Value, 2005

Anthem of Virginia

July 2004

Anthem of Virginia, a Blue Cross and Blue Shield Plan, is using the AHRQ Patient Safety Indicators (PSIs) as part of a program that pays bonuses for inpatient and outpatient quality of care. The program is designed to provide financial incentives to improve patient safety, patient health outcomes, and patient satisfaction.

The Quality-In-Sights®: Hospital Incentive Program (Q-HIP) is offered by Anthem to Virginia and its contiguous states' hospitals. The Q-HIP performance objectives are based on safety and care processes set forth by AHRQ, JCAHO, the Leapfrog Group, the American College of Cardiology, and other nationally recognized organizations.

Hospitals that score at least 90 percent on a 100-point rating scale can receive a one-percent higher reimbursement from the insurance company. Patient safety improvements, measurable improvements in health outcomes, and patient satisfaction determine the scoring. Q-HIP consists of Patient Safety (30 percent; 32 percent in year two); Health Outcomes (55 percent; 53 percent in year two); and Patient Satisfaction (15 percent).

Richardson Grinnan, Anthem's Medical Director of Quality Support Systems, states, "Our program is the first in the country to link all three components—patient safety, outcomes, and satisfaction—and that linkage is critical if we are going to drive real change in the health delivery system."

The incentive opportunity for the participating hospitals is a maximum of one percent, paid prospectively after each 12-month measurement period. The first measurement period began in July 2003. Each hospital that has achieved qualifying performance scores will receive a positive payment adjustment up to one percent additional reimbursement. Each hospital that fails to achieve the minimal performance scores will not receive increased payment.

The AHRQ PSIs are a software tool that can help hospitals enhance their patient safety performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. The tool uses secondary diagnosis codes to detect 23 types of adverse events, such as complications of anesthesia, blood clots in the legs or lungs following surgery, fracture following surgery, and four types of birth-related injuries. Hospitals can then investigate to determine whether the problems detected were caused by potentially preventable medical errors or have some other explanations. They were developed and validated by the AHRQ-funded UCSF-Stanford Evidence-based Practice Center.

The selected AHRQ PSIs included in the Virginia Anthem program are as follows:

• Complications of anesthesia.
• Death in low-mortality DRGs.
• Iatrogenic pneumothorax.
• Selected infections due to medical care.
• Postoperative hemorrhage or hematoma.
• Postoperative sepsis.
• Obstetric trauma—vaginal with instrument.
• Obstetric trauma—vaginal without instrument.
• Obstetric trauma—cesarean delivery.
• Post-operative hip fracture (added in year two).
• Post-operative PE or DVT (added in year two).
• Post-operative respiratory failure (added in year two).

Anthem is working with AHRQ to develop better ways of using these indicators within each hospital and will reevaluate the data for scoring consideration for year three. Due to unfamiliarity with the AHRQ indicators and the lack of internal programmers using the AHRQ software by participating hospitals, hospitals have encountered some difficulties in collecting the data internally, performing appropriate risk adjustment, and analyzing the data.

In an effort to resolve these issues, Anthem will have Virginia Health Information (VHI) provide each participating hospital with its data from an analysis of each of the 12 indicators. VHI is an organization that creates and disseminates health care information, promotes informed decision-making by Virginia consumers and purchasers, and seeks to enhance the quality of health care delivery in the state. The AHRQ indicators will not be scored in year two.

A committee composed of representatives from Anthem and all participating hospitals reviews and makes recommendations on an annual basis in an effort to ensure that all indicators and measures are consistent with industry standards and evolving standards of best practices. AHRQ has already started work on a user-friendly software tool that will eliminate the dependence on third-party statistical software packages and knowledgeable programmers. The new PC-based software will enable anyone who has access to hospital inpatient discharge data to run the QIs. It is scheduled for release in the summer of 2005.

Impact Case Study Identifier: CDOM 05-01
AHRQ Product: Healthcare Cost & Utilization Project (HCUP)
Topic(s): Patient Safety
Scope: Virginia, Tennessee, North Carolina, Washington DC

Measures of Patient Safety Based on Hospital Administrative Data—The Patient Safety Indicators. File Inventory, Technical Review No. 5. AHRQ Publication No. 02-0038, August 2002. Agency for Healthcare Research and Quality, Rockville, MD.

Patient Safety Indicators, Version 2.1, Revision 1. March 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.qualityindicators.ahrq.gov/psi_download.htm

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