Cost to Primary Care Practices of Responding to Payer Requests for Quality and Performance Data

Jacqueline R. Halladay; Sally C. Stearns; Thomas Wroth; Lynn Spragens; Sara Hofstetter; Sheryl Zimmerman; Philip D. Sloane

doi:10.1370/afm.1050

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Table 1.

Characteristics of the Primary Care Practices Studied

	Participating Primary Care Practices
		Small Private			Nonprofit or CHC			Teaching
Characteristic	Large Group Practice A	Practice B	Practice C	Practice D	Practice E	Practice F	Practice G	Practice H
CCNC = Community Care of North Carolina (Medicaid); CHC = federally qualified community health center; EHR = electronic health record; FM = family medicine; FTE = full-time equivalent; IM = internal medicine; IPIP = Improving Performance in Practice (grant-funded demonstration project); P=pediatrics; PQRI=Physician Quality Reporting Initiative 2007 pilot program (Medicare).
^a Community type (by population): rural = <25,000 population; town = 25,000 to 100,000 population; small city = 100,000 to 500,000 population.
^b Bridges to Excellence (Blue Cross/Blue Shield of North Carolina).
Community^a	Town	Town	Small city	Rural	Rural	Rural	Rural	Small city
Practice type	Private	Private	Private	Private	CHC	CHC	Nonprofit	Teaching
Medical specialties represented	FM, IM	IM	P	FM	FM, IM, P	FM, IM	FM, IM	FM
Clinician FTEs
Physician	8.0	1.0	1.0	1.0	2.8	3.0	4.0	6.8
Nurse-practitioner or physician’s assistant	6.0	1.5	0	1.0	2.4	3.0	4.75	2.7
Other personnel FTE	36.0	7.5	3.0	7.0	24.0	22.0	36.0	30.5
Patient insurance, as % of visits
Medicare	34	47	0	40	28	29	29	21
Medicaid	9	18	58	18	26	11	28	20
Private insurance	45	32	40	37	27	44	28	56
Uninsured	12	3	2	2	19	16	13	2
Medical record type	EHR	Paper	Paper	EHR	Paper	EHR	EHR	EHR
Disease registry	No	Yes	Yes	No	Yes	No	No	Yes
Information technology specialist on staff	Yes	No	No	No	No	Yes	No	Yes
Reporting program participation
PQRI	Yes	Yes	No	Yes	No	No	No	Yes
CCNC	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No
IPIP^b	No	Yes	Yes	No	No	Yes	No	No
Bridges to Excellence	Yes	No	No	No	No	No	Yes	No

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Table 2.

Categories of Costs Identified and Estimated for Each Program and Practice

		Direct Cost of Personnel Time
Category	Nonpersonnel Costs	Quality Data Capture^a	Data Collecting and Reporting^a
Note: Staff/personnel time costs are calculated as follows: cost = (hours devoted to task) (hourly salary + 22% [for benefits]). Source for benefit rate: http://www.pohly.com/books/mgmacost-multispecialties.html.
^a Staff includes any employee, clinician, or administrator associated with the practice or program.
^b Includes only the proportion of costs devoted to collecting and reporting data specifically for the reporting program.
Definition	Cost of hardware, software, program materials, or participation fees^b	Patient care or administrative process alterations caused by program participation	Time expended specifically on data collecting and reporting for the program
Types of costs identified and estimated	Application fees  Cost of written program materials  Software or software upgrades Hardware  Data backup (electronic or paper), data security  Legal consultations for agreements  Excess clinical supplies needed to participate	Personnel time to decide whether to participate in the program  Personnel time to decide on measures to work on within a program  Meeting times (formal and informal) to inform practice staff of program expectations, requirements, changes in staff roles and duties.  Regional meetings with other practices or administrators of the program(s)  Staff time to develop, improve, or add a new process to capture quality data item and document the item  Information technology support time  Staff time devoted to improving information interoperability necessary for data capture, submission, and cross-communication with different electronic systems  On-site staff time provided and paid for by the program and devoted to educating and/or assisting the practice	On-site staff time provided and paid for by the program and devoted to extracting data elements  Report generation time, and/or report review time  Data entry and upload  Developing and maintaining a list of active patients for whom a measure applies; work to contact patients who are potentially inactive  Chart audit/data abstraction

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Table 3.

Estimated Implementation and Maintenance Costs of Performance Data Reporting in 8 Primary Care Practices, by Program and Practice

	Implementation Costs $			Maintenance (Annualized) Costs $
Program and Practice	Total	Per Clinician FTE	Incurred by Program^a	Total	Per Clinician FTE	Incurred by Program^a	Major Cost Sources, $	Estimated Incentive Payment (per FTE), $
AM = annualized maintenance cost; CEO = chief executive officer; EHR = electronic health record; IT = information technology; n/a = not available; QI = quality improvement; S=start-up cost.
^a Includes only the estimated cost of program services delivered on-site in the primary care practice.
^b No maintenance participation costs available either because of nature of program (no maintenance phase of reporting) or insufficient time in program.
^c CCNC started in 1998; several practices did not have access to costs data from implementation.
^d Participating practices received $2.50 per patient per month, primarily for case management; payment was not tied to data reporting.
Physician Quality Reporting Initiative (PQRI)
A	5,949	425	0	12,200	871	0	S/AM: Data entry by clinicians and billing staff	7,000 (500)
B	920	368	0	207	83	0	None	0; denied incentive due to operational issues
D	22,200	11,100	0	8,657	4,329	0	S: Personnel time to collaborate with others (laboratory, Medicare, a patient revenue management company); internal meetings to plan and comply with the program	4,000 (1,000)
							S/AM: Technical support with server, and server upgrades
H	5,894	475	0	7,200	581	0	S: Data entry time; leadership meetings	2,000 (210)
							AM: Data entry by clinicians and IT personnel costs for program monitoring
Improving Performance in Practice (IPIP)
B	3,571	1,428	2,545	5,044	2,018	141	S/AM: Maintaining the active list of patients; data entry	2,000 (800)
C	2,689	2,689	1,000	4,229	4,229	820	S/AM: Data abstraction by clinician	2,000 (2,000)
F	18,210	3,035	1,673	11,563	1,927	1,673	S/AM: Meetings; staff time to develop work- around for laboratory values (because of lack of information interoperability)	2,000 (333)
Bridges to Excellence: Diabetes (DPRP)
A	8,658	618	0	2,940	$205	$0	S: Internal audit to verify data accuracy (not required by QI organization).	7,500 year 1 (536)   12,000 year 2 (857)
							S/AS: Administrative meetings
G	4,270	488	45	n/a^b	n/a^b	n/a^b	S: Planning and decision making	0; could not submit
							S: Data entry and backup work
Bridges to Excellence: Physician Practice Connections (PPC)
A	11,294	$807	$0	n/a^b	n/a^b	$0	S: Meetings of decision makers and/or stakeholders	65,000, year 1 (4,642)   35,000, year 2 (2,500)
Community Care of North Carolina (CCNC)
A	1,865	133	1,266	2,954	211	1,147	S/AM: Regional meeting attendance	0^d
B	709	284	268	146	58	197	S: Initiation of new processes for some measures; meetings and work to credential clinicians	0^d
							AS: Report review
C	563	563	261	n/a^b	n/a^b	n/a^b	S/AS: Regional meeting attendance; chart audits required staff participation due to EHR	0^d
D	n/a^c	n/a^c	n/a^c	719	360	1,628	S/AS: Internal meetings; audit preparation; audits required office staff participation because of EHR	0^d
E	n/a^c	n/a^c	n/a^c	761	146	1,022	AM: Network meetings, some report review by CEO	0^d
G	n/a^c	n/a^c	n/a^c	2,788	319	5,477	S/AM: High Medicaid volume resulted in case manager on site, who provided direct teaching of personnel; audits required office staff participation because of EHR	0^d

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The Article in Brief

Cost to Primary Care Practices of Responding to Payer Requests for Quality and Performance Data

Jacqueline R. Halladay , and colleagues

Background Primary care practices are increasingly required to participate in quality improvement (QI) programs. This study set out to determine the cost to practices of participation in programs requiring them to gather and report data on care quality indicators.

What This Study Found Responding to payer requests for quality and performance data can be costly for primary care practices, with estimated costs of implementation ranging from less than $1,000 to $11,100 per practitioner, and maintenance from less than $100 to $4,300 per year. Researchers found substantial variation among the four reporting programs studied in the way measurement data elements are defined, gathered, and transmitted. Major expenses included personnel time for planning, training, registry maintenance, visit coding, data-gathering, and entry.

Implications

The authors recommend that quality improvement programs choose their performance measures judiciously.
QI programs should consider offering financial incentives that allow practices to at least recoup their costs, as well as other motivators such as computer skills training, assistance with electronic system challenges, and quality improvement training for staff.