Q1. What will be done with the data?
Answer:: Health plan administrative or claims data will be aggregated by the project’s data manager (ViPS) to create a single report for each physician. . The reports will be shared with the NYQA participating health plans, individual physicians, and the project’s evaluators.
Q2. How will it be decided who is the responsible physician if more than one physician
is caring for a patient?
Answer:: The assigned Primary Care Professional (PCP) will be responsible for patients who belong to a plan that assigns a PCP. In other cases, the attribution method will be developed by the NYQA in a joint workgroup with representation of members of the PA.
Q3. Is collection of the data HIPAA compliant?
Answer:: Yes
Q4. Will each plan use the report in the same way?
Answer:: Each plan is responsible for the development of its own pay for performance program. The reports will be standardized but due to anti trust concerns the use of the reports to develop the payment component of the project will rest with each individual plan. At this time we are unsure how each plan will utilize the report in development of their P4P program.
Q5. How will interpretation of the data be used to change the way I practice?
Answer: Based on the aggregate report that you will be provided, you will decide if and how your practice will need to change.
Q6. Will the information (report) be severity adjusted or adjusted for differing patient/
populations?
Answer:: As part of this grant no severity adjustment will be employed.
Q7. Will it be possible for the physicians to validate the information in the aggregate
report?
Answer:: No, The initial funding was not adequate to develop a verification portal or process for physician data correction. However, outside funds were secured to pilot a data correction and verification portal pilot. A small number of physicians will work with the portal demonstration project to develop processes for aggregated data verification and correction and it is the intent of the NYQA project to develop an actionable portal for the future. However, individual health plans may give practices an opportunity to review the health plan specific data.
Q8. Will the same standard be used by all the plans?
Answer:: The reports will be standardized, but each plan will only receive information on physicians that they contract with. How each plan utilizes the report to develop their pay for performance program, because of anti trust rules must be left up to each plan.
Q9. Will performance be measured as an absolute or rate of change?
Answer:: The NYQA and PA will work jointly with the data manger, ViPS to develop benchmarks for each of the measures. Plans will discuss the use of standardized benchmarks but are free to establish their own thresholds for payments and to determine if they wish to use set goals, rate of improvement or some combination. .
Q10. When will physicians get to see their data?
Answer:: Baseline reports will be generated in the fall of 2008 and the measurement reports (those that will generate the P4P incentive payments) will be generated in the fall or 2009. The baseline reports will be calculated on services dates 2005-2007 and the measurement reports will be calculated on data from 2006-2008.
Q11. Can reports be run for groups as a whole?
Answer:: The NYQA is interested in determining the level of interest that groups have in receiving group specific reports. As a pilot the NYQA will be working to develop a methodology to identify group practices. Currently the NYQA plans to develop reports only at the physician level.
Q12. How do I get information about a particular plan's participation and program?
Answer:: Due to anti trust concerns each plan must develop and inform physicians of its P4P program. Physicians should contact the health plans that they contract with to learn about the plans P4P program design.
Q13. Do I have to provide any additional information on my claim forms or submit any new documents?
Answer:: No, the health plans collect HEDIS measure information from claims systems. This grant will not require any additional forms/documents/medical record submissions.
Q14. Do I have to make any specific documentation entries in my medical records?
Answer:: No, there are no new or additional documentation requirements.
Q15. How are the different insurance companies going to pay incentives? When?
Answer:: There are 13 health plans participating in NYQA. Each plan will determine the details of their own P4P program. What has been agreed to is that the same information is being collected and each plan will utilize the single physician specific aggregate report. Some plans will make payments to individual practitioners based on this data and some will further aggregate the data to make payments to medical groups.
Q16. Will I be penalized if I refer a diabetic patient for an eye exam and they fail to
keep the appointment or my post MI patient fails to renew their beta-blocker?
Answer:: The participating health plans in the NYQA project have committed to paying incentives measures on the data set. At this time the aggregate report will not be severity adjusted nor adjusted for patient characteristics or compliance. If a patient is deemed to have missed a service it will be reflected in the responsible physician report.
Q17. Will I be penalized if a post-MI patient can't take a beta-blocker because of bradycardia or hypotension?
Answer:: HEDIS measure all have specific data requirements. The Health plans have agreed to use these definitions. The HEDIS measure noted above excludes patients with a current ICD-9 coded diagnosis of asthma, hypotension, heart block, sinus bradycardia, or COPD. If possible we will post measure specific details on the NYQA site. (These measures are copyrighted)
Q18. How should I record the diagnosis for pediatric patients with upper respiratory
infections so that the cases that deserve antibiotics are properly differentiated from
those who don’t?
Answer:. The HEDIS measure looks for children who are diagnosed during an outpatient visit with either URI (ICD-9 465) or acute nasopharyngitis (ICD-9 460). If a child has no other diagnosis that can be coded on that date, the measure assumes that an antibiotic was not appropriate. Children who filled a prescription for an antibiotic in the previous 30 days are excluded from the measure. Children are also excluded if they have one of the following excluded diagnoses on the date of service or three days after: intestinal infections, pertussis, bacterial infection unspecified, Lyme disease, otitis media, acute sinusitis, acute pharyngitis*, acute tonsillitis* chronic sinusitis, infections of the pharynx, larynx, tonsils and adenoids, prostatitis, cellulitis, acute lymphadenitis, impetigo, skin staph infections, pneumonia, gonococcal infections and venereal diseases, syphilis, Chlamydia, inflammatory diseases of the female reproductive organs, infections of the kidney, and cystitis or UTI. *NOTE that children who have pharyngitis or tonsillitis should have had a strep test before antibiotics are prescribed or they will fail another HEDIS measure.
Q19. What happens if I give an antibiotic for a different indication at a visit in which I
also diagnose a non-antibiotic-requiring upper respiratory infection?
Answer:: As long as a separate diagnosis is recorded where an antibiotic is required and is coded as such then it is OK to also code a URI. See above
Q20. Can I opt out of this program?
Answer:: There is really no opt in or opt out. Information will come from the plans based on their administrative data to the data aggregator and a physician specific report will be developed using data from all the plans. How that information will be utilized is and will be plan specific. Physicians should contact their plans to learn of the specific details of their P4P program.
Q21. Will my data be publicized?
Answer:: No, there is no public reporting during the two years of the DOH P4P demonstration funding. NYQA is committed to public reporting with a goal of 2010. The type of report, the measures reported, and to what level of detail (physician, group, and practice site) will be a joint decision between the physicians and the other stakeholders.
Q22. Are they subject to FOIL release?
Answer:: The NYQA is a grant funded project and as such is not bound by Freedom of Information Law.
Q23. What happens after the pilot grant-supported program is over?
Answer:: The NYQA and the PA will seek to continue to function and the lessons learned will provide the basis for continued cooperation in improving patient care. The NYQA will be developing a business plan and will look to secure funding from members as well as foundations and other sources.
Q.24 What are some tips on succeeding with performance measures?
Answer::
- Knowledge of the measures and coding will assist with success. The measures are based on national standards and best practices and employing treatment standards will result in greater compliance. While this pilot set of 10 measures addresses only a handful of conditions, by working on these measures your practice can gain experience in using measures to gauge how closely you are able to consistently follow evidence-based guidelines.
- Designate an office “Quality Manager”; someone to be responsible for performance measurement
- Bill for all services provided ( link to PA educational coding tools on web site)
- Code accurately and completely
- Review encounter forms to be sure that codes used will count
- Verify with your billing company that correct codes are billed
- Request current “actionable” reports from plans and review baseline NYQA report
- To improve coding and billing practice
- To identify practice patterns not consistent with measured standards
- To identify patients who need to be called in for care
- For future success, reinvest bonus money
- To strengthen skills and resources related to data management
- Consider implementation of a registry or an electronic health record with a registry function
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