Straub Clinic and Hospital

Equal Share Tied to Quality Metrics

Starting with the next compensation calculation in April 2010, we will continue phasing in a “pay for performance” plan over one year, which will tie the equal share component of the compensation plan to performance on specific quality metrics for primary care physicians. For internists and family physicians, the initial quality metrics will be for your diabetic and hypertensive patients. Additional measures and criteria may be added over time, as this is a work in progress. This change is consistent with the expected health care reimbursement changes that are being discussed by Medicare and HMSA, to pay for “value” rather than “volume.” We are uniquely positioned to benefit from these expected changes in reimbursement, because of our strengths as a multispecialty clinic and hospital, and because of our ability to manage and report data available to us through Epic.

Here is an explanation of the Pay for Performance program that ties quality metrics to the Equal Share, in a “Frequently Asked Questions” format:

1)  What is the Equal Share going to be based on and how will it be phased in? The change in awarding the equal share based on quality metrics rather than productivity will be phased in. as of May 2/3 of the Equal share will be based on hitting New 2011 quality targets which have been adjusted to meet national benchmarks. Targets are calculated using the quality metrics of your HMSA commercial patients (HMO and PPO) who have either diabetes or hypertension. Your performance is compared to the HMO HEDIS database, a national commercial database which includes millions of patients, from which your percentile scores are calculated.

2)  What are the adult equal share quality measures? For each measure the total patients who were compliant with that measure are divided by total patients on the registry for the provider. You must have at least 30 patients with diabetes or hypertension for the data to be included. Each measure has percentile targets. For the equal share program, the physician needs to have at least three of the following six measures at the 50th percentile:

  1. Diabetes: LDL-Cholesterol control (<100 mg/dL)- The test must be resulted within the last twelve months and be <100 to be compliant.
  2. Diabetes: Blood Pressure <= 139/89 The most recent blood pressure taken at the last endocrinology, cardiology or primary care visit is used in this measurement. If more than one blood pressure is taken in a visit, the lowest of the systolic and diastolic measures are used. The blood pressure must be recorded in the vitals area of Epic rather than documented in the notes. The value must be less than both 140 and 90 to be compliant. White coat hypertension exists throughout all populations and is reflected in the percentiles. We cannot count patient reported or home blood pressure recorded values. All MAs and nursing staff in endocrinology, cardiology and primary care have received training and passed proficiency testing for accurate blood pressure recording.
  3. Diabetes: Nephropathy Testing- The patient is compliant for this measure if a Microalbumin test has been done in the last twelve months or the patient is on an ACE/ ARB medication.
  4. Diabetes: Hemoglobin A1c (HbA1c) >9- This is a measure of diabetic poor control. If the last test was done over twelve months prior or if the test result greater than 9.0. Lower score correlates with a higher percentile.
  5. Diabetes: All measures met – This bundle measures is patient-centric. The patient is considered compliant for the bundle if they are compliant for nine diabetes ‘ideal care’ elements which include:
  6. Hemoglobin A1c tested in the last twelve months.
  7. Hemoglobin A1c <7.0
  8. LDL tested in the last twelve months
  9. LDL <100
  10. Blood pressure <=139/89 and measured in the office in the last twelve months
  11. Nephrology- Microalbumin in the last twelve months or on an ACE/ ARB
  12. Pneumovax administered
  13. Non-smoking and its documented in vitals section
  14. Hypertension without diabetes: Blood pressure <=139/89- The most recent blood pressure taken at the last endocrinology, cardiology or primary care visit is used in this measurement. If more than one blood pressure is taken in a visit, the lowest of the systolic and diastolic measures are used. The blood pressure must be recorded in the vitals area of Epic rather than documented in the notes. The value must be less than both 140 and 90 to be compliant. White coat hypertension exists throughout all populations and is reflected in the percentiles. We cannot count patient reported or home blood pressure recorded values.

3)  What defines Diabetes? Active problem list which includes ICD9 codes 250.** , 357.2, 362.0 (Diabetic Retinopathy), 366.41 (Diabetic cataract), 648.0 (Diabetes Mellitus). We exclude Gestational Diabetes (648.8), Steroid induced (251.8, 962.0), Polycystic ovaries (256.4). Patients are between the ages of 18 and 75.

4)  What defines Hypertension? Active problem list which includes ICD9 codes between '401' and '401.99'. Patients are between the ages of 18 and 85.

5)  How is a patient included in my panel? First, a physician listed in Epic as the patient’s general PCP. Second, they are of the age and have the registry-specific condition indicated on their problem list (Diabetes/ Hypertension). Third, they must have come for a primary care office visit in the last twenty-four months.

6)  What if the lab tests were done at DLS? All Clinical Labs of Hawaii (CLH) results for tests ordered at Straub/ KMC are included in Epic. DLS labs ordered at Straub or KMC are now also included

7)  How can I get an update of how I am doing? Individual physicians will receive their quality dashboards by the 10th of every month for the previous month via email. This information is shared only with your chief and the PAG. You will also receive your percentile scores based on the last 4 months data with every future compensation calculation.

8)  How can I improve my quality metrics? The best and easiest way is for you and your clinic assistant to act on the “Health Maintenance Due” items in Epic with each patient encounter. Detailed registries are available to see which patients are overdue for which items to support your PSR or MA to bring in patients for recommended care. If you need help reviewing your registry or getting patients in, please work with your clinic manager. They can also work with our HealthAdvantage staff to see how we can help with outreach. For blood pressure control, ensure that your clinic staff is not ‘rounding’ to the nearest ten and retake the patient’s blood pressure after they have been resting if the initial reading is high. Not allowing patients to sit for five minutes is another common reason for falsely elevated readings.

The April salary calculation will also begin including the bonus for hitting the 75th and 90th percentile for these and other measures, as well as for taking care of more complex patients. Thanks for all that you do to support your patients and to deliver the highest quality and best customer service in the Pacific region.

If you have any questions about this new pay for performance program, please contact Dr. Ken Robbins at or at 522-3102, or Dr Dale Glenn at or cell 221 3037.