Evaluation of the relationship between a chronic disease care management program and california pay-for-performance diabetes care cholesterol measures in one medical group.

BACKGROUND: Pay for performance (P4P) is a business model in which health plans pay provider organizations (medical groups) financial incentives based on attainment of clinical quality, patient experience, and use of information technology. The California P4P program is the largest P4P program in the united states and represents a potential revenue source for all participating medical groups. The clinical specifications for the California P4P program are based on the national Committee for Quality assurance (NCQA), Health Plan Employer Data, and information set (HEDIS), and each clinical measure has its own benchmark. in 2005, participating medical groups were paid on the basis of 9 clinical measures that were evaluated in the 2004 measurement year. The cholesterol testing measure represented 4.44%-7.14% of the total P4P dollars available to participating medical groups from the health plans.

OBJECTIVES: To (1) compare the percentage of medical group members aged 18 to 75 years with diabetes (type 1 or type 2) who received a low-density lipoprotein cholesterol (LDL-C) test and attained LDL-C control (<130 mg per dl) after enrolling in a chronic disease care management (CDCM) program with similar members managed by routine care, and to (2) assess the potential effect of CDCM on the quality performance ranking and financial reimbursement of a medical group reporting these measures in the 2004 California P4P measurement year.

METHODS: This is a retrospective database review of electronic laboratory (lab) values, medical and hospital claims, and encounter data collected between january 1, 2003 and December 31, 2004 at 1 California medical group comprising 160 multispecialty providers. Requirements were continuous patient enrollment in 1 of the 7 health plans participating in P4P during the measurement year (2004) with no more than 1 gap in enrollment of up to 45 days. Patients aged 18 to 75 years were included in the diabetes cholesterol measure (denominator) if they had at least 2 outpatient encounters coded for a primary, secondary, or tertiary diagnosis of diabetes (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.xx, 357.2, 362.0, 366.41, 648.0) or 1 acute inpatient (Diagnosis Related Group code 294 or 295) or emergency room visit for diabetes. Lab values were obtained from multiple sources, including archived lab databases during the same measurement period (numerator). The CDCM program provided education and recommendations for diet, lifestyle, and medication modification delivered by a multidisciplinary team of nurses, pharmacists, and dieticians, and this intervention was compared with routine care for patients not enrolled in the CDCM program.

RESULTS: Of the 54,000 health plan members enrolled in this medical group under capitated reimbursement, 1,859 patients (3.4%) met the California P4P specifications for eligibility for the diabetes cholesterol measures and were evaluated. Of these, 8.9% (165/1,859) were followed by the CDCM program and 91.1% (1,694/1,859) by routine care. The LDL-C lab testing rate for patients in the CDCM program was 91.5% (151/165), and the LDL-C goal rate was 78.2% (129/165) compared with 67.8% (1,148/1,694) and 55.7%, respectively, for routine care (P < 0.001 for both comparisons). if the LDL-C lab testing and goal attainment rates for the CDCM group were compared with rates for peer medical groups, this medical group would have scored in the 75th and 90th percentiles, respectively, corresponding to an annual revenue potential of $28,512 for this medical group if the total incentive payment from the health plan was $1 per member per month (PMPM), or $57,024 if the total incentive P4P payment was $2 PMPM.

CONCLUSIONS: Preliminary data from 165 patients with diabetes managed in a CDCM program in a medical group operating under a small P4P financial incentive showed higher rates of LDL-C lab testing and goal attainment than from patients managed by routine care. Had these rates of LDL-C testing and goal attainment achieved in the CDCM program been extended to the entire P4P population with diabetes, this medical group would have generated incentive payments under the P4P program and ranked higher in publicly available quality scores.