FINAL EXAMINATION          DUE: 11:59 PM, MAY 24HSA 312 – 01:        MANAGED HEALTH CARE·       PAYING PROVIDERS.·       UTILIZATION MANAGEMENT¨    ¨    ¨    ¨    ¨    ¨QUESTIONS TO BE ANSWERED ARE IN GREEN.·       QUESTIONS HAVE MULTIPLE PARTS – BRIEFLY ANSWER EACH PART.·       ANSWERS SHOULD BE SHORT – 3-4 SENTENCES PER QUESTION.·       SINGLE SPACED.·       12 POINT TYPE.·       DOWNLOAD THE QUESTIONS FOR THE FINAL, WRITE ANSWERS UNDER THE QUESTIONS, AND SUBMIT THE FINAL DOCUMENT VIA THE ASSIGNMENTS PROCESS.QUESTION 1: TWO KEY APPROACHES TO PAYING PROVIDERS.USING ATTACHED READING 1 (SLIDES 5-6, 13 – 15)), AND READING 2., ANSWER THE FOLLOWING:PART A:    What is the basic difference between Fee-For-Service Payments and Bundled Payments as the two (2) main approaches to paying providers for Personal Health Care Services?     (HINT: How do those terms relate (respectively) to the restaurant terms A La Carte and Prix Fixe?)PART B: Give ONE (1) example of a Fee-For-Service Payment, and ONE (1) example of a Bundled Payment, for specific types of clinical providers (Doctor, hospital, Skilled Nursing Facility).PART C: Give ONE (1) positive effect of Fee-For-Service Payment on the behavior of a clinical provider, and ONE (1) positive effect of a Bundled Payment on the behavior of one or more clinical providers.QUESTION 2: PAY FOR PERFORMANCE: THE CONCEPT/ RELATIONSHIP TO PERFORMANCE MEASURESUSING READING 1 (USE SLIDES 11-12), READING 3, READING 3.A., READING 4., READING 4.A., AND READING 4.B. ATTACHED, ANSWER THE FOLLOWING:PART A:    What is the basic premise of Pay-for-Performance (P4P) – In other words, how is this form of payment expected to positively impact on the behavior of clinical providers? (Doctors and hospitals, for instance.)PART B: What is a Quality Measure or Performance Measure/Indicator – how are such Measures related to the concept and practice of Pay-for-Performance?NOTE: JUST USE READINGS 4., 4.A., AND 4.B. TO GET A GENERAL SENSE OF PERFORMANCE MEASURES, WHAT THEY ARE, AND WHAT THEY DO. DO NOT GET INTO THIS IN TOO MUCH DETAIL – LOOK AT 4.B. TO LEARN WHAT HEDIS IS, AND TO GET A COUPLE OF EXAMPES.QUESTION 3: BUNDLED PAYMENTS: PRINCIPLES/EXAMPLES/MEDICARE/MS-DIAGNOSIS RELATED GROUPSUSING ATTACHED READING 1(SLIDES 6, 13-15), READING 5.A., AND READING 5.B.PART A:    USING DIAGNOSIS RELATED GROUPS (DRGs) AS AN EXAMPLE:  Briefly describe the basic concepts behind Bundled Payments – include ONE (1) expected Positive outcome of this kind of payment.PART B: What types of clinical groups (patients with specific diagnoses, patients receiving certain surgical or medical procedures) are the best candidates for creating Bundled Payments? Why are they the best candidates?QUESTION 4: DISEASE MANAGEMENT AND POPULATION HEALTHUSING READING 7, READING 6.A, READING. 6.B., AND READING 6.C. ANSWER THE FOLLOWING:PART A: Disease Management is based on a Population Health approach to looking at clinical data. BRIEFLY: What is a Population Health approach?PART B: Briefly indicate TWO (2) ways in which Disease Management and Case Management are different Utilization Management approaches.PART C: Briefly discuss how Disease Management emphasizes Coordination of Care for identified populations of potential high utilizers of Personal Health Care Services, including individuals with multiple chronic conditions. (HINT: Think about Collaborative Practice Models, and Routine Reporting between Providers and Health Plans.)QUESTION 5: IDENTIFYING AREAS ON WHICH TO FOCUS UTILIZATION MANAGEMENTUSING READING 8 (SLIDES 5 – 10). ANSWER THE FOLLOWING:PART A:  Briefly describe Hospital Acquired Complications and Conditions: What are they? Give ONE (1) example.PART B:  Why do you think that computer analysis of the incidence of these kinds of events (for instance, at a hospital) can help to focus efficient and effective Utilization Management activities? (HINT: Do clinical providers and administrators in hospitals have control over the occurrence of these events?)QUESTION 6: CURRENT TRENDS IN UTILIZATION MANAGEMENT: COMPUTER ANALYSIS OF LARGE DATA SETS/IDENTIFICATION OF HIGH UTILIZERS/ADDRESSING BOTH CLINICAL AND SOCIAL NEEDS OF PATIENTS.USING READING 7 AND READING 10.B., ANSWER THE FOLLOWING:PART A: What kinds of data did the Hot spotting Model used in Camden New Jersey use to identify the highest utilizers of Personal Health Care Services?PART B: Using this Reading, and the example of an individual clinical intervention in the Reading, describe ONE (1) way in which this Utilization Management approach focused on Social aspects of the patient’s life in order to improve their health status.
FINAL EXAMINATION DUE: 11:59 PM, MAY 24 HSA 312 – 01: MANAGED HEALTH CARE · PAYING PROVIDERS. · UTILIZATION MANAGEMENT ¨ ¨ ¨ ¨ ¨ ¨ QUESTIONS TO BE AN
1 3M Health Information Systems Reducing Hospital Acquired Complications: The Maryland P4P Experience Norbert Goldfield, MD, Medical Director, Clinical and Economic Research, 3M Health Information Systems Carol Everhart, RN, MS Director of Quality Initiative s, Western Maryland Health System (Cumberland, MD) 1© 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 3M Health Information Systems Pay for Performance: Aligning quality outcomes with financial performance ƒUltimate goal is to improve patient care, improve population health, imp rove patient experience, and reduce costs ƒ Align interest of patient, provider, payer and purchaser ƒ Identify cost reduction opportunities on a continuous basis ƒ Determine gain-sharing opportunities for providers based on quality of c are provided, a performance scorecard © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 2 3M Health Information Systems Transforming the inpatient hospital payment system 3© 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. Pay for Outcomes Outcomes Adjust payments to hospitals based on their complication and readmission rate Hospital Incentive Improve quality outcomes Best Practice Identify the hospitals with lowest complication and readmission rates Pay Adjust payments to hospitals to reflect their complication and readmission rate compared to best practice Impact Revised payments to hospitals result in a net savings of X% Benefits: Immediate savings Short- and long-term incentives to improve quality 3M Health Information Systems Maryland’s outcomes, quality-based payment hospital acquired conditions program ƒMaryland HSCRC sets hospital rates for all payers ƒ In 2009, MD HSCRC began adjusting individual hospital inpatient rates based on hospital’s risk-adjusted 3M Potentially Preventable Complica tion (PPC) performance ƒ Incentivizes hospitals to reduce potentially preventable complications ƒ MD measures hospital performance using 49 of the 3M PPCs-a much more comprehensive list than the CMS HACs ƒ In two years following implementation, statewide rate of PPCs dropped by 20% removing over $105 MM of inpatient costs from the system ƒ Considerable variation among hospitals in PPC performance © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 4 3M Health Information Systems Potentially preventable complications (PPCs) Harmful events (accidental laceration during a procedure) or negative outcomes (hospital acquired pneumonia) that may result from the proces s of care and treatment rather than from a natural progression of underlyi ng disease © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 5 3M Health Information Systems Assumptions ƒNot all inpatient complications are preventable ƒ Even with optimal care inpatient complications will occur ƒ Patients who have had a problem with the quality of care will be more likely to have an inpatient complication ƒ Hospitals with quality of care problems will have higher rates of inpati ent complications ƒ A patient’s risk of an inpatient complication is related to the patie nt’s reason for admission and severity of illness at the time of admission © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 6 3M Health Information Systems Key themes ƒFocus on high impact outcomes ƒ Methodology that is: ƒ clinically based ƒ transparent ƒ actionable (i.e. drill down) ƒ Incentives based on severity-adjusted relative performance and best practice ƒ Patient-based risk adjustment (i.e. multip ly interacting co-morbid conditions) ƒ Flexible payment options ƒ shadow system ƒ built in savings upfront © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 7 3M Health Information Systems Determining PPCs: A general rule If a hospital or other health care facility has a statistically signific antly higher rate of a complication (or group of complications) than comparable hospitals and facilities, reasonable clinicians would be concerned that a potential quality of care problem exists, and would suggest further investigation in order to account for the difference. © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 8 3M Health Information Systems Maryland’s focus: PPCs ƒComplications unlikely to be a consequence of the natural progression of underlying illness ƒ Not present when patient first admitted ƒ Associated with care during hospitalization ƒ Examples: UTI, Septicemia, Iatrogenic pneumothorax, encephalopathy ƒ Maryland hospital acquired conditions (HACs) ƒ Set of 49 ƒ Expansion beyond the Medicare HACs © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 9 3M Health Information Systems Top 15 PCCs by cost (multiple states and payer data) 10 © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. Description FreqCost of PPC % Pat Cost Post-Operative Respiratory Failure with Tracheostomy 164 $118,841 50.78% Renal Failure with Dialysis 620 $47,888 38.53% Decubitus Ulcer 1,668 $28,272 31.16% Post-Operative Wound Infection & D eep Wound Disruption with Procedure 200 $27,814 29.67% Acute Pulmonary Edema and Respiratory Failure with Ventilation 2,725 $27,134 30.08% Gastrointestinal Ostomy Complications 732 $25,882 31.33% Clostridium Difficile Colitis 2,478 $25,401 31.11% Extreme CNS Complications 675 $23,526 24.02% Septicemia & Severe Infections 7,018 $23,451 26.59% Infection, Inflammation and Clotting complications of Peripheral Vascular Catheters and Infusions 3,399 $22,747 26.32% Major Gastrointestinal Complications with Transfusion or Significant Bleeding 530 $21,923 29.86% Reopening Surgical Site 408 $19,442 29.16% Other Gastrointestinal Complications without Transfusion or Significant Bleeding 910 $17,886 26.17% Pneumonia & Other Lung Infections 10,781 $16,901 24.89% Pulmonary Embolism 1,057 $16,331 25.44% 3M Health Information Systems Achieved results ƒMaryland All Payer ƒ PPC used for payment adjustment ƒ First year: ƒ 11.9% reduction in PPCs ƒ $ 62.5 million in averted costs to state and providers ƒSecond year: ƒ additional 8% reduction over first year ƒ $ 43 million in additional averted cost © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 11 3M Health Information Systems Why the Maryland approach works ƒTarget is clear, attainable (peers are already doing it) and achieves good patient care (not pay for reporting) ƒ The financial return on PPCs within a DRG system is such that the hospitals gain additional profit (reduced cost) in excess of reduced p ayment (i.e reduced case mix). Natural gain sharing environment. ƒ The program is not going away – effort and time spent today will be rewarded tomorrow ƒ After initial opposition the hospitals embraced the change – they have a positive story to tell as a result © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 12 3M Health Information Systems The next frontier: Potentially preventable events ƒMaryland focus: ƒ PPCs ƒ 1-2% of inpatient hospital ex penditures (Maryland’s focus) ƒCMS focus: ƒ Potentially preventable readmissions ƒ 2-5% of inpatient hospital expenditures ƒPotentially preventable initial admissions ƒ Potentially preventable ancillary services ƒ Potentially preventable ED visits © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 13 3M Health Information Systems Potentially preventable events A population based (not disease specific) measure of the vast majority of what is potentially preventable in a health system © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 14 Potentially Preventable Readmissions (PPR) Potentially Preventable Complications (PPC) Potentially Preventable Initial Admissions (PPIA) Potentially Preventable Visits (PPV) Potentially Preventable Services (PPS) 3M Health Information Systems Achievable savings on Day 1 ƒPotentially preventable readmissions ƒ 2-5% of inpatient hospital expenditures ƒ Potentially preventable complications ƒ 1-2% of inpatient hospital expenditures ƒ Potentially preventable initial admissions ƒ 4-8% of inpatient hospital expenditures ƒ Potentially preventable ER visits ƒ 1-2% total expenditures ƒ Potentially preventable outpatient ancillaries/ procedures ƒ 2-3 % total expenditures © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 15 3M Health Information Systems Western Maryland Regional Medical Center Western Maryland Health System • Cumberland, Maryland 3M Health Information Systems WMHS overview ƒRegional provider of healthcare services creat ed by the affiliation of Memorial Hospital and Sacred Heart Hospital in April 1996 ƒ New replacement hospital opened in November 2009 ƒ Replaced two aging hospitals with 289 beds ƒ Capacity ƒ 275 licensed beds ƒ248 acute care beds ƒ 16 psychiatric beds ƒ 13 rehabilitation beds ƒ 88 long-term care beds ƒ Statistics – FY2011 ƒ Admissions – 15,521 ƒ Average daily census – 195.8 ƒ Emergency department visits – 55,183 ƒ Region’s largest employer – 2300 employees ƒ Over 250 physicians and advanced practice professionals on staff © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 17 3M Health Information Systems WMHS specialty centers ƒDesignated area-wide trauma center, stroke center and cardiac interventional center by the Maryland Institute of Emergency Medical System Services ƒ WMHS Heart Institute, which includes cardiac surgery ƒ Schwab Family Regional Cancer Center ƒ Surgical specialties include thoracic surgery and spine surgery ƒ Frostburg Nursing and Rehabilitation Center © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 18 3M Health Information Systems Service area ƒWMHS leads the market with a 74% market share in its primary service area © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 19 3M Health Information Systems Value based purchasing (VBP) ƒAuthorized program under Patient Protection and Accountable Care Act 2010 ƒ Gives CMS the power to base a portion of hospital reimbursement on how well hospitals perform in 25 core measures ƒ CMS flex muscle and move from passive bystander to active buyer of higher-quality healthcare © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 20 3M Health Information Systems Score to beat “Anyone above that threshold is in the money. If you didn’t make i t, no harm, no foul” -Trent Haywood, MD, JD, chief medical officer of Irving, Texas ƒ Well not exactly – there are winners and losers ƒ VBP – not a collaborative but a competition © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 21 3M Health Information Systems Quality-based reimbursement ƒState of Maryland –implemented in July 2009 ƒ Payment adjustments to hospital rates based on performance of identified measures in calendar year 2008 ƒ Rewards for hospitals performing the best ƒ 0.5% of overall inpatient hospital budget © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 22 3M Health Information Systems Baseline scores are SET ƒJuly 2010 – June 2011 (baseline period) ƒ July 2011 – March 2012 (performance period) ƒ Oct 1, 2012 payment phase ƒ CMS will withhold 1% of base DRG reimbursement ƒ Earn money back based on how well hospital scores on performance measures during evaluation period © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 23 3M Health Information Systems So, what are the measures? ƒ17 core Clinical Process of Care measures ƒ 8 measures based on HCAHPS surveys ƒ Hospital Consumer Assessment of Healthcare Providers and Systems ƒ 20 potential measures are waiting in the wings ƒ Hospital acquired conditions ƒ Patient safety ƒ Inpatient quality ƒ Mortality ƒ Likely to be introduced in FY 2014 © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 24 3M Health Information Systems What are “core measures?” ƒDeveloped to assess the gap between recommended best medical practice and actual applied care ƒ Studies show: ƒ 29% of failed core measures cases actually received best medical practice care but failed documentation requirements Early, GL, et al. Mo Med. 2011 May-Jun;108(3):179-81 © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 25 3M Health Information Systems PPC examples ƒPPC 1: Stroke and intracranial hemorrhage, identified when a subarachnoi d hemorrhage is a secondary diagnosis and not POA ƒ PPC 05: Pneumonia, identified if pneumonia is a secondary diagnosis not POA, but only if the LOS > 2 days ƒ PPC 18: Major GI complications with significant bleeding, requires secondary diagnosis not POA, for example, esophageal hemorrhage AND a transfusion procedure 4 or more days after major surgery © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 26 3M Health Information Systems Western Maryland Health System standings 3M Health Information Systems Summary 3M Health Information Systems WMHS PPC dashboard © 3M 2011. All rights reserved 3M Confidential Not For Distribution Potentially Preventable  Condition s Actual Expe c te d Monthly  $$  Impact   YTD $$  Impact September PPC  31 Pressure  Ul ce r 6.00 1.47  per month 99,515.04 $               298,545.12 $           Key  Dr iP resen t  on  Ad m i t  ‐Documentation  miss i 1.00 Hospital  Acquired  Developed  after  day   2 5.00 PPC  1 4Ve ntri c ul a r  Fibrillation/Cardiac  Arr e s t 8.00 2.78  per month 93,584.16 $               298,680.48 $           Key  Dr iMET  Tea m  Calls 0. 00 PPC  4 7Encephalopathy 8.00 1.05  per month 92,462.80 $               290,692.40 $           Key  Dr iP resen t  on  Ad m i t  ‐DocumentationMissing Documented  days  after  admission PPC  4 Ac u t e  Pulmonary  Ed e m a  and  Res p   Fa il ure  with  Ve nti l a t i on   10.00 2.45 per month 166,892.75 $            235,418.25 $        Key  Dr iEa r l y  intervention  (ventilator  support  prior  to  day  3) PPC  2Extreme  CNS  Complica tions 0.00 .47  per  month 0.00 ‐ $                    Th i s  PPC  moved  fro m  under  the  exp ec t ed  range  to  over  the  exp ec t ed  in  3rd  Q  FY  11 ‐  no occurences  noted  in  July PPC  1   Stroke  &  Intracranial  Hemmorrhage 10.00 1.64  per month 42,514.08 $               140,195.24 $           3M Health Information Systems Conclusions ƒDocument, document, document ƒ Coders cannot make assumptions ƒ Diagnosis codes cannot be assigned for abnormal lab values ƒExample: ABG 7.23/56/178 ƒ Diagnosis listed as pathology and radiology reports cannot be coded in t he inpatient setting unless the attending physician documents such diagnosis in the record ƒ Be careful, precise and consistent in usin g seemingly similar words that for coding purposes are not interchangeable ƒ “Urosepsis” is to be coded as a urinary trac t infection only unless stated as “sepsis due to urinary tract infection” ƒ Codes can be assigned for “presumed,” “possible” or “probable” condition ƒ DOCUMENT present on admit (POA) conditions ƒ Example: pressure ulcers © 3M 2012. All rights reserved. For conference presentation only. Further use or disclosure requires prior approval from 3M. 30 3M Health Information Systems Why is all this important? ƒComplete, accurate documentation and code assignment have far-reaching benefits ƒ Severity of illness (SOI) ƒ Risk of mortality (ROM) ƒ Accurate codes support your level of billing, assist in accurate reimbursement, and provide meaningful data in outcomes assessment and other quality indicators ƒ Specificity in code assignment provides the full picture of treatment rendered to the patient and can impact reimbursement 3M Health Information Systems Strategies for success ƒStart with high dollar, high volume PPCs ƒ Review cases, service lines, DRGs where you do well and where you have opportunity to improve ƒ Does diagnosis code reflect what was really happening? UTI or asymptomatic bacteriuria ƒ Does POA coding reflect what’s documented or what was POA? ƒ Codes that increase SOI may also affect PPCs ƒ Quality, finance, clinical, and HIM leadership working together to understand issues and practices
FINAL EXAMINATION DUE: 11:59 PM, MAY 24 HSA 312 – 01: MANAGED HEALTH CARE · PAYING PROVIDERS. · UTILIZATION MANAGEMENT ¨ ¨ ¨ ¨ ¨ ¨ QUESTIONS TO BE AN
THE HOTSPOTTERS – EDITED EXCERPTS FROM AN NEW YORKER ARTICLE Can we lower medical costs by giving the neediest patients better care? by Atul Gawande January 24, 2011 – THE NEW YORKER. The critical flaw in our health-care system … is that it was never designed for the kind of patients who incur the highest costs. Medicine’s primary mechanism of service is the doctor visit and the E.R. visit. (Americans make more than a billion such visits each year, according to the Centers for Disease Control.) For a thirty-year-old with a fever, a twenty-minute visit to the doctor’s office may be just the thing. For a pedestrian hit by a minivan, there’s nowhere better than an emergency room. But these institutions are vastly inadequate for people with complex problems: the forty-year-old with drug and alcohol addiction; the eighty-four-year-old with advanced Alzheimer’s disease and a pneumonia; the sixty-year-old with heart failure, obesity, gout, a bad memory for his eleven medications, and half a dozen specialists recommending different tests and procedures. It’s like arriving at a major construction project with nothing but a screwdriver and a crane. THE CAMDEN, NEW JERSEY EXPERIMENT: ORIGINS OF HOTSPOTTING – LATE 1990s THROUGH 2010 Prelude: Camden was in civic free fall, on its way to becoming one of the poorest, most crime-ridden cities in the nation. The local school system had gone into receivership. Corruption and mismanagement soon prompted a state takeover of the entire city. Just getting the sewage system to work could be a problem. Using Data to Better Deploy Police Forces: Around that time, a police reform commission was created, and a young doctor, Dr. Brenner was asked to serve as one of its two citizen members. He agreed and, to his surprise, became completely absorbed. The experts they called in explained the basic principles of effective community policing. He learned about George Kelling and James Q. Wilson’s “broken-windows” theory, which argued that minor, visible neighborhood disorder breeds major crime. He learned about the former New York City police commissioner William Bratton and the CompStat approach to policing that he had championed in the nineties, which centered on mapping crime and focusing resources on the hot spots. The reform panel pushed the Camden Police Department to create computerized crime maps, and to change police beats and shifts to focus on the worst areas and times. When the police wouldn’t make the crime maps, Brenner made his own. He persuaded Camden’s three main hospitals to let him have access to their medical billing records. He transferred the reams of data files onto a desktop computer, spent weeks figuring out how to pull the chaos of information into a searchable database, and then started tabulating the emergency-room visits of victims of serious assault. He created maps showing where the crime victims lived. He pushed for policies that would let the Camden police chief assign shifts based on the crime statistics—only to find himself in a showdown with the police unions. Using Data to Understand Hospital Utilization in Camden, New Jersey: Although Brenner’s recommendations for effectively deploying policemen were ultimately rejected, Brenner started to use the data he had been studying to look at the way patients flowed into and out of Camden’s hospitals. “I’d just sit there and play with the data for hours,” he says, and the more he played the more he found. For instance, he ran the data on the locations where ambulances picked up patients with fall injuries, and discovered that a single building in central Camden sent more people to the hospital with serious falls—fifty-seven elderly in two years—than any other in the city, resulting in almost three million dollars in health-care bills. “It was just this amazing window into the health-care delivery system,” he says. So, he took what he learned from police reform and tried a CompStat approach to the city’s health-care performance—a Health stat, so to speak. He made block-by-block maps of the city, color-coded by the hospital costs of its residents, and looked for the hot spots. The two most expensive city blocks were in north Camden, one that had a large nursing home called Abigail House and one that had a low-income housing tower called Northgate II. He found that between January of 2002 and June of 2008 some nine hundred people in the two buildings accounted for more than four thousand hospital visits and about two hundred million dollars in health-care bills. One patient had three hundred and twenty-four admissions in five years. The most expensive patient cost insurers $3.5 million. Brenner wasn’t all that interested in costs; he was more interested in helping people who received bad health care. But in his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. “Emergency-room visits and hospital admissions should be considered failures of the health-care system until proven otherwise,” he told me—failures of prevention and of timely, effective care. Focusing on High Utilizers: If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs. And, if the stats approach to crime was right, targeting those with the highest health-care costs would help lower the entire city’s health-care costs. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients. Things, of course, got complicated. It would have taken months to get the approvals needed to pull names out of the data and approach people, and he was impatient to get started. So, in the spring of 2007, he held a meeting with a few social workers and emergency-room doctors from hospitals around the city. He showed them the cost statistics and use patterns of the most expensive one per cent. “These are the people I want to help you with,” he said. He asked for assistance reaching them. “Introduce me to your worst-of-the-worst patients,” he said. They did. Then he got permission to look up the patients’ data to confirm where they were on his cost map. “For all the stupid, expensive, predictive-modelling software that the big venders sell,” he says, “you just ask the doctors, ‘Who are your most difficult patients?,’ and they can identify them.” EXAMPLE – A Comprehensive Approach to Working with High Utilizers – Medical and Social Interventions: The first person they found for him was a man in his mid-forties whom I’ll call Frank Hendricks. Hendricks had severe congestive heart failure, chronic asthma, uncontrolled diabetes, hypothyroidism, gout, and a history of smoking and alcohol abuse. He weighed five hundred and sixty pounds. In the previous three years, he had spent as much time in hospitals as out. When Brenner met him, he was in intensive care with a tracheotomy and a feeding tube, having developed septic shock from a gallbladder infection. Brenner visited him daily. “I just basically sat in his room like I was a third-year med student, hanging out with him for an hour, hour and a half every day, trying to figure out what makes the guy tick,” he recalled. He learned that Hendricks used to be an auto detailer and a cook. He had a longtime girlfriend and two children, now grown. A toxic combination of poor health, Johnnie Walker Red, and, it emerged, cocaine addiction had left him unreliably employed, uninsured, and living in a welfare motel. He had no consistent set of doctors, and almost no prospects for turning his situation around. After several months, he had recovered enough to be discharged. But, out in the world, his life was simply another hospitalization waiting to happen. By then, however, Brenner had figured out a few things he could do to help. Some of it was simple doctor stuff. He made sure he followed Hendricks closely enough to recognize when serious problems were emerging. He double-checked that the plans and prescriptions the specialists had made for Hendricks’s many problems actually fit together—and, when they didn’t, he got on the phone to sort things out. He teamed up with a nurse practitioner who could make home visits to check blood-sugar levels and blood pressure, teach Hendricks about what he could do to stay healthy, and make sure he was getting his medications. ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH STATUS: A lot of what Brenner had to do, though, went beyond the usual doctor stuff. Brenner got a social worker to help Hendricks apply for disability insurance, so that he could leave the chaos of welfare motels, and have access to a consistent set of physicians. The team also pushed him to find sources of stability and value in his life. They got him to return to Alcoholics Anonymous, and, when Brenner found out that he was a devout Christian, he urged him to return to church. He told Hendricks that he needed to cook his own food once in a while, so he could get back in the habit of doing it. The main thing he was up against was Hendricks’s hopelessness. He’d given up. “Can you imagine being in the hospital that long, what that does to you?” Brenner asked. I spoke to Hendricks recently. He has gone without alcohol for a year, cocaine for two years, and smoking for three years. He lives with his girlfriend in a safer neighborhood, goes to church, and weathers family crises. He cooks his own meals now. His diabetes and congestive heart failure are under much better control. He’s lost two hundred and twenty pounds, which means, among other things, that if he falls he can pick himself up, rather than having to call for an ambulance. “The fun thing about this work is that you can be there when the light switch goes on for a patient,” Brenner told me. “It doesn’t happen at the pace we want. But you can see it happen.” With Hendricks, there was no miraculous turnaround. “Working with him didn’t feel any different from working with any patient on smoking, bad diet, not exercising—working on any particular rut someone has gotten into,” Brenner said. “People are people, and they get into situations they don’t necessarily plan on. My philosophy about primary care is that the only person who has changed anyone’s life is their mother. The reason is that she cares about them, and she says the same simple thing over and over and over.” So he tries to care, and to say a few simple things over and over and over. Was this kind of success replicable? Robert Wood Johnson Foundation and the Camden Hot-Spotting Approach. As word went out about Brenner’s interest in patients like Hendricks, he received more referrals. Camden doctors were delighted to have someone help with their “worst of the worst.” He took on half a dozen patients, then two dozen, then more. It became increasingly difficult to do this work alongside his regular medical practice. The clinic was already under financial strain, and received nothing for assisting these patients. If it were up to him, he’d recruit a whole staff of primary-care doctors and nurses and social workers, based right in the neighborhoods where the costliest patients lived. With the tens of millions of dollars in hospital bills they could save, he’d pay the staff double to serve as Camden’s élite medical force and to rescue the city’s health-care system. But that’s not how the health-insurance system is built. So, he applied for small grants from philanthropies like the Robert Wood Johnson Foundation and the Merck Foundation. The money allowed him to ramp up his data system and hire a few people, like the nurse practitioner and the social worker who had helped him with Hendricks. He had some desk space at Cooper Hospital, and he turned it over to what he named the Camden Coalition of Healthcare Providers. He spoke to people who had been doing similar work, studied “medical home” programs for the chronically ill in Seattle, San Francisco, and Pennsylvania, and adopted some of their lessons. By late 2010, his team had provided care for more than three hundred people on his “super-utilizer” map. 5
FINAL EXAMINATION DUE: 11:59 PM, MAY 24 HSA 312 – 01: MANAGED HEALTH CARE · PAYING PROVIDERS. · UTILIZATION MANAGEMENT ¨ ¨ ¨ ¨ ¨ ¨ QUESTIONS TO BE AN
1 Health System Improvement Measuring Health Care Quality: An Overview of Quality Measures ISSUE BRIEF / MAY 2014 WWW.FAMILIESUSA.ORG / Evidence Generation MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES ISSUE BRIEF / MAY 2014 WWW.FAMILIESUSA.ORG In this brief, we answer these questions: » What are the types of quality measures? » How are quality measures developed? » Where do data on health care quality come from? » How are quality measures used? » What’s next in quality measurement? For a glossary of key terms in quality measurement, see page 14. Measuring the quality of health care is important because it tells us how the health system is performing and leads to improved care. But what are the different types of quality measures, how are they developed, and how are they used? This brief provides an overview of these issues. What is quality measurement in health care, and why is it important? Quality measurement in health care is the process of using data to evaluate the performance of health plans and health care providers against recognized quality standards. Quality measures can take many forms, and these measures evaluate care across the full range of health care settings, from doctors’ offices to imaging facilities to hospital systems. Measuring the quality of health care is a necessary step in the process of improving health care quality. Too often, the quality of care received in the United States is substandard: Patients receive the proper diagnosis and care only about 55 percent of the time, 1 and wide variations in health care quality, access, and outcomes persist. 2 Research consistently shows that there is chronic underuse, overuse, and misuse of services. Furthermore, the way health care is delivered is often fragmented, overly complex, and uncoordinated. These problems can lead to serious harm or even death. Quality measurement can be used to improve our nation’s health care by: 1) preventing the overuse, underuse, and misuse of health care services and ensuring patient safety; 2) identifying what works in health care—and what doesn’t—to drive improvement; 3) holding health insurance plans and health care providers accountable for providing high-quality care; 4) measuring and addressing disparities in how care is delivered and in health outcomes; and 5) helping consumers make informed choices about their care. In our fact sheet on quality measurement, Measuring Health Care Quality: An Introduction , we explain what quality measurement in health care is and why it is important, and we discuss the ways that quality measurement can improve health care quality. Patients receive the proper diagnosis and care only about 55 percent of the time 55% 3 can give a complete picture of the quality of care that is provided and received. Rather, each type of measure addresses a key component of care. A Structure Measures Structure measures evaluate the infrastructure of health care settings, such as hospitals or doctor offices, and whether those health care settings are able to deliver care. These measures include staffing of facilities and the capabilities of these staff, the policy environment in which care is delivered, and the availability of resources within an institution. What are the types of quality measures? Quality measures assess care across the full continuum of health care delivery, from the level of individual physicians all the way up to the level of health insurance plans. Hundreds of different quality measures are used in health care. These measures generally fall into four broad categories: 1) structure, 2) process, 3) outcome, and 4) patient experience. We discuss each of these measures below. However, it is important to note that no single type of measure “ The right care for the right person at the right time, the first time.” i — Carolyn Clancy, former Director of the Agency for Healthcare Research and Quality (AHRQ) Table 1. Types of Quality Measures TYPE DESCRIPTION EXAMPLE Structure Assesses the characteristics of a care setting, including facilities, personnel, and/or policies related to care delivery. Does an intensive care unit (ICU) have a critical care specialist on staff at all times? Process Determines if the services provided to patients are consistent with routine clinical care. Does a doctor ensure that his or her patients receive recommended cancer screenings? Outcome Evaluates patient health as a result of the care received. What is the survival rate for patients who experience a heart attack? Patient Experience Provides feedback on patients’ experiences of care. Do patients report that their provider explains their treatment options in ways that are easy to understand? Note to the reader: Unless otherwise stated, we use the term “provider” as a catchall to refer to the individuals (e.g., nurse practitioners) and the institutions (e.g., hospitals) that are responsible for providing health care services. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 4 the ability to perform certain functions does not capture whether or not these functions actually occur, nor does it capture whether those functions improve patient health. In short, the fact that a health care provider or facility meets the requirements of a structure measure may not result in that provider delivering care that improves patient health. For example, some forms of provider accreditation and certification require providers to use electronic health records. A provider could buy an electronic health record system but continue to rely on paper records and still meet this structural requirement. „ Examples of structural measures include: Does a hospital have a hand hygiene protocol in place? Does a physician’s office use computerized order entry for prescriptions? 4 Structure measures are often used by insurance companies and regulators to determine whether a provider has certain capacities needed to deliver high- quality care, such as whether a hospital has a system in place to order prescription drugs electronically. These measures are also commonly used in the certification or accreditation of health plans and providers. Two key reasons for using structure measures are that characteristics of health care settings can significantly affect the quality of care, and care settings that meet certain standards have an advantage when it comes to providing high-quality care. 3 Although structure measures provide essential information about a provider’s capacity, it is important to note the limitations of these measures. In particular, structure measures provide just one piece of the full picture of care. For example, the fact that a hospital has Key Considerations • Structure measures are necessary to ensure that all plans, providers, and care settings have the critical tools needed to provide high-quality care. • While structure measures provide essential information about a provider’s ability and/or capacity to provide high-quality care, they cannot measure the actual quality of the care received or whether the care improved patients’ health. • Structure measures should be considered a key part of a suite of quality measures, but they should never be relied on as the sole measure of quality. Table 2. Entity Being Evaluated ENTITY DESCRIPTION EXAMPLE Health Plan Assesses the services provided by the health plan and the overall performance of providers in the plan’s network. Does the health plan cover treatment of alcoholism or other drug dependence? Provider Assesses the quality of a provider’s facilities and/or the overall quality of care provided. Does the hospital provide services to treat alcoholism or other drug dependence? Health Care Professional Assesses the quality of care provided by an individual health care professional. Did the physician tell the patient that treatment is available for alcoholism or other drug dependence? MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 5 » Process measures may also not capture the true quality of the care provided. For example, a measure that looks at what percentage of patients who smoke received smoking cessation advice will yield the same results whether the advice provided was a brief admonition to quit or a conversation with the patient about barriers he or she faces when trying to quit and the availability of smoking cessation supports. „ Examples of process measures include: Are nurse practitioners routinely examining the feet of diabetes patients to check for wounds? Are physicians prescribing the appropriate drugs to their diabetic patients? 6 B Process Measures Process measures are used to determine the extent to which providers consistently give patients specific services that are consistent with recommended guidelines for care. These measures are generally linked to procedures or treatments that are known to improve health status or prevent future complications or health conditions. 5 In most cases, assessing whether a provider meets the requirements of process measures is clear-cut: Did patients receive recommended care or not? Process measures are useful in that they give providers clear, actionable feedback and a straightforward way to improve their performance. However, overreliance on process measures to track performance and administer provider incentives can be problematic, for several reasons. » Process measures are not available for many key areas of care, such as whether the care provided was appropriate, or whether a provider coordinated treatment for patients with physical and mental illnesses, for example. » Process measures that do exist tend to focus on preventive care and the management of chronic conditions, which may distract from other important quality areas that are more difficult to measure. Areas where measuring quality is harder include teamwork and organizational culture. Key Considerations • Having well-designed process measures is critical and can mean the difference between providing recommended care and just checking off a box. ii • While process measures typically reflect professional standards of care, they do not always consistently predict outcomes, and users should be aware of their limitations. iii Good process measures should always be backed by evidence that can reliably link a process with improved outcomes. • Current process measures are broadly focused on the areas of prevention and chronic disease management. • Process measures are lacking in key areas of care that can also contribute to outcomes, such as care coordination and technology. Process measures that are developed in the future should focus on these key areas. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 6 » Measuring outcomes often requires detailed information that is available only in medical records, and this information is difficult and expensive to obtain. » Gathering enough data to provide useful information about a particular outcome can also be a challenge. » Although social determinants of health (such as access to safe housing, social support, and economic opportunity) can have a profound impact on health outcomes, there is little agreement on whether or not providers can be held accountable for the confounding effects of social determinants. 7 » Differences in patient population can make certain outcomes more difficult to achieve. For example, ensuring that a certain percentage of a provider’s diabetic patients have controlled blood sugar levels may be more difficult for a provider with a patient population that is sicker or that has multiple chronic conditions. „Examples of outcome measures include: What was the amputation rate for patients with diabetes? What percentage of cancer patients went into remission? What was the quality of pain relief for patients who’d had knee surgery? C Outcome Measures Outcome measures evaluate patients’ health as a result of the care they have received. More specifically, these measures look at the effects, either intended or unintended, that care has had on patients’ health, health status, and function. They also assess whether or not the goals of care have been accomplished. Outcome measures are where the rubber meets the road: Patients are interested in surviving illness and improving their health, not the clinical processes that support these outcomes. Outcome measures frequently include traditional measures of survival (mortality), incidence of disease (morbidity), and health-related quality of life issues. And while these measures often incorporate patient-reported information on how satisfied patients are with the health care services they’ve received, these measures do not assess the full extent of the patient experience (as described on page 7). Although outcome measures are important to patients and providers, their usefulness is limited by the fact that developing outcome measures that are truly meaningful can be quite hard. Key challenges to developing meaningful outcome measures include: Key Considerations • Because outcome measures reflect what is most important to patients, it is especially critical that they are developed with patient needs, values, and preferences in mind. • When developing, evaluating, and using outcome measures, it is important to recognize the potential impact of social determinants of health, as well as critical differences in patient populations. • Outcome measures can be particularly useful for patients when they are choosing providers or health care services if the measures come with relevant information on cost. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 7 Experts are increasingly advocating for the inclusion of patient experience as a key measure of quality as the movement to improve health care quality continues to develop and evolve. This trend has been aided, in part, by the fact that the National Quality Strategy includes measures of patient experience as a key element. 9(For more information on the National Quality Strategy, see “How the Affordable Care Act Improves Health Care Quality” on page 8.) „ Examples of patient experience measures include: How long did patients have to wait before being seen? Did a physician give easy-to-understand information to her patients that addressed their health questions or concerns? Did someone from the provider’s office follow up regarding the results of a blood test, x-ray, or other lab work? 10 D Patient Experience Measures Patient experience measures provide feedback on patients’ experiences of their care, including the interpersonal aspects of care. But these measures assess many other aspects of care, ranging from the clarity and accessibility of information that doctors provide, to whether doctors tell patients about test results, to how quickly patients are able to get appointments for urgently needed care. Research shows that positive patient experiences have a well-documented relationship to clinical quality: Patients with better care experiences are often more engaged in their care, more committed to treatment plans, and more receptive to medical advice. 8 Key Considerations • Patient experience measures should be developed with patient input to ensure that they are representative of their needs, values, and preferences. • These measures reveal critical information about the extent to which care is truly patient- centered. • Although these measures are relatively new, experts are relying more and more on them as a core element of health care quality. • Patient experience measures provide a rigorous, validated alternative to the subjective reviews that are posted on a large number of online review sites. iv MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 8 How the Affordable Care Act Improves Health Care Quality Beyond expanding health insurance and access to care, the Affordable Care Act includes numerous provisions related to improving the quality of care in the United States. The health care law did the following: » Created a National Quality Strategy, the first overarching policy that is designed to lead federal, state, and local efforts to improve the quality of care and align public and private payers in their quality and safety efforts. » Established a Center for Quality Improvement and Patient Safety to conduct and support research on best practices for improving how health care is delivered. » Established the Patient-Centered Outcomes Research Institute (PCORI) to support the generation of patient-centered evidence that can be used in measure development. » Created the Center for Medicare and Medicaid Innovation (CMMI) to test new payment and delivery models that include quality measurement and improvement as a key design component. » Established a mandatory physician quality reporting program (beginning in 2015) and the development of a physician compare website for Medicare beneficiaries. » Requires public reporting on the quality of health insurance plans that are sold in the new state health insurance marketplaces. » Requires additional reporting of patient data related to race, ethnicity, sex, and language, and requires qualified health plans to implement activities to reduce disparities (variations in access to care and in health outcomes due to factors such as race, ethnicity, gender, and socioeconomic status). » Authorized numerous new payment and delivery models, such as value-based physician payment, accountable care organizations (ACOs), and patient-centered medical homes, that all use quality as a key metric of success. v MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 9 Often, professional societies, such as the American Heart Association (AHA) or the American College of Surgeons (ACS), and public agencies like AHRQ, will be the first to identify a critical mass of evidence on a particular treatment. These societies or agencies then develop clinical guidelines that may end up becoming standards of care for many diseases and conditions. These guidelines can be a starting point for determining where quality measurement is needed and for providing the critical evidence needed to develop such measures. In addition, some societies or agencies go a step beyond creating clinical guidelines—they create the measurements themselves. How does evidence become a quality measure? The evidence base that is used to develop clinical guidelines is vast. The process of translating this evidence base into quality measures varies widely according to the type of measure, as well as the entity that is charged with developing the measure. In general, the process of developing a quality measure includes convening a set of stakeholders to evaluate the evidence and define the parameters of a quality measure. Steps in this process generally include: » Convening a committee whose members have expertise on the particular issue to be measured » Evaluating the evidence base , including primary research and clinical practice guidelines How are quality measures developed? All quality measures begin with an evidence base. But how does research become an evidence base and then a validated quality measure that can be applied to multiple providers and/or health insurance plans? Sound quality measurement begins with clinical research that links a particular process, structure, or outcome with improved patient health or experience of care. For example, research has found that administering a beta blocker as soon as possible to a patient who is experiencing a heart attack can reduce the risk of death. This protocol, supported by sound evidence, was later developed into a clinical practice guideline. A clinical practice guideline is a diagnostic or treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. Who develops the evidence base? A range of different groups are involved in funding and developing the evidence base that is used to create clinical practice guidelines. These groups include public agencies like the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), and the Patient-Centered Outcomes Research Institute (PCORI). Private businesses, such as pharmaceutical companies and medical device developers, as well academic research institutes, foundations, and advocacy organizations, are also involved in developing this evidence. THE PATH FROM RESEARCH TO FINALIZED QUALITY MEASURE evidence base research clinical guidelines measure development standard of care finalized quality measure measure endorsement MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 10 » Reaching consensus on the best measurement approach by considering numerous criteria, including what the proposed measure would evaluate and how that is relevant to consumers, the scientific soundness of the evidence base, the feasibility of measurement, and how data will be collected » Developing detailed specifications about what will be measured and how » Vetting the specifications with key interest groups, such as professional societies or consumer groups » Conducting rigorous testing to ensure that the measure works as it was designed » Obtaining final approval by the entity charged with developing the measure Who develops quality measures? The entities that develop quality measures include: » Government agencies , such as the Centers for Medicare and Medicaid Services (CMS) and the Agency for Health Care Research and Quality (AHRQ) » Private nonprofits , such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) » For-profit companies , such as Healthgrades and U.S. News and World Report When public agencies and nonprofits develop quality measures, they often provide opportunities for comment on their measures and make the measure specifications publicly available. On the other hand, for-profit companies often do not have the same level of transparency in their measure development processes. 11 How do measures get endorsed? After a quality measure is developed, it is often endorsed by professional societies and/or consumer groups. The endorsement process is a consensus- based process that allows stakeholders to evaluate a proposed measure. Usually, a nonprofit (such as the National Quality Forum—NQF) or government agency (such as AHRQ) convenes stakeholders to rigorously review potential quality measures and endorse those that meet pre-established standards. These stakeholders include the following: » health care professionals » consumers » payers (such as insurance companies) » employers » hospitals » health plans Measures endorsed by organizations like NQF are generally recognized as reflecting a thorough scientific and evidence-based review. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 11 Where do data on health care quality come from? Once an agency, nonprofit organization, or company has developed a quality measure, data must be collected to support that measure. These data come from a variety of sources. Often, complex measures require data from more than one source. Some common sources of the data that are currently used to track quality measures include: » Administrative data: Administrative data include health insurance claims that are used to bill payers for health care services. This type of data is often the easiest to obtain, because health plans and providers already have a robust infrastructure to collect and share these data. However, administrative data are limited in the types of measures they can support. For instance, while claims data can capture which services were provided to which patients, they cannot be used to determine whether these services were appropriate for the patients who received them. » Disease registries: These are organized systems that capture data on patients with a specific disease or condition beyond what is available in administrative claims data. Public health agencies, including the Centers for Disease Control and Prevention (CDC), often develop and house disease registries. This data system can capture information from multiple data sources, including administrative data, as well as birth and death records and Census data. » Medical r ecords: The information that providers keep in patients’ health records contains far more detail than claims data, including information on medical histories and current medical conditions. However, these data can be difficult to obtain, for several reasons. For example, providers may use paper records that require chart review. Some providers have electronic health records, but different providers often use different record systems, which makes it difficult to gather and synthesize data across providers. » Qualitative data: Qualitative data, such as data from patient surveys, focus groups, and interviews, or data from “mystery shopper” programs, provide the level of detail needed for reporting patient experience measures. These data are generally collected through patient surveys that are administered by mail, phone, or email, and they provide feedback on many different elements of the care patients receive. Collecting data on quality measures is a key challenge. In the past, most health plans and providers were not required to track and report data that measure quality. Now, busy providers are often responsible for tracking different quality measures for different payers. For example, a provider may have to track one set of measures for a health plan, another set for CMS, and a third set for an accreditation agency. Having to meet different requirements can be burdensome for providers. Making the process of collecting data on health care quality less onerous for providers may require new tools and technologies, as well as recognition of the time it takes providers to mee t reporting requirements. Key Considerations • The United States does not have a designated agency that is responsible for defining standards for the development of quality measures or for quality reporting. This has led to burdensome submit requirements for health plans and providers, who must submit quality data to numerous agencies and organizations. • Just as importantly, patients often have trouble understanding information on health care quality that comes from so many sources. • Future efforts to improve the way health care quality is measured should focus on aligning quality measures across the different groups that have developed or endorsed them, as well as on creating a single federal agency with the authority to regulate the process of developing quality measures and the way information on quality is disseminated to consumers. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 12 The Promise of Electronic Medical Records for Measuring Quality The expanding use of electronic medical records has the potential to transform the way that data on quality are collected, assessed, and reported by making information about health care and health outcomes more accurate, timely, useful, and accessible. vi How are quality measures used? Currently, the most common uses of quality measurements include public reporting, provider incentive programs, and accreditation and/or certification of providers and health plans. » Public reporting: Providers and health plans, both public and private, are increasingly making quality measurement data available to the public to increase provider accountability and promote informed consumer choice. For example, the Centers for Medicare and Medicaid Services (CMS) provides robust quality performance data for hospitals in the Medicare program on its Hospital Compare website. CMS also reports quality data for the Medicare program on nursing homes, home health agencies, and Medicare Advantage plans, among others .12 Increasingly, private plans are also publicity reporting provider performance on quality measures, often combined with price and cost data. 13 » Provider incentive programs: Quality measures are frequently used to direct financial rewards or penalties to providers based on their performance. For example, rather than paying providers for the volume of care they deliver or the number of patients they care for, payers can link all or part of a payment to the quality of care that is delivered. New models of care delivery, including accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), use quality measurement as a critical method of allocating payments to participating providers. » Accreditation and certification: Quality measures frequently inform the standards that are used by organizations such as the National Committee for Quality Assurance (NCQA), URAC, and the Joint Commission on Accreditation of Health Care Organizations (JCAHO) in their accreditation and/or certification of providers and plans. Accreditation and certification are often viewed as important symbols of quality and can serve as a “seal of approval” for consumers. 14 For example, the Affordable Care Act requires all qualified health plans that are sold in the state health insurance marketplaces and the federally facilitated marketplace to be accredited. 15 Key Considerations • Administrative data such as health insurance claims are easy and cheap to collect, but they often cannot provide the level of detail needed to assess health outcomes. • Medical records, particularly electronic medical records, are a key source of data for reporting outcome measures. However, a lack of standardization across record systems can make reporting difficult. • While qualitative data such as patient surveys are important for measuring patient experience, they can be time-consuming and expensive to collect, as well as burdensome for providers. New methods for collecting data on patient experiences should be explored. • As with all personal health data, privacy is a critical issue. Though quality measures are not intended to disclose information on individual patients, ongoing vigilance is needed to ensure that quality measurement and reporting comply with existing privacy laws. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 13 What’s next in quality measurement? Using quality measurement to improve health care is a relatively new endeavor. While the U.S. health care system has made great strides in developing and implementing quality measures over the past 15 years, much work remains. One key step in this effort is the creation of the National Quality Strategy, the first comprehensive federal undertaking aimed at improving the quality of care in this country. The Affordable Care Act required the secretary of Health and Human Services (HHS) to establish this national strategy for improving health care that set priorities and that provided a plan for achieving its goals: better care, affordable care, and healthier people and communities. 16 Over the past three years, HHS has worked with numerous stakeholders to develop a set of priorities for the National Quality strategy, which include: » Making care safer by reducing the harm that is sometimes caused during the delivery of care » Promoting the most effective prevention and treatment practices for the leading causes of death » Promoting effective communication about and coordination of care » Ensuring that all individuals and families are engaged as partners in their care » Working with communities to promote healthy living » Making quality care more affordable for individuals, families, employers, and governments by developing and increasing the use of new health care delivery models 17 Ongoing work to develop programs that operationalize these principles will be needed to ensure that the National Quality Strategy lives up to its promise. The process of developing meaningful quality measures and putting them into use is ongoing and will be refined over time. But as we collect and evaluate more data on quality, we’ll be closer to ensuring that every American gets the right care at the right time, the first time. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 14 Morbidity: The incidence of disease, or how frequently a condition or illness occurs in a given population. Patient experience: The full range of patients’ interactions with the health care system, from scheduling appointments to interactions with their providers to the course of treatment, including whether these interactions meet patient needs and health goals. Patient-centered care: Health care that recognizes and incorporates the distinct wishes and needs of individual patients, with an emphasis on patient values and preferences. Quality health care: The right care for the right person at the right time, the first time. 18 Quality measure: A tool that is used to measure performance against a recognized standard of care. Standard of care: Care that is delivered in accordance with clinical practice guidelines or other evidence-based care protocols. Value: The relationship of the clinical benefits of health care to the cost of providing that care. Glossary of Key Terms in Quality Measurement Accreditation: Recognition that is granted to an institution (such as a health care provider or health plan) by a professional association or non-governmental agency demonstrating that the institution meets pre- established standards. Certification: Recognition that is granted to an individual health care worker by a professional association or non- governmental agency demonstrating the individual’s competency relative to a pre-determined set of criteria. Clinical practice guideline: A standard of care based on current, high-quality evidence that outlines the recommended course of care, including relevant options and their outcomes, and that is designed to help providers make the best possible care decisions. Disparities in health care: Variations in access to care and in health outcomes due to factors such as race, ethnicity, gender, and socioeconomic status. Evidence-based care: Health care that applies the best available research (evidence) when making decisions about a patient’s care. MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 15 Endnotes 1 Elizabeth McGlynn, Stephen Asch, John Adams, et al., “The Quality of Care Delivered to Adults in the United States,” The New England Journal of Medicine 348, no. 26 ( June 2003): 2,641, available online at http://www.nejm.org/doi/full/10.1056/NEJMsa022615 . 2 Agency for Healthcare Research and Quality, 2012 National Health Care Qualit y Report (Rockville, MD: Depar tment of Health and Human Ser vices, May 2013), available online at http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/2012nhqr.pdf . 3 Paul Clear y and Margaret O’Kane, Evaluating the Qualit y of Health Care (Washington: Office of Behavioral and Social Sciences Research), available online at http://www.esourceresearch.org/tabid/794/default.aspx . 4 Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse, Tutorials on Qualit y Measures: Selecting Structure Measures for Clinical Qualit y Measurement , available online at http://www.qualitymeasures.ahrq.gov/tutorial/StructureMeasure.aspx , accessed on October 31, 2013. 5 Jerr y Cromwell, Michael Trisolini, Gregor y Pope, Janet Mitchell, and Leslie Greenwald, Pay for Performance in Health Care: Methods and Approaches (Research Triangle Park, NC: Research Triangle International, 2011), available online at ht tp://w w w.r ti.org/pubs/r tipress/ mitchell/BK-0002-1103-Ch04.pdf . 6 National Committee for Quality Assurance, The Essential Guide to Health Care Qualit y (Washington: NCQA), available online at http://www. ncqa.org/Por tals/0/Publications/Resource%20Librar y/NCQA _Primer_web.pdf . 7 Rober t A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, Achieving the Potential of Health Care Performance Measures (Washington: Urban Institute, 2013), available online at ht tp://w w w.r wjf.org/content/dam/farm/repor ts/repor ts/2013/r wjf40619 5. 8 Aligning Forces for Quality, Good for Health Good for Business: The Case for Measuring Patient E xperience of Care (Washington: AFQ ), available online at http://forces4quality.org/case-patient-experience . 9 Depar tment of Health and Human Ser vices, 2012 Annual Progress Report to Congress: National Strategy for Qualit y Improvement in Health Care (Washington: HHS, August 2012), available online at http://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf . 10 Agency for Healthcare Research and Quality, Patient E xperience Measures from the CAHPS Clinician and Group Surveys , Document no. 1309, updated May 2012, available online at https://cahps.ahrq.gov/sur veys-guidance/cg/cgkit/1309_CG_Measures.pdf . 11 Rober t A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, op. cit. 12 Centers for Medicare and Medicaid Ser vices (CMS), Hospital Compare website, available online at http://www.medicare.gov/ hospitalcompare/search.html . 13 Rober t A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, op. cit. 14 National Committee for Quality Assurance, op. cit. 15 Patient Protection and Affordable Care Act , Public Law 111-148 (March 23, 2010), as modified by the Health Care and Education Reconciliation Act of 2010 , Public Law 111-152 (March 30, 2010), Title 1, Subtitle D, Section 1311. 16 Depar tment of Health and Human Ser vices, op. cit. 17 Ibid. 18 Transcript of remarks by Carolyn Clancy, Measuring Health Care Qualit y (Washington: Kaiser Family Foundation, 2008), available online at http://kff.org/archived-kaiseredu-org-tutorials/ . Sidebar Notes i Tra nscript of remarks by Carolyn Clancy, Measuring Health Care Quality (Washington: Kaiser Family Foundation, 2008), available online at http://kff.org/archived-kaiseredu- org-tutorials/ . ii Mark Chassin, Jerod Loeb, Stephen Schmaltz, and Robert Wachter, “Accountability Measures–Using Measurement to Promote Quality Improvement,” The New England Journal of Medicine 363, no. 7 (August2010), available online at http://www.nejm.org/doi/ pdf/10.1056/NEJMsb1002320 . iii Robert A. Berenson, Peter J. Pronovost, and Harlan M. Krumholz, Achieving the Potential of Health Care Performance Measures (Washington: Urban Institute, 2013), available online at http://www.rwjf.org/ content/dam/farm/reports/reports/2013/ rwjf406195 . iv Aligning Forces for Quality, Good for Health Good for Business: The Case for Measuring Patient Experience of Care (Washington: AFQ), available online at http:// forces4quality.org/case-patient-experience . v Robert Wood Johnson Foundation, Provisions Related to Quality in the Affordable Care Act (Princeton, NJ: RWJF, May 2010), available online at http://www.rwjf. org/content/dam/web-assets/2010/05/ provisions-related-to-quality-in-the-new- health-reform-law . vi Paul Cleary and Margaret O’Kane, Evaluating the Quality of Health Care (Washington: Office of Behavioral and Social Sciences Research), available online at http://www.esourceresearch.org/tabid/794/ default.aspx , accessed on October 31, 2013 . MEASURING HEALTH CARE QUALITY: AN OVERVIEW OF QUALITY MEASURES 1201 New York Avenue NW, Suite 1100 Washington, DC 20005 202-628-3030 [email protected] www.FamiliesUSA.org facebook / FamiliesUSA twitter / @FamiliesUSA Publication ID: 024HSI050114 This publication was written by: Caitlin Morris, Senior Policy Analyst, Families USA Kim Bailey, Director of Research, Families USA The following Families USA staff contributed to the preparation of this material (listed alphabetically): Evan Potler, Art Director Carla Uriona, Director of Content Strategy Ingrid VanTuinen, Director of Editorial © Families USA 2014 A selected list of relevant publications to date: Measuring Health Care Quality: An Introduction (March 2014) Principles for Consumer-Friendly Value-Based Insurance Design (December 2013) Key Differences between Reward/Penalty Programs and Value-Based Insurance Design (October 2013) For a more current list, visit: www.familiesusa.org/publications




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