006, Issue 2. Art. No.: CD DOl: /1465 I858.CD pub2. Sirovich BE, Gottlieb DJ, Welch HG, et i, "Regionl vritions in helth cre intensity nd physicin perception ofqulity ofcre." Annls 0/Interni Medicine 2006; 144: Wennberg, JE, Fisher ES, Skinner JS. "Geogrphy nd the Debte Over Medicre Refonn." Helth Affirs Wennberg JE, Cooper MM. "The Drtmouth Atls of Helth Cre 2003," Chicgo: Americn Hospitl Assocition; 2003.