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Payoff Seen from Obesity Measures, Medicare Advantage Pay-for-Performance System

By John Reichard, CQ HealthBeat Editor

October 30, 2012 -- So often the strategies that policy wonks prescribe to get better value for the health care dollar prove disappointing. But health plan quality measures and pay-for-performance systems might be a different story.

A study released last week by the leading national group that evaluates health plans draws two main conclusions: that Medicare's program for making higher payments to health plans based on performance is reaping dividends, and that, prodded by quality measures, doctors are stepping up efforts to identify and counsel obese patients.

Medicare's bonus payment program for health plans that rank higher on quality measures is mired in controversy, with Republicans saying Democrats are using it to hide the eventual sharp cuts the health care law (PL 111-148, PL 111-152) makes to the plans.

Nevertheless, the study by the National Committee for Quality Assurance (NCQA) concludes that there is a payoff from those bonus payments. Originally established by the insurance industry, NCQA has won a reputation for independence and promoting quality measurement that improves health care.

Plans have shown big improvements on measures in the star rating system, NCQA President Margaret O'Kane said in an interview. "Colorectal screening was one," she said. It showed "a huge jump" in 2011, with plan improvements that year determining whether or not plans received the bonus payments for higher performance, which began in 2012.

On average, PPOs in the Medicare Advantage program screened 55 percent of their enrollees for colorectal cancer in 2011, up from 41 percent in 2012. Medicare HMOs improved from 57.6 percent to 60 percent.

Similarly, plans did a much better job of lowering the use of high-risk medications among the elderly, O'Kane said.

Progress on Medicare Use
The NCQA report said one measure identified the share of Medicare beneficiaries 65 and older who use two or more medications that experts agree should usually be avoided in the elderly. Examples of such drugs include benzodiazepines for insomnia and the chronic use of painkillers like Naproxen.

After several years of almost no change, the usage rate of those drugs among the Medicare Advantage 65 and older population has dropped by a third, from about 6 percent to 3.6 percent, the report said. "This is a beautiful example of stopping the health care system from doing harm," O'Kane said. Such measures help avoid injury from falls and car crashes.

The report also showed that caregivers in health plans are more likely to screen enrollees for obesity, not only among the elderly but also among the young.

The report said that calculating body mass index—the ratio of body fat determined by height and weight—is the first step toward developing a plan for weight management.

In 2009, NCQA introduced adult BMI assessment to its quality measures. In 2011, "we have seen major jumps in improvement on this measure across commercial, Medicaid and Medicare lines of business and for HMOs and PPOs," the report said. "The greatest gains are among Medicare plans—with an increase of 18 percentage points for HMOs and almost 26 percentage points for PPOs."

O'Kane said of the measure that "partly it's making sure everyone has a reminder system for the doctor." Measuring BMI "naturally leads to counseling."

NCQA begins with such a measure and later might begin asking a plan about whether its doctors provide counseling on nutrition and exercise.

The report said "we also see significant gains in three measures of care related to obesity in children 3 to 17 years of age. One measure calls for clinicians to counsel on physical activity, another to counsel on nutrition and another to assess BMI."

The NCQA system does have its shortcomings. For example, plans may choose not to be evaluated. That means it's likely that the rating system does not identify the poorest-quality plans, which have an incentive not to be rated and found wanting.

Some Shortcomings Identified
Plans also deteriorated on some measures. Use of appropriate medications for asthma in Medicaid patients declined. In 2010, NCQA reported a significant drop in immunizations for children. And in 2011 "the rate made no recovery in either the commercial or the Medicaid product line," the report said.

O'Kane attributed the falloff to the "urban legend" that vaccines are tied to autism. "What we're not seeing, that we hoped to see, was a rebound" she said in a press briefing on the report, "We're starting to have outbreaks of preventable childhood disease" as a result. "It's very distressing."

Another challenge, O'Kane said, is to get doctors in health plans to prevent patients from overusing antibiotics. "We really do overuse antibiotics," she said. "That's a tough one." Doctors simply don't take the time to explain to patients who demand antibiotics why they shouldn't be used, she said.

The study was notable in other respects, O'Kane said. For many years HMOs with their seemingly tighter control over providers have outperformed PPOs on quality measures. Now, "I think what you see with the PPOs is kind of a catch-up effect," O'Kane said. "You're seeing these very great leaps in performance."

And while some plans choose not to be measured by NCQA, the new study reported its highest ever total enrollment of people in plans subject to NCQA measures. The tally: 125 million people, or 7 million more than last year. Another finding: NCQA-Accredited Medicare Advantage plans outperform non-accredited plans on more than 75 percent of quality measures. All Medicare Advantage plans are required to report data on NCQA measures but they are not required to become accredited by NCQA.

Assessing the Impact of Measures
Many observers seem to agree that quality measures truly do make a difference in goading providers and plans to make improvements. But in the press briefing, Tom Miller of the American Enterprise Institute expressed considerable uncertainty about their impact.

"The question is are we measuring what matters," he said. "We have the problem of looking at the long string of causation"—from looking at the measures on which a plan performs well—"to assuming that that equates to high quality care, and the bigger assumption that that equates to better health in the final analysis," he said.

Miller also said that the jury is out on whether the measures lead to lower costs, saying that to the extent they make care more efficient, people may want more of it. But at least then they would be getting better value for their health care dollars, he acknowledged.

Miller also expressed uncertainty about the impact of bonus payments to Medicare Advantage plans. He said "the analyses thus far have indicated that the magnitude of the pay for performance amount has been small and not enough to make a difference. It hasn't moved the needle that strongly," he said, though experience with such systems is at an early stage. He also questioned how effective payments are in boosting quality with more average performers also getting bonuses. "I think that the strength of that signal was diluted," he said.

O'Kane responded that NCQA believes strongly that when systems work well the result is not only higher quality but also more affordable care. "You can see that plans are really paying attention" to the measures that lead to higher payments," she added, citing for example higher levels of colon cancer screening. "As a result, people are going to be walking around well and alive years from now," she said.

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