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Vital Signs

Feds put dollars behind the push for quality

By Katherine Vonderhaar

The pressure was on to meet several hypertension goals as part of a federal demonstration project; at Dartmouth- Hitchcock in 2007-08, 98.5% of patients had their blood pressure checked.

In the third year of a federal demonstration project aimed at improving care by attaching financial incentives to quality measures, the Dartmouth-Hitchcock Clinic again earned a bonus from the government.

Care: The Clinic is one of 10 multispecialty group practices participating in the Centers for Medicare and Medicaid Services Physician Group Practice (PGP) Demonstration. The project is designed to reward PGPs for improving the quality and efficiency of care provided to Medicare beneficiaries. Dartmouth-Hitchcock earned $3.6 million for its performance in 2007-08, the project's third year, whose results were just announced.

During each of the demo's five years, a PGP can earn a payment if its rate of spending on Medicare patients rises more slowly than the rates of other providers in their area. If the rate lags enough, the government shares up to 80% of its savings with the PGP, depending on how well the group meets several quality goals. In year two, four of the 10 PGPs--including Dartmouth-Hitchcock--generated enough savings to receive payments. (For more on the second year's results, see the article "Clinic gets pay-for-performance bonus from feds".) In the third year, five of the 10 PGPs got bonuses.

Targets: Various quality goals are being phased in during the five-year demo. In year three, five targets for hypertension and cancer screening were added to the first two years' benchmarks --which were for diabetes, congestive heart failure, and coronary artery disease. All 10 PGPs met at least 28 of the 32 total goals in year three.

Dr. Martin Sedlacek, a nephrologist at DHMC, led the effort to meet the blood pressure goals. He studied how to best apply national guidelines for measuring and treating high blood pressure across the Clinic. One of the most important steps was to reeducate staff on the complexities of measuring blood pressure. Readings can be affected by factors such as cuff size, the position of the patient's arm, and how the patient's sleeve is arranged. Accurate measurements are critical because blood pressure is "a big predictor for future trouble," says Sedlacek.

Despite these efforts, the Clinic missed two of the three hypertension goals. Most patients had their blood pressure measured, but not enough had their pressure under control (defined as less than 140/90). And not enough patients with elevated blood pressure were given a plan of care.

"Our ambition is to do the right thing every time," says Sedlacek.

"Our ambition is to do the right thing every time when the patient comes in," says Sedlacek. "This requires a continuous effort." Dartmouth-Hitchcock is not trying to meet the government goals simply to get the bonuses, he adds, but "because it's the right thing to do."

Actually, the jury is still out on whether pay-for-performance initiatives like the PGP demo are the best way to improve the quality and efficiency of care. After three years, four of the 10 PGPs in the demo haven't received any performance payments. In fact, one of the groups that met all of year three's 32 quality goals didn't earn a payment because it hadn't kept costs down sufficiently.

Seminal: But for Dartmouth-Hitchcock, participating in the demo has been "seminal," says Dr. Barbara Walters, senior medical director of the Clinic and the project's coordinator. It has even resulted in a pilot program with CIGNA that applies the demo's framework to commercially insured patients.

Furthermore, the demo has led to dialogue among the PGPs, Walters says. The 10 groups have a monthly virtual meeting to share best practices, and the other participants are now "valued colleagues," she says.

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