Public Reporting and Physician Pay
The Wisconsin Collaborative for Healthcare Quality (WCHQ) is a voluntary not-for-profit imitative established in 2003 with the mission to publicly report provider performance for the intent of improving care in the state of Wisconsin. WCHQ is governed by a multi-stakeholder group including providers, employers, insurers, and consumer advocates. Over the last eight years WCHQ has built a quality reporting system that compares physician providers and now includes over 30 measures including indirect outcomes measures such as A1C levels as well as direct outcome measures such as cardiac surgical mortality reported at the physician group level.
The Commonwealth fund recently funded a study of WCHQ’s impact on quality performance across the state. Geoff Lamb, M.D. a professor at the Medical College of Wisconsin designed and executed a prospective study of WCHQ members and compared the organizations participating to those that didn’t on quality scores. One of the key findings of this study was that organizations that reported data publicly and which performed poorly rapidly improved to a similar level of performance to the mean of the whole group of reporting organizations (ref 1). Although the study did not prove that public reporting organizations overall delivered higher quality than organizations that didn’t publicly report, the trend was in that direction. The other thing the study showed was that the number of organizations using WCHQ data as the quality benchmark for setting physician group performance targets increased from three at the start to eight three years later.
ThedaCare physicians have been setting physician performance targets based on WCHQ benchmarks for eight years. Each year ThedaCare has significantly improved performance on almost all of the many indicators (ref. 2). Prior to having the WCHQ data comparison ThedaCare Physicians had been very focused on improving quality. The provider sponsored health plan Touchpoint owned by ThedaCare was awarded number one in the nation status by the National Committee on Quality Assurance for two years in a row, 2000 and 2001. HEDIS scores were used to create a quality bonus model at the health plan. Each year ten HEDIS measures were chosen by ThedaCare Physician leaders for bonus targets.
The maximal award was a ten percent bonus based on the physician’s baseline compensation if all ten performance targets were hit. If only one target was hit, a one percent bonus was paid and so on. The health plan administered the bonus but it only encompassed the Touchpoint Health Plan patients. The 80% of patients weren’t part of the equation. Interestingly, although physicians said they didn’t treat the health plan patients differently than any other payer there was a 20% discrepancy in quality performance the health plan members were actually receiving better quality than the non health plan patients. ThedaCare Physician leaders were concerned about this discrepancy and thus formed WCHQ which is an all payer, all patient data base that doesn’t discriminate by any particular health plan. After WCHQ was created the health plan continued to pay a maximum ten percent bonus to physicians who met all quality targets but ThedaCare Physicians redesigned the compensation plan so that it included all patients and decided to use the WCHQ data as the performance result to determine eligibility.
Recently WCHQ reported updated results which show that ThedaCare is performing at 8 standard deviations above the mean on the chronic disease quality measures and 20 standard deviations above the mean on preventative measures. It is also true that each organization reporting data to WCHQ has been improving so the benchmark performance continues to improve each year making it more difficult to be in the number one spot. Recently Dean Health system in Madison has declared the strategic goal of being number one in all WCHQ metrics. The competition is on, which is what public reporting of pertinent performance data can do.
ThedaCare Physicians has determined the next challenge is to incorporate cost data and quality data together into a measurement of value. At the moment the physician compensation committee is deciding what percentage of compensation should be at risk for value metrics. With the advent of the publicly accessible data from the Wisconsin Health Information Organization (WHIO) comparative physician cost data is now available across episode treatment groups. This information is generated from an all payer claims data base established in Wisconsin in 2009 which now holds over four million of the state’s 5.4 million residents insurance claims data. The Medicare data is missing in action despite multiple attempts to convince CMS to release it to WHIO but even without it accurate comparisons of physician cost is possible because of the number of episodes attributed to each physician using the commercial and Medicaid claims.
The power of public reporting has led to many changes within the Wisconsin physician groups and is leading to better quality being delivered year over year. Physicians are competing on cost and quality rather than the size of marketing budgets which is good for patients and for people who pay the healthcare bill.