Bridges to Excellence"Recognizing High-Quality Care: Analysis of Physician Quality and Resource Use

Physicians recognized as high quality by Bridges to Excellence performed better than their peers on claimsbased quality measures and, in some cases, on resource use measures.
Published Online: October 15, 2008
Meredith B. Rosenthal, PhD; Francois S. de Brantes, MBA; Anna D. Sinaiko, MPP; Matthew Frankel, MBA; Russell D. Robbins, MD, MBA; and Sara Young, MBA

Objective: To examine whether physicians who sought and received Bridges to Excellence (BTE) recognition performed better than similar physicians on a standardized set of population-based performance measures.

Study Design: Cross-sectional comparison of performance data.

Methods: Using a claims dataset of all commercially insured members from 6 health plans in Massachusetts, we examined population-based measures of quality and resource use for physicians recognized by the BTE programs Physician Office Link and Diabetes Care Link, compared with nonrecognized physicians in the same specialties. Differences in performance were tested using generalized linear models.

Results: Physician Office Link–recognized physicians performed significantly better than their nonrecognized peers on measures of cervical cancer screening, mammography, and glycosylated hemoglobin testing. Diabetes Care Link–recognized physicians performed significantly better on all 4 diabetes process measures of quality, with the largest differences observed in microalbumin screening (17.7%). Patients of Physician Office Link–recognized physicians had a significantly greater percentage of their resource use accounted for by evaluation and management services (3.4%), and a smaller percentage accounted for by facility (-1.6%), inpatient ancillary (-0.1%), and nonmanagement outpatient services (-1.0%). After adjustment for patient age and sex, and case mix, Physician Office Link–recognized physicians had significantly fewer episodes per patient (0.13) and lower resource use per episode ($130), but findings were mixed for Diabetes Care Link–recognized physicians.

Conclusions: Our findings suggest that the BTE approach to ascertaining physician quality identifies physicians who perform better on claims-based quality measures and primary care physicians who use a less resource-intensive practice style.

(Am J Manag Care. 2008;14(10):670-677)

Bridges to Excellence (BTE) rewards physicians based on the results of site surveys and retrospective review of clinical data. Physicians recognized as high quality performed better than their peers on claims-based measures of quality and, in some cases, resource use measures.

  • Physicians recognized by BTE appear to rely more on evaluation and management, and less on tests and procedures.
  • Higher performance for recognized physicians may have predated the recognition program.
  • Further research is needed to examine whether the recognition by BTE is associated with patient flow or performance improvement.
During the past several years, both public and private payers have adopted pay for performance in a wide variety of contexts with the hope of prompting more evidence-based and higher value patterns of care.1-3 When it was launched in 2002 by a group of large employers collaborating with several health plans and provider organizations, Bridges to Excellence (BTE) was one of the first multistakeholder pay-for-performance programs.4,5 Its programs have relied on certification of performance based on self-reported (subject to audit) medical record and practice systems data. Physicians are invited by BTE to seek certification and begin receiving payments for all patients covered by the program’s sponsors. Incentives for physicians who meet or exceed the performance criteria were initially determined from actuarial analyses that estimated savings to employers from better quality of care6 and are paid by participating employers and health plans directly to physicians, according to a specified bonus schedule that can vary between implementation regions.

Now operated through an independent not-for-profit entity with a board comprised of employer, health plan, and physician representatives, BTE’s model is in operation nationwide through licenses to health plans, employer coalitions, and state agencies.7 Bridges to Excellence was first implemented in Massachusetts in 2003 with 2 major physician reward components: the Physician Office Link (POL) and the Diabetes Care Link (DCL). Attainment of the quality standards set by BTE is associated with both financial rewards and public recognition.

In 2003, approximately 20 physicians in Massachusetts were recognized by BTE under what was then its only program: DCL. By the end of 2006 there were more than 1000 BTE-recognized physicians in Massachusetts across all BTE programs and total payments to these physicians reached $2.4 million. (In 2004 the Cardiac Care Link was introduced. Because that program is newer, we do not examine it in our analysis.) Nationally, 8500 physicians have been recognized and a total of $10 million paid out. Although the BTE model continues to expand, comparative studies of BTE-recognized physicians and their practice patterns are lacking. In this article, we examine the quality, care delivery patterns, and resource use of BTE-recognized physicians compared with nonrecognized physicians in Massachusetts.

On quality measures alone, this comparison is of interest because of BTE’s unusual reliance on voluntary certification through a site survey and chart review that yields data regarding quality measures similar to those used in the Healthcare Effectiveness Data and Information Set (HEDIS). For the POL in particular, which is intended to reward overall population health management, substantial weight is placed on the structural measures of quality derived from the site survey. Thus, it is not clear that physicians with BTE certification would necessarily get better-than-average scores on the quality measures alone. Moreover, there is no comparative aspect to BTE recognition—the standards are set nationally and fixed (ie, they do not reflect relative rankings within a market), so it is unknown whether the physicians seeking certification are those whose performance is above average or simply those with larger numbers of eligible patients (and thus with more to gain). Finally, because BTE certifies physicians for 3 years based on a single retrospective review of 25 sampled charts for the quality measures, we also considered it important to ask whether a contemporaneous comparison between recognized and nonrecognized physicians would show better performance for BTE physicians. Even if recognized physicians performed better than average with the selected patients, these differences might not have persisted.

METHODS
We examined population-based measures of the quality of care and resource use for Massachusetts physicians participating in BTE’s first 2 rewards programs, POL and DCL. Using an administrative dataset comprised of claims from all commercially insured members of 6 Massachusetts plans, we compared the performance of recognized physicians with the performance of nonrecognized physicians.

Bridges to Excellence Program Design
The POL program focuses on promoting the office practice’s use of systems to enhance the quality of patient care. Today, this assessment is commonly being referred to as a core characteristic of a Medical Home.8 Practices that can demonstrate specific processes and systems of care can earn up to $50 for each patient covered by a participating employer. (The rewards were designed to last 3 years, the period of time during which the recognition is valid.) To obtain the rewards available through the POL program, eligible physicians must pass the National Committee for Quality Assurance (NCQA) Physician Practice Connections assessment program or meet a comparable standard set by the Massachusetts Quality Improvement Organization: MassPRO. The standards for the POL, which are described in Table 1,9 include maintenance of patient registries for the purpose of identifying and following up with at-risk patients, provision of educational resources to patients, and use of electronic systems to maintain patient records, provide decision support, enter orders for prescriptions and lab tests, and provide patient reminders.



The DCL program rewards physicians with $80 per year for each diabetic patient covered by a participating employer. To obtain the rewards, eligible physicians must demonstrate that they provide high levels of diabetes care by passing NCQA’s Diabetes Physician Recognition Program, which was developed in collaboration with the American Diabetes Association.10 To qualify for the 3-year recognition, physicians submit medical record data on glycosylated hemoglobin (A1C), blood pressure, and lipid testing, as well as data on eye, foot, and nephropathy exams, for a random sample of 25 diabetes patients. (The 25 charts are selected retrospectively for patients who have been in the practice’s care for at least 1 year. A date is selected at random from a set window of time, and the next 25 charts for patients with a diagnosis for diabetes are pulled for analysis. Both the sampling method and the actual charts are reviewed and subject to NCQA audit.) The NCQA assesses the data submitted by the physician and attributes points based on the level of disease management demonstrated by the physician. All information submitted for POL and DCL certification is subject to audit.

Data Sources
We obtained data from BTE on the identities of physicians recognized for the POL and DCL programs between 2003 and 2006. Administrative data, including claims and enrollment files, were obtained from the Massachusetts Group Insurance Commission (GIC), which has created a database that includes all claims from all commercially insured members (not just those for GIC members) from the 6 health plans that serve the GIC (Harvard Pilgrim Healthcare, Tufts Health Plan, Unicare, Fallon, Neighborhood Health Plan, and Health New England). The GIC’s data cover approximately 50% of privately insured residents and more than 7000 physicians in Massachusetts including all but 2 BTE-recognized physicians. Physician-level measures of quality and resource use per episode were computed by Mercer Human Resources Consulting using profiling software licensed from Resolution Health, Inc, and Ingenix, respectively.

Quality and Cost Measures
To ascertain differences between recognized and nonrecognized physicians, we examined claims-based quality measures and average resource use per standardized episode for several categories of services and the total. (Episodes were created using Symmetry’s Episode Treatment Groupers, a unit of Ingenix. These episodes are defined using proprietary algorithms that identify in claims data clinical events that trigger, break, and end an episode. Similarly, algorithms based on clinical logic are used to group all claims related to that episode. For a more complete description, see reference 11.) For the POL cohort, we examined a set of measures typically used for examining primary care quality, including cervical cancer screening, mammography, A1C testing, cholesterol screening for individuals with coronary heart disease, and cholesterol screening for individuals with hypertension. For the DCL cohort, we examined 4 widely used claims-based measures of diabetes care quality. These were A1C testing, cholesterol testing, microalbumin testing, and diabetic retinal exams. Measure specifications were adapted by Resolution Health, Inc, from HEDIS and other national evidence-based guidelines to conform to the provider profiling context. The most recent 18 months of outpatient claims and pharmacy data were used for evaluation and calculation of each quality score (eg, A1C testing rate).

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