Dr. Allen has been the Chief Medical Officer for Greater Newport Physicians (GNP) since January 2001. In this role, Dr. Allen oversees all clinical costs and quality associated with the GNP Independent Practice Association (IPA). GNP is an IPA affiliated with Hoag Hospital in Newport Beach that serves more than 125,000 members in Southern California.

Dr. Allen chairs the statewide Clinical Data Repository project for California's medical group industry association, CAPG. He serves on steering committees for several state wide projects and other industry associations/consortia.

Dr. Allen has held various full time medical director positions, including other IPAs, a corporate director for HealthCare Partners medical group, national medical director for Prescription Solutions, regional director for PacifiCare/Secure Horizons, and medical director for a Hospital, home health agency and SNF. Prior to his administrative career, Dr. Allen practiced as a full time internist and hospitalist for five years.

Question #1:

In your opinion, what are the most significant obstacles to achieving and rewarding provider quality?

To reward quality, one must accurately measure both quality and change in quality over time. This requires: collection and analysis of data, presentation of this data to physicians in a manner that results in desired behavioral changes, financial incentives for quality improvement (if possible), and giving practitioners tools to facilitate their quality improvement efforts. All of these steps pose significant challenges, just a few of which are listed below.

• Systematic collection of data, including pharmacy data, lab claims, lab values and professional claims requires a significant commitment of resources.
• Once the data is collected, development of dashboard reports to assure data integrity is required if major errors (which undermine physician acceptance) are to be avoided. Again, this requires a significant commitment of resources.
• Physicians will more readily accept measurement of their quality if the methodology and the individual patients that contribute to the measurement are made available. Their feedback should be incorporated into the measurement process, including any data problems and the inclusion of non-claims based data they find upon chart review. An example would be incorporation of a hysterectomy diagnosis in the HEDIS pap smear measure (which would remove their patient from the denominator).
• Tools should be developed, such as patient negative lists derived from disease registries, to help the physician be successful in improving quality. These tools must be of very high integrity. Outside of a large organized medical group, physician's offices have few spare resources to pull charts and contact patients. If the physicians or their office staff discover that patients are frequently misidentified as needing a test or procedure, they may cease to engage in quality improvement efforts.
• Finally, for financial incentives to drive quality improvement, significant monies must be set aside, at a time when financial pressures at the office practice level are at an all time high. Absent direct ties between performance and enhanced revenue from payors, the long term sustainability of such financial incentives may be in question.

Question #2:

In your opinion, what are the most forward thinking initiatives or solutions that should be widely explored to achieve the systematic change necessary for successful pay-for-performance?

• State wide Pay for Performance initiative, tying revenue from the payors to quality at the level of the medical group. In some states, the appropriate focus of incentives may be at the HMO level. Such revenue for quality is critical to sustainability of quality improvement. This will be even more important as premiums continue to outpace the CPI.
• State wide clinical data warehouse, allowing benchmarking, measurement of quality associated with multiple populations over time, jump starting smaller entity's disease registry efforts etc.
• State wide quality improvement programs, such as the Breakthroughs in Chronic Care Program in CA, Institute for Clinical Systems Improvement in Minnesota and others. Such programs bring together various stakeholders, for the sole purpose of engaging in process improvements designed to improve quality.

Please expand on any initiatives with which you are currently involved that benefit your organization or the health care industry.

• Development of an internal clinical data warehouse, comprising lab claims and values, pharmacy and professional claims and inpatient claims, all linked to eligibility, going back 4 years.
• Using this data warehouse to develop disease registries for many chronic disease states as well as preventive care.
• Using these disease registries to:
  • Send Q 6 month patient negative lists to practitioners, showing them their patients who apparently require a test or procedure to be in compliance with current standards in preventive care and disease management.
  • Provide monthly updates to each physician's patient negative lists, available over the internet whenever the physician desires to pull up their patients.
  • Create q 6 month reports to physicians of their performance surrounding various quality measures, relative to their peers.
  • Send q 6 month reminders and educational material out to patients in need of one or more tests or procedures.
• Translating the above experience into a state wide clinical data warehouse for the purpose of benchmarking quality across multiple medical groups in California. Additional functionality will include ad-hoc benchmark reporting by medical groups on both utilization and quality. Disease registries will be available to medical groups without the infrastructure to create them internally.

Please provide highlights of your presentation at the Leadership Summit and any preliminary results or data that can be shared.

• Provide a business case for development of a clinical data warehouse to fuel quality improvement efforts.
• Discuss some key obstacles surrounding development of a clinical data warehouse, and how to overcome these obstacles.
• Understand the kinds of quality improvement tools that can be developed using a data warehouse.
• Consider some key strategies for engaging physicians once the above capabilities are developed.

Please state what you hope to achieve by participating in the 3rd Annual World Congress Leadership Summit on Health Care Quality and Pay for Performance Contracting.

• Network with others who are developing state of the art systems to improve quality. Looking for key tactics translatable to our health care system.
• Share some insights surrounding technology investment as it relates to quality improvement.