Medical audit of hospital records has been a major component of quality of care assessment, altho... more Medical audit of hospital records has been a major component of quality of care assessment, although physician judgment is known to have low reliability. We estimated interrater agreement of quality assessment in a sample of patients with cardiac conditions admitted to an American teaching hospital. Physician-reviewers used structured review methods designed to improve quality assessment based on judgment. Chance-corrected agreement for the items considered more relevant to process and outcome of care ranged from low to moderate (0.2 to 0.6), depending on the review item and the principal diagnoses and procedures the patients underwent. Results from several studies seem to converge on this point. Comparisons among different settings should be made with caution, given the sensitivity of agreement measurements to prevalence rates. Reliability of review methods in their current stage could be improved by combining the assessment of two or more reviewers, and by emphasizing outcome-orie...
Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some... more Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. Retrospective cohort study. Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.
Objective. To examine the effects of incentive payment frequency on quality mea-sures in a physic... more Objective. To examine the effects of incentive payment frequency on quality mea-sures in a physician-specific pay-for-performance (P4P) experiment. Study Setting. A multispecialty physician group practice. Study Design. In 2007, all primary care physicians (n5 179) were randomized into two study arms differing by the frequency of incentive payment, either four quarterly bonus checks or a single year-end bonus (maximum of U.S.$5,000/year for both arms). Data Collection/Extraction Methods. Data were extracted from electronic health records. Quality measure scores between the two arms over four quarters were compared. Principal Findings. There was no difference between the two arms in average quality measure score or in total bonus amount earned. Conclusions. Physicians ’ responses to a P4P program with a small maximum bonus do not differ by frequency of bonus payment.
To assess the effect of a physician-specific pay-for-performance program on quality-of-care measu... more To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice. In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance. We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives. Eight of 9 rep...
Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some... more Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. Retrospective cohort study. Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.
RationalePoor and minority children have greater asthma prevalence and morbidity, than their same... more RationalePoor and minority children have greater asthma prevalence and morbidity, than their same-aged counterparts in more privileged groups. This may be due in part to difficulties controlling asthma triggers at home. We measured the prevalence of asthma triggers in the homes of poor, predominately African-American children and determined if the presence of triggers was associated with low health-related quality of
Medical audit of hospital records has been a major component of quality of care assessment, altho... more Medical audit of hospital records has been a major component of quality of care assessment, although physician judgment is known to have low reliability. We estimated interrater agreement of quality assessment in a sample of patients with cardiac conditions admitted to an American teaching hospital. Physician-reviewers used structured review methods designed to improve quality assessment based on judgment. Chance-corrected agreement for the items considered more relevant to process and outcome of care ranged from low to moderate (0.2 to 0.6), depending on the review item and the principal diagnoses and procedures the patients underwent. Results from several studies seem to converge on this point. Comparisons among different settings should be made with caution, given the sensitivity of agreement measurements to prevalence rates. Reliability of review methods in their current stage could be improved by combining the assessment of two or more reviewers, and by emphasizing outcome-orie...
Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some... more Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. Retrospective cohort study. Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.
Objective. To examine the effects of incentive payment frequency on quality mea-sures in a physic... more Objective. To examine the effects of incentive payment frequency on quality mea-sures in a physician-specific pay-for-performance (P4P) experiment. Study Setting. A multispecialty physician group practice. Study Design. In 2007, all primary care physicians (n5 179) were randomized into two study arms differing by the frequency of incentive payment, either four quarterly bonus checks or a single year-end bonus (maximum of U.S.$5,000/year for both arms). Data Collection/Extraction Methods. Data were extracted from electronic health records. Quality measure scores between the two arms over four quarters were compared. Principal Findings. There was no difference between the two arms in average quality measure score or in total bonus amount earned. Conclusions. Physicians ’ responses to a P4P program with a small maximum bonus do not differ by frequency of bonus payment.
To assess the effect of a physician-specific pay-for-performance program on quality-of-care measu... more To assess the effect of a physician-specific pay-for-performance program on quality-of-care measures in a large group practice. In 2007, Palo Alto Medical Clinic, a multispecialty physician group practice, changed from group-focused to physician-specific pay-for-performance incentives. Primary care physicians received incentive payments based on their quarterly assessed performance. We examined 9 reported and incentivized clinical outcome and process measures. Five reported and nonincentivized measures were used for comparison purposes. The quality score of each physician for each measure was the main dependent variable and was calculated as follows: Quality Score = (Patients Meeting Target / Eligible Patients) x 100. Differences in scores between 2006 and 2007 were compared with differences in scores between 2005 and 2006. We also compared the performance of Palo Alto Medical Clinic with that of 2 other affiliated physician groups implementing group-level incentives. Eight of 9 rep...
Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some... more Withdrawals of health plans from Medicare have affected more than 1.6 million beneficiaries. Some plans claim that providing higher quality care raises costs, lowers profits, and spurs withdrawal because plans cannot sustain high quality care under current payment levels. To assess whether higher performance by Medicare health plans on quality indicators was associated with withdrawal. Retrospective cohort study. Taking each county where a contract was active as a unit of analysis, Medicare managed care plans active in 2310 contract-county combinations in 1997 were studied and followed for 3 years. Independent variables were scores on six indicators from the Health Plan Employer Data and Information Set (HEDIS) for each contract, collapsed into two summary measures: clinical and ambulatory care access. Separate Cox proportional hazards regressions were used for each indicator, and each summary measure, to assess the association of HEDIS performance with our outcome measure, time-to-withdrawal from Medicare. Multiple potential confounders were adjusted for. Of 2310 managed care contract-county combinations, 877 (38%) withdrew. The proportion of contract-counties with high scores on the summary clinical quality measure that withdrew was one-fifth that for low scorers (4.2% vs. 20.5%). For summary ambulatory care access performance, the corresponding ratio was two-fifths (12.8% vs. 32.0%). Lower payments were associated with higher withdrawal risk, but also higher clinical and ambulatory care access quality performance. In separate multivariable analyses controlling for confounders, both high clinical performance (HR, 0.18; 95% CI, 0.08-0.42) and high ambulatory care access performance (HR, 0.53; 95% CI, 0.27-1.07) were independently associated with lower withdrawal risk. Health plans continuing to provide care to Medicare beneficiaries have higher average performance on HEDIS clinical and ambulatory care access measures than plans that withdrew.
RationalePoor and minority children have greater asthma prevalence and morbidity, than their same... more RationalePoor and minority children have greater asthma prevalence and morbidity, than their same-aged counterparts in more privileged groups. This may be due in part to difficulties controlling asthma triggers at home. We measured the prevalence of asthma triggers in the homes of poor, predominately African-American children and determined if the presence of triggers was associated with low health-related quality of
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