Archive for Quality Measurement
by Lola Butcher
April 22, 2008 at 3:10 pm · Filed under Quality Measurement, Business of Health
“Health care was missed by the industrial revolution,” said Steve Swensen, MD, director of quality at Mayo Clinic.
But it is under way at Mayo Clinic. Mayo looks good in the Dartmouth Atlas of Health Care, which ranks hospitals on quality, but its leaders do not seem too happy about that. A panel of Mayo executives discussed Mayo’s initiative to systematically improve quality.
What it takes:
- Infrastructure
- Leadership and Culture
- Systems Engineering
Some bullets on infrastructure needed to drive quality:
Integration across entities: As a patient moves from one part of organization to another, the hand-off should be seamless.
Integration within entities: Staff should be motivated to provide patient-centered care, not increase their own revenues. (Mayo physicians are salaried.)
Mayo wants to move away from process measures to more meaningful measures, such as “was the diagnosis correct?” and “Can we diagnosis, treatment started and recovery under way within a week?”
What systems are there to capture quality information on a timely and regular basis? How to get quality data within nine days after end of the month, for example?
- Electronic Medical Records
EMRs needs to be integrated across the inpatient and outpatient environments–and eventually personal health records as well.
Use EMR “alerts” to prompt needed actions.
Mayo established Quality Academy to educate staff about process improvement.
Recent decision to put Quality Academy under College of Medicine to integrate into the system, the residency and nursing training programs.
Staff members are required to demonstrate competency in placing central lines in simulation center, for example.
by Fred Fortin
April 22, 2008 at 1:50 pm · Filed under Uncategorized, Policy Makers, Transparency/Public Disclosure, Quality Measurement
The WHCC conference sessions on transparency in healthcare are demonstrating that this movement is way more than a passing fad. As all stakeholders in the healthcare system — private institutions, government agencies, health plans, employers, group practices, research organizations, online service companies — are all getting in the mode of how to open up the black boxes in healthcare to consumers and payers of all stripes.
What’s fascinating is is to witness not just the measures, programs and politics unfold, but also the evolution of the questions that are being asked. Reed V. Tuckson, MD, UnitedHealth Group observes, for example, that the question of what is the best hospital is morphing into the question of what is the best hospital for me and my particular medical condition.
Robin Downey, a Senor Vice President with Aetna argues that once consumers ‘get it’ about the usefulness of healthcare information, they just want more and more. With her health plan, the black box they are opening, is “what is it going to cost me to be a covered by Aetna?” This is not just about co-pays, and premiums, but also about what Aetna is paying to their contracted doctors and hospitals. So they are starting to disclose Aetna’s actual negotiated rates with their provider network. And people are surprised wondering if they are giving away their bread and butter, that is, proprietary information that they have spent considerable money to develop.
The bar for transparency is rising, and the market place is responding. Hang on.
by Fred Fortin
March 12, 2008 at 10:57 pm · Filed under Insurance, Public Purchasers, Policy Makers, Consumer Engagement, Health IT, Quality Measurement
Let’s look at what Wired editor-in-chief Chris Anderson is saying in his soon-to-be-out new book, FREE! — as discussed in this issue of Wired – and reflect for a moment on the implications for healthcare. Anderson argues that there’s a number of models or trends as to why things on the Internet are going to be, well, free.
• Freemium: A basic web service or software is supported by payers of the premium version of that service. One percent of the subscribers pay for the other 99 percent;
• Advertising: Free content, services, or software that’s accompanied by advertising geared to interested audiences;
• Cross-Subsidies: You get something with the intent that it gets you to pay for something else. Get the music free, now you want to go to the concert;
• Zero Marginal Cost: Somethings are so cheap to produce — again music is an example — that people offer it up for all kinds of reasons that have nothing to do with money;
• Labor Exchange: Using a web service, in and of itself, creates value for somebody else. The user is providing information that is worth more than the band width to get it.
• Gift Economy: It’s just altruism and it’s free — Wikipedia, Craigslist for example.
Can we see healthcare in here anywhere? Absolutely. It is everywhere flowing through all these models. There are many examples. But let’s not just list all the sites that you could point to. Let’s just say they are legion.
The real and most interesting question has to do with the impact of free healthcare on those aspects of healthcare for which we pay dearly. Healthcare on the internet is in some ways like the music industry — get the song free, then go to the concert and pay through the nose for the scarce experience of seeing the real thing (or band).
Sure, you can see the many forms of health information, advice, education and peer support, as recruitment strategies for the more expensive real deal — the physician visit, or the drug de jour, for example. In this view the internet creates even more demand for high cost care, and thus higher cost for the rest of us. Nothing in healthcare can really be free. Far from it. It is just a sophisticated bait and switch marketing strategy where the healthcare information, in itself, is a teaser of little value for some other product or service. So back to square one.
But there are some scenarios that move more in Anderson’s direction. Anything that is not tied down can be distributed through the internet under the above models. By this I mean, that anything which does not involve the laying on of hands can go on the net. With all of the interactivity possible now, especially with video capabilities, that inherent limitation — while still quite substantial — is getting smaller and smaller. And if it can go on the net, it will, and thus it will be on there for free.
In addition, an overwhelming percentage of energy consumers invest in “healthcare” is wrapped up in navigating the complexity of the system, determining their clinical options and planning for the repercussions of what ails you — all of which, the services available on the net excel at.
More important than probably anything else I’ve said so far, is the wedding of the emerging transparency in healthcare — price and quality of care ratings for example — to the internet. Value-based, healthcare 2.0 is on America’s doorstep and clamoring to be let in. It will attach itself and be amplified in a new internet-consumer-driven EMR, PHR, and “comparative-effectiveness” heaven that cannot help but have a disruptive impact on healthcare’s current anachronistic economic base.
But how, and how fast, are the only really important questions now, not if or when. What economic pressures will the net put on traditionally conservative healthcare institutions? How will they respond? Which of their highly valued, on the ground services, will be commodified and then free or nearly so?
Healthcare is a late bloomer when it comes to the information technology revolution, but it will, as they say, suffer from 100 percent of the effects of that technology. Are we prepared and being mindful of the changes all around us? That remains to be seen.
by David Williams
January 17, 2008 at 9:36 pm · Filed under Quality Measurement
A short paper in the current issue of the Journal of Child Neurology (Hypokalemic Sensory Overstimulation) raises some tantalizing possibilities about ADHD:
- In some patients, ADHD may be caused by an excess of sensory stimulation arriving at the brain, rather than being a disorder of the brain itself
- For such patients, potassium supplements may be an effective treatment
- ADHD symptoms may indeed be triggered by sugar in some people
- ADHD and PMS may be related in some women –and their PMS may also be treatable with potassium
- Dentists may be well-positioned to identify possible ADHD patients
Read more at the Health Business Blog.
by Fred Fortin
October 23, 2007 at 1:29 pm · Filed under Transparency/Public Disclosure, Quality Measurement
I reported previously on a landmark case where a Washington D.C. federal judge ruled in favor of a consumer group that sued the Department of Health and Human Services (DHHS)to allow disclosure of specific data about doctors from the Medicare Claims database.The non-profit Consumers Checkbook filed the suit to allow access to the database so that consumers will be able to find out how many times their physician has performed a procedure that they may be facing. Federal rules now protect the privacy of this physician information.
I asked then whether any action — such as an appeal — would be in contrast to the Administration’s current transparency and value-based initiatives. I also took the opportunity at the time to pose the question to DHHS Secretary, Mike Leavitt on his new blog. No response.
Well it is now reported that DHHS has decided to appeal the ruling. DHHS spokesperson Kevin Schweers said that the department is “fully committed to making available as much Medicare data as allowable by law.” He added, “Unfortunately, in the case at hand, two federal courts interpret the law differently, and we’re caught in the middle until that dispute is settled. When that day does come, it’ll be a day too late as far as we’re concerned.”
A cryptic yet understandable response. I hope the public interest in this case stays alive as it travels through the justice system.
by Fred Fortin
October 17, 2007 at 11:52 pm · Filed under Uncategorized, Insurance, Policy Makers, Transparency/Public Disclosure, Pay-for-Performance, Quality Measurement, Value-based health care
The Robert Wood Johnson Foundation has sponsored a series of articles on legal barriers to health information that lays before us the reality of how difficult transparency efforts and moves to promote quality outcomes through financial incentives could become. In an article by Rosenbaum, Kornblet, and Borzi, the authors examine a number of possible allegations that could be brought against health plans that try to use some form of physician tiering based on quality or efficiency measures.
But first the authors issued a cautionary note, that for most of us, would seem obvious, but apparently still needs mentioning. They warn that
“Regardless of the legal theory chosen . . . certain basic attributes in current health plan practices are sure to trigger one or more theories and allegations: (1) secrecy in both the standards used and the weights used to perform rankings; (2) the absence of a transparent rational basis for the methods chosen; and (3) the absence of a process by which physicians can examine the data on which their rankings rest and challenge errors in data or methodology.”
To be honest, I don’t know of a reputable health plan that in this litigious day and age would be so lacking in common sense that they would knowingly go against this advice. If anything, health plans are too highly attuned to the risk of legal challenges. Progress in improving care will more likely be impeded rather than be pursued with the kind of reckless abandon implied here. But it is also my experience that no matter what reasonable precautions you take, lawsuits seem to materialize anyway and are a constant source of concern and expense.
In a nutshell, these are some of the legal strategies, according to the authors, that could be used by providers against health plans:
- Allegations of violation of statutory or common law fair process/due process requirements
- Allegations of violation of federal laws regulating health plans, state insurance laws, and more generalized consumer fraud statutes
- Allegations of violation of defamation and libel common law principles or statutes
- Allegations of violation of federal and state laws applicable to certain categories of sponsored health plans
- Allegations of intentional interference with contract/breach of contract
- Allegations of restraint of trade
- Allegations of violation of civil rights laws
It is beyond this post to go into any further detail about these strategies. But it’s easy to see that there’s a lot of legal ground that has to be covered here before physicians and health plans can become comfortable with each other around these issues, and before this national agenda can get the type of momentum it needs to make meaningful gains in the quality of health care.
by Fred Fortin
September 27, 2007 at 11:52 pm · Filed under Uncategorized, Quality Measurement
BNA (paid subscription required) reported this week on a study done by researchers at UCLA’a medical school (published in Archives of Surgery) comparing hospital quality data on six publicly available websites. And the news was not good. According to the report for three of the private websites, “the searches demonstrated significant inconsistencies. For example, for colon removal, one hospital was ranked best by two sites, but worst by the other site, and the hospital ranked best on that site was ranked worst on another.”
In addition to the three unnamed private websites, the researchers studied hospital ratings on CMS Hospital Compare, the Joint Commission’s Quality Check, and the Leapfrog Group’s Hospital Quality and Safety Survey Results. Timeliness, methods and incomplete data were said to account for some of the differences.
I think we should expect a lot more of this kind shake out of quality data over the next decade or so until professional consensus, market place pressure and better methodological governance takes better hold. But this kind of disparity in the numbers will lead to more patient confusion and feed a lack of trust in all quality data.
I don’t know about you, but I’d be a little nervous if I was the one facing colon surgery and looking at these findings.
by Scott MacStravic
September 10, 2007 at 2:08 pm · Filed under Employer CEOs, Health Plan/Payer CEOs, Quality Measurement, Health Management
Charging and paying on a “per eligible” basis may be perceived as more appropriate than charging on a flat fee or per population basis. After all, only members of the population that are identified as having a particular health risk behavior, risk condition, or chronic illness figure to benefit from participating in an HM intervention designed for each such challenge. Why pay for members of the population who have no chance of returning any benefit, since they will not be eligible for nor participate in any intervention?
Of course, since people are more likely to have more than one risk behavior/condition or chronic disease, there may be many who are “eligible” for more than one HM intervention. When charges are set for each separate HM intervention based on fixed fees or numbers in the population, there may be no added cost if some members enroll in more than one intervention. If charges are set per participant, there will automatically be multiple charges for members who enroll in more than one intervention. If charges are set per eligible, the question of whether multiple enrollments will be permitted, and if so, whether there will be added charges for “double dippers”, will have to be settled between provider and client.
HM interventions tend to be specific to the behavior, risk condition, or chronic disease in most cases. Some providers may offer a generic approach to more than one chronic disease, when the program is aimed at promoting similar adherence to medications and lifestyle changes. But most tailor the intervention to a specific aim, such as smoking cessation, diet improvement, increased exercise, or to managing a specific risk condition such as weight loss, stress reduction, or insomnia, or disease, such as asthma, diabetes or congestive heart failure. Most chronic diseases are sufficiently unique as to warrant a customized, separate intervention, and many risk behaviors and conditions are equally unique.
Moreover, in most cases, those eligible for particular HM interventions have multiple risk behaviors, conditions, or chronic diseases. It will often not be until the HCO or a client chooses which and how many HM interventions to offer that any guess can be made as to what total costs will be. And until individual members of the population choose which to enroll in, since most will participate in one at a time, it is difficult to predict what the numbers of participants will be. Knowing the fees to be charged per eligible at least gives purchasers and providers a reliable prediction of costs and benefits, once the average benefit for HM programs is known.
Of course, the benefit to purchasers will vary widely depending on the particular HM intervention. Smoking cessation, for example, has been found to yield relatively low cost savings to many clients, because the number of people who smoke is relatively small, roughly 20%, and the number who succeed in long-term abstinence from tobacco is often even lower than that. Even a 20% prevalence rate times a 20% quit rate would mean only 4% of members will yield any benefit. By contrast, for an HM intervention such as chronic pain, where prevalence may be as high as 50% across all categories of pain, and the numbers who gain significant relief may be as high as 50%, the number of good eligibles can be as high as 25% of the entire population.
The biggest advantage to paying/charging per eligible is that the charges/payment can be predicted as soon as the prospect or client knows how many members of the risk population will be eligible. When the client is an insurer, or even an employer only interested in reducing sickness care costs, the numbers eligible for particular HM interventions can often be determined based on claims analysis for sickness care and prescription drug use. This analysis can be performed before approaching any HM provider, and predictions of costs based on per-eligible fees, together with savings per HM category, made prior to choosing an HM provider.
Once fees are set based on the number of eligibles in each HM intervention purchased, the client can promote participation among those eligible without worrying about any added costs for participation. Fees that are based per eligible will not vary, whether 10% or 100% of those eligible choose to participate. Of course, if incentives are used to promote participation, these will apply to each participant, in addition to the per-eligible HM provider fees. It is then up to the client to judge for how many and which participants the incentive costs make sense.
Like flat or per population fees, per eligible fees make most sense when prospects or clients wish to know early on what their costs are likely to be – before they invest in an HRA or other means of determining eligibility, or when they have invested in the HRA, but not yet chosen the HM provider. Once the per-eligible fee is established, they can judge whether the number of those eligible warrant investing in particular HM interventions, given the probable participation without vs. with particular incentives. Then the incentive costs per participant, added to the fees, can be used to decide how much it makes sense to offer and pay in incentives.
To compare flat fee/per population HM provider quotes to per-eligible quotes, the percentage eligible, i.e. the prevalence rate of the risk behaviors, risk conditions or diseases in question, can be determined, then this rate is simply divided into the flat fee rate to yield an equivalent rate. If one HM provider offers a flat fee that amounts to $10 per population member for smoking cessation, for example, and the percentage of smokers in the population is 20%, then the equivalent fee is $10 divided by 20% or $50. That would be equal to another provider that charges $50 per eligible.
While per eligible-fees may seem more sensible than per population or flat fees, the latter can be translated into the former equivalent as soon as the numbers eligible have been determined. So they are comparable for decision making, as long as the HCO or prospect/client concerned has at least some basis for determining up front how many members of the at-risk population will be eligible for which HM interventions. If per-eligible savings and other economic benefits have been reliably measured in the past, and if the at-risk population is close enough in important characteristics to the populations for whom such value has been measured, this may prove sufficient for decision making, and comparison between providers who offer one or the other of these charging methods.
To use charges per eligible in projecting different results based on participation rates, the charge per eligible is divided by different participation rates to calculate the “effective” charge per participant. For example, if the charge per eligible were $50, and 10% participation were planned, the effective charge per participant would be $50 divided by 10% = $500. This is what makes fees per employee or per eligible troublesome if the numbers of eligibles and then the numbers of participants are both low.
For example, with smokers, if fixed cost per employee is $25 and only 12% of employees smoke, $25/12% = $208. If smoking cessation saves $1000 per quitter, but the quit rate is only 15%, for example, then there is no way a participation rate of even 100% in the smoking cessation program could produce a net savings. Even if all 12% participated, only 15% of the $1000 = $150 value of quitting would be achieved per eligible, while the cost would be $208 per eligible. The challenge is always to translate the method of setting charges into the way financial benefits will be achieved so that they can be compared directly in planning, implementing and evaluating HM interventions.
A simple way of translating fixed fee, per eligible and per participant charges and payments will be described in the final posting in this series.
by Emily DeVoto
April 23, 2007 at 3:06 pm · Filed under Quality Measurement, 4th WHCC
This session was chaired by Thomas Valuck, MD, JD, Director, Special Program Office for Value-Based Purchasing, Centers for Medicare & Medicaid Services (CMS); panelists were Brent James, Vice President for Medical Research and Executive Director of the Institute for Healthcare Delivery Research, Intermountain Health Care; and Tom Sackville, Chief Executive, International Federation of Health Plans and former British Minister of Health.
Here’s a summary of a slide I liked from Brent James:
Three ways to get a better number:
1. Measure, manage, and improve
2. Subuptomize - make one area loook better at the expense of others that are unknown, unmeasured, or outside of scope
3. Game the numbers - move high-risk patients around, cherry-pick patients, etc.
Tom Sackville added a dose of wry British humor to the proceedings, poking fun at the U.S. Congress as well as himself. The British National Health system found that implementing 150-some measures in a pay-for-performance scheme led to a box-ticking frenzy, in which gross overestimates of prevalence of various disorders were a red flag.
Here’s a summary of the Q and A (paraphrased), beginning with questions from the moderator, Thomas Valuck:
1. What are the negative effects of incentivizing?
Brent James replied that the worst thing you can do to a physician is tell him that money is more important than their professional care. We have found that bigger payments started to become perverse incentives. Professional incentives must come first, then you can back them up and add a little money to make professional incentives real.
A question for Mr. Sackville: Did you see anything interesting about the polling questions? How does it compare to NHS system?
Answer: In Britain, they’ve gone much too far down the road of financial incentives. Huge bureaucracy ensued as well. Don’t give people the temptation to fiddle with the rules; you create a very cynical bunch of people out of a very vocational group of docs.
Audience questions: Assuming quality and costs are important, how do consumers use information for decisionmaking? Is it possible consumers use stories, not statistics, because that’s what they’re used to? Emily: Great Question.
Brent James talked about a study in which researchers gave carefully prepared information to patients; the conclusion was that people act on emotion. Data may not be sufficient - e.g., adjuvant chemotherapy for breast cancer - stories are equally important in such cases.
Tom Sackville agreed: “Most people are left unimpressed by statistics.” People judge health service by what happens to them, their families, what people tell them about it. Most people disapprove of HMOs in general, based on stories, he said, but a lot fewer disapprove of their own HMO.
Question: How does panel see P4P functioning, if at all, under consumer-directed health plans? Moderator follow-up: We haven’t had very good access to information, so we don’t know how to use it. Does P4P create a Garrison Keillor effect: is every doctor above average?
Brent James talked about evaluation of patient education around heart disease; education been shown to be a critical element of patient outcomes. Counseling takes 30 to 45 minutes to effect desired outcome. Or, you can give patients a sheet of information. This led James to offer a good example of gaming the numbers: Some clever staff in one hospital overcompensated by delivering an information sheet to every bed in the hospital, whether the condition was relevant or not, and even when the patient was asleep; the hospital got a perfect score for patient education, but distributing the information this way didn’t improve patient outcomes.
James noted that all publicly traded companies have a CPA, and most of the financial measures are integrated into daily hospital operations. Apparently these systems represent an opportunity to support quality measurement.
Question: Please comment on pay for choice, to get consumers to pick high quality doctors.
James: How do tell which providers are high quality? Attribution of outcomes is the problem. Thus, you have an initial technical problem to solve before you can incentivize patients.
Sackville: In the UK, nothing incentivizes doctors to talk to their patients about prevention. Parents are losing control of what kids eat, and there’s a growing obesity problem. Is something going to be done to bring sticks and carrots to this area? We need to get tougher on patients, too. [Emily: Growing obesity problem (my unintended pun, but is there a better word?). Carrots (Sackville’s). Sorry…]
Overall, both of these speakers were pretty frank and realistic about the potential for misuse of quality measurement and pay-for-performance systems. I dropped some text at the end about how to model such systems to avoid these problems, because the presentation got a little rushed at the end and what I wrote down wasn’t completely understandable to me when I went to reconstruct it. So let’s leave that good question out there and see if we can get a fuller discussion.
