The Business Case for Pediatric Asthma Quality Improvement
The Business Case for Pediatric Asthma Quality Improvement
In the two and a half years that the PACE intervention was active, it was not able to demonstrate a positive business case. In contrast to expectations, the PACE intervention did not reduce expensive ED visits or hospital care. In fact, we found evidence of increases in spending on ED visits among treatment practices relative to control practices in two of the intervention years. In addition, the design of the PACE incentive may have contributed to the challenge of achieving a business case.
First, the cost of the intervention to the Monroe Plan was high. Due to the significant financial investment in PACE, the intervention would need to have achieved at least $386 000 in utilization-related savings (an ~3.6% reduction in total PMPM payments), discounted over 3 years, in order for the Monroe Plan to have achieved a positive return on investment. A previous study of Medicaid-enrolled children with asthma found, similarly, that primary care case management and medical homes, two interventions aimed at increasing guideline-concordant care, resulted in increased spending relative to traditional fee-for-service Medicaid despite decreases in ED and hospital use. The higher spending was driven, in part, by greater access to outpatient services and medications among children in these enhanced care models. However, the payer's investment in monthly case management and medical home program fees also played an important role, suggesting that quality improvement may come at a cost.
Second, from the perspective of many of the practices participating in the PACE intervention, the absolute size of the incentive was relatively small, and the amounts received by practices were not proportional to the numbers of chart audits performed. Providers received incentive payments per eligible member rather than per chart audit conducted. As a result, practices with many Monroe Plan-enrolled children with asthma received substantial incentive payments, yet audited a smaller percentage of patient charts relative to smaller practices. For example, one large practice conducted 193 chart audits and received total incentive payments of $32 100. In contrast, one small practice conducted 110 chart audits, but only received incentive payments of $7135.
Finally, the implementation of the chart audit and feedback process did not necessarily ensure that all providers received feedback on their individual performances. There was often a lead physician at each of the treatment practices that took responsibility for the chart audit activity. This physician then met with the Monroe Plan medical director to discuss the performance feedback. It was left up to these lead physicians to share performance data with providers within their practices.
This study has several limitations that should be noted. First, our study relies on claims data. Administrative data are designed for billing and reimbursement purposes and not for research; therefore, it is possible that there may be errors in coding of diagnoses or procedures. Additionally, claims data do not provide any direct information about asthma severity or control for patients in our study population. Still, claims data were the only available source of information on our study population and the use of PMPM measures and randomization diminishes the effects of any errors on our results. Moreover, analysis of baseline utilization of ED visits and hospital admissions for asthma suggested no significant differences in asthma control between treatment and control group practices. Still, it is possible that unmeasured differences existed in asthma severity or control which may have affected our ability to identify the effects of the intervention.
Second, there were significant differences in the racial and ethnic makeup of treatment and control group practices. Race and ethnicity have been shown to be associated with asthma control, use of the ED and compliance with proposed therapies; therefore, these differences could have affected our results. Third, factors external to the intervention might have had an impact on its final outcome. In particular, the H1N1 pandemic in 2009 and other asthma education efforts going on in the Rochester, New York area might have influenced utilization of health care services during the intervention period. Randomization of practices helps to reduce the chances for bias; however, if these events had systematically different effects on treatment and control practices, this would cause us to inappropriately attribute effects to the intervention.
Internationally, public and private payers are seeking interventions that can support the delivery of high-quality care to low-income populations at a sustainable cost. Mate et al. provide a framework for insurers, describing the levers by which they can help drive quality improvement. Among these levers are the following: (i) providing access to and encouraging the use of clinical guidelines or protocols, (ii) incentivizing or requiring collection of data on compliance with evidence-based care and (iii) investing in provider education. The framework authors note that insurance strategies must be used within the local context and in combination with coordinated activities by other stakeholders. Consistent with this notion, this study suggests that an insurer-led pay-for-reporting intervention tied to audit and feedback, alone may not be enough to produce the meaningful short-term reductions in utilization of high-cost services in pediatric asthma that would be needed to produce a positive return on investment. Still, findings from this study provide valuable lessons to inform the future design of reimbursement strategies to encourage quality improvement programs.
Discussion
In the two and a half years that the PACE intervention was active, it was not able to demonstrate a positive business case. In contrast to expectations, the PACE intervention did not reduce expensive ED visits or hospital care. In fact, we found evidence of increases in spending on ED visits among treatment practices relative to control practices in two of the intervention years. In addition, the design of the PACE incentive may have contributed to the challenge of achieving a business case.
First, the cost of the intervention to the Monroe Plan was high. Due to the significant financial investment in PACE, the intervention would need to have achieved at least $386 000 in utilization-related savings (an ~3.6% reduction in total PMPM payments), discounted over 3 years, in order for the Monroe Plan to have achieved a positive return on investment. A previous study of Medicaid-enrolled children with asthma found, similarly, that primary care case management and medical homes, two interventions aimed at increasing guideline-concordant care, resulted in increased spending relative to traditional fee-for-service Medicaid despite decreases in ED and hospital use. The higher spending was driven, in part, by greater access to outpatient services and medications among children in these enhanced care models. However, the payer's investment in monthly case management and medical home program fees also played an important role, suggesting that quality improvement may come at a cost.
Second, from the perspective of many of the practices participating in the PACE intervention, the absolute size of the incentive was relatively small, and the amounts received by practices were not proportional to the numbers of chart audits performed. Providers received incentive payments per eligible member rather than per chart audit conducted. As a result, practices with many Monroe Plan-enrolled children with asthma received substantial incentive payments, yet audited a smaller percentage of patient charts relative to smaller practices. For example, one large practice conducted 193 chart audits and received total incentive payments of $32 100. In contrast, one small practice conducted 110 chart audits, but only received incentive payments of $7135.
Finally, the implementation of the chart audit and feedback process did not necessarily ensure that all providers received feedback on their individual performances. There was often a lead physician at each of the treatment practices that took responsibility for the chart audit activity. This physician then met with the Monroe Plan medical director to discuss the performance feedback. It was left up to these lead physicians to share performance data with providers within their practices.
This study has several limitations that should be noted. First, our study relies on claims data. Administrative data are designed for billing and reimbursement purposes and not for research; therefore, it is possible that there may be errors in coding of diagnoses or procedures. Additionally, claims data do not provide any direct information about asthma severity or control for patients in our study population. Still, claims data were the only available source of information on our study population and the use of PMPM measures and randomization diminishes the effects of any errors on our results. Moreover, analysis of baseline utilization of ED visits and hospital admissions for asthma suggested no significant differences in asthma control between treatment and control group practices. Still, it is possible that unmeasured differences existed in asthma severity or control which may have affected our ability to identify the effects of the intervention.
Second, there were significant differences in the racial and ethnic makeup of treatment and control group practices. Race and ethnicity have been shown to be associated with asthma control, use of the ED and compliance with proposed therapies; therefore, these differences could have affected our results. Third, factors external to the intervention might have had an impact on its final outcome. In particular, the H1N1 pandemic in 2009 and other asthma education efforts going on in the Rochester, New York area might have influenced utilization of health care services during the intervention period. Randomization of practices helps to reduce the chances for bias; however, if these events had systematically different effects on treatment and control practices, this would cause us to inappropriately attribute effects to the intervention.
Internationally, public and private payers are seeking interventions that can support the delivery of high-quality care to low-income populations at a sustainable cost. Mate et al. provide a framework for insurers, describing the levers by which they can help drive quality improvement. Among these levers are the following: (i) providing access to and encouraging the use of clinical guidelines or protocols, (ii) incentivizing or requiring collection of data on compliance with evidence-based care and (iii) investing in provider education. The framework authors note that insurance strategies must be used within the local context and in combination with coordinated activities by other stakeholders. Consistent with this notion, this study suggests that an insurer-led pay-for-reporting intervention tied to audit and feedback, alone may not be enough to produce the meaningful short-term reductions in utilization of high-cost services in pediatric asthma that would be needed to produce a positive return on investment. Still, findings from this study provide valuable lessons to inform the future design of reimbursement strategies to encourage quality improvement programs.
