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Communicating Health Care Quality To Consumers

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Communicating Health Care Quality To Consumers Partners Quality Measurement Committee May 11, 2004 Adapted from a talk given to the Managed Care Executive Group on ... – PowerPoint PPT presentation

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Title: Communicating Health Care Quality To Consumers


1
Communicating Health Care Quality To Consumers
Partners Quality Measurement Committee May 11,
2004
  • Adapted from a talk given to the Managed Care
    Executive Group on March 25, 2004 by Brad
    Fluegel, CEO of Reden Anders, and Jeff
    Levin-Scherz, CMO, Partners Community HealthCare,
    Inc

2
Goals
Introduction
  • Describe pressures to increase information
    transparency on health care quality
  • Evaluate stakeholder implications
  • Describe implementation challenges
  • Examine incentives to promote information
    transparency in health care quality
  • Suggest future impact of availability of health
    care quality data

3
Pressure for Transparency
Stakeholder Perspectives
Implementation Challenges
Incentives to Promote Information Transparency
The Future How To Use This Information
4
When its time to purchase a car, we go to
www.consumerreports.org
Pressure For Transparency
5
To evaluate a mutual fund, we go to
www.morningstar.com
Pressure For Transparency
6
Current State
Pressure For Transparency
  • There are already quality data out there
  • However, the source and usefulness of the data
    vary

7
(No Transcript)
8
Increasing total financial cost of medical care
will also drive demand for increased information
about value
Pressure For Transparency
Source Centers for Medicare and Medicaid
Services, Office of the Actuary, 2002.
9
Increasing consumer financial responsibility will
increase pressure for information transparency
Pressure For Transparency
Source Heffler, Stephen, et al, Health Spending
Projections for 2002-2012, Health Affairs Web
Exclusive, February 7, 2003.
10
Growing interest in consumer directed health care
will also increase pressure for information
transparency
Pressure For Transparency
  • Employers are looking to shift more
    responsibility in terms of health care selection,
    cost and utilization
  • Cost savings may have been squeezed out of
    managed care practices
  • Consumer directed health care presents several
    opportunities
  • Increased employee accountability
  • Enables consumerism and cost-effective use of
    services
  • Requires employee tools
  • Web-based health information
  • Health risk assessments
  • Provider pricing and quality information
  • Encourages provider competition in terms of price
    and quality

11
Pressure for Transparency
Stakeholder Perspectives
Implementation Challenges
Incentives to Promote Information Transparency
The Future How To Use This Information
12
Consumers demand (but often ignore) information
on health care quality
Stakeholder Perspectives
  • When is information available?
  • Time of selecting care?
  • Time of enrollment in health plan?
  • Is information readily understandable?
  • Reading level
  • Implications
  • Is the information relevant to the consumer?
  • At the level of consumer decision-making?
  • Appropriate based on consumer demographics?
  • Are statistics appropriately conveyed
    graphically?

13
In 2002, impact of quality ratings on consumers
was negligible
Stakeholder Perspectives
Source Harris Poll, 2002, http//www.harrisinter
active.com.
14
Other consumer findings from Harris Poll
Stakeholder Perspectives
  • Quality is
  • More and more treatment
  • Having choices
  • Being in a waiting room with people who earn more
    money than you
  • Evidence based medicine and community health
    applied systematically
  • The right to sue
  • A subsequent Forrester internet only poll is a
    bit more optimistic
  • 11 used the internet to determine hospital or MD
    quality
  • 10 made choices based on this information
  • Demographics of this group are unusual (ie gt50
    broadband at home)

15
Employers are pushing hard for information
transparency (but not taking primary
responsibility)
Stakeholder Perspectives
  • Many would like to move away from responsibility
    for health care, and see consumer information as
    a means to get there
  • Employer collaboratives are pushing health care
    parties to provide additional data
  • Leapfrog
  • Bridges to Excellence
  • Mercer and Group Insurance Commission
    (Massachusetts)
  • Niagara Business Group on Health
    (http//www.myhealthfinder.com)
  • Many others

16
Health Plans want to stake out their role as
providers of consumer information
Stakeholder Perspectives
  • Although NCQA rates health plans, it is less and
    less relevant given that health plans
    increasingly have the same providers
  • Health plans, historically differentiated by
    provider networks and care delivery, are now
    about benefit design and administration
  • Fearful of loss of position on value chain

17
Health plans are likely to combine patient
education with financial incentives
Stakeholder Perspectives
Source Milliman USA 2002 HMO Intercompany Rate
Survey
18
Pacificare Quality Index
Stakeholder Perspectives
19
Tufts Health Plan Physician Group Profile
Stakeholder Perspectives
20
Health plans and providers are increasingly
adding quality measures to pay for performance
contracts
Stakeholder Perspectives
  • Discharge management
  • Outpatient management
  • Engagement with case and disease management
    programs
  • Risk assessment
  • Generic utilization
  • Access to care

How much is enough? Should the pay for
performance measures be self-financing?
21
Government has led the way in providing health
care quality information
Stakeholder Perspectives
  • HCFA produced hospital quality data in late 1980s
  • Criticized for lack of severity adjustment
  • Pennsylvania Cost Containment Council
  • Hospital specific cardiac mortality and
    complication rates
  • New York State
  • Cardiac surgery mortality and complications by
    facility and individual surgeon
  • Massachusetts
  • 1999 Law directed the Department of Public
    Health to produce data comparing cardiac surgery
    outcomes
  • 2002 Debate about HIPAA implications of data
    request
  • 2004 Public report still not available

22
Dialysis Compare _at_ www.medicare.gov
Stakeholder Perspectives
Percent of the facility's patients who received
adequate hemodialysis in 2002
http//www.medicare.gov/Dialysis/Search/QualityCom
pare/QualityCompare.asp
23
Dialysis Compare _at_ www.medicare.gov
Stakeholder Perspectives
Patient Survival Actual Compared to Expected
(January 1999 - December 2002)
Patient Survival for the Facilities you Selected
is
24
Dialysis Compare _at_ www.medicare.gov
Stakeholder Perspectives
Percent of the facility's patients treated for
anemia (low blood count) in 2002 that were
adequately managed
25
Nursing Home Ratings CMS
Stakeholder Perspectives
26
Physicians believe that they are all (far) above
average in quality
Stakeholder Perspectives
  • and will generally quarrel with any data set
    that suggests otherwise.
  • Questions raised on true intent of profiling
  • Administrative data is often
  • Inconsistent or just plain wrong
  • Less than timely
  • Difficult to appropriately risk adjust
  • Dilemma about profiling larger groups (more
    statistically valid but more heterogeneous and
    less useful to patients) or individual doctors
    (less valid but more useful to patients)
  • Providers will devote considerable effort to
    those measures that will be disclosedand might
    neglect other, more important clinical issues

27
Hospitals also believe they are above average in
quality
Stakeholder Perspectives
  • Longer history of regulation and reporting
  • Leapfrog acceptance rate up
  • 59 of queried hospitals in 22 regions responded
  • 410 additional hospitals responded voluntarily
  • JCAHO core measures
  • Claims data are inaccurate and unreliable, but
    the most readily available source of information

The Wisconsin Hospital Association recently
initiated the http//www.wicheckpoint.org/ web
site where quality indices (JCAHO Core Measures)
of 122 hospitals are listed
28
Wisconsin Hospital Association Quality Ratings
Stakeholder Perspectives
29
New York State Hospital Quality Ratings
Stakeholder Perspectives
Interpretation N, Confidence Range,
Risk-Adjusted Mortality http//www.myhealthfinder
.com/newyork/full.php?table15
30
Vendors are eager to sell software and consulting
to evaluate and display quality
Stakeholder Perspectives
31
Pressure for Transparency
Stakeholder Perspectives
Implementation Challenges
Incentives to Promote Information Transparency
The Future How To Use This Information
32
Implementation challenges
Implementation Challenges
  • Metrics
  • Opportunity to educate often not proximate to
    decision point
  • Public transparency can discourage complete
    reporting of complications
  • Difficult to get winners to play
  • Presentation

33
Report card authors face difficult choices
Implementation Challenges
Choice Approach Issues
Source of data Claims Easy and cheap to obtain, but inaccurate
Source of data Chart review More accurate, but very expensive
Level of reporting Large groups of physicians Heterogeneous, more valid statistically, less useful to patients
Level of reporting Individual physician n too small, hard to do risk adjustment, most useful to patients
Display of data Stars or bar graphs Intuitive and familiar to consumers but inaccurate
Display of data Statistical ranges Closer to truth, but more difficult to explain
34
Report card subjects can find plenty of (valid)
reasons to object strenuously
Implementation Challenges
  • Data integrity
  • Timeliness
  • Comparability of data
  • Benchmark determination
  • Validity of measures as indicators of quality
  • Appropriateness of display methodology
  • Distraction of attention from other quality
    improvement objectives

35
NCQA report card guidelines
Implementation Challenges
  • Know your target audience
  • Identify project participants
  • Decide on the information to include
  • Ensure data credibility
  • Identify sources of information
  • Make decisions about report card format
  • Set realistic schedule for report card production
  • Keep project participants informed
  • Consider approaches for dissemination
  • Decide whether to evaluate report card

Source NCQA 10 Steps to a Successful Report
Card Project, 1998
36
The IT element of data capture is also quite
complicated
Challenges in Presentation
Source Halamka, HIMSS 2002
37
What if the data just dont seem to make sense?
Challenges in Presentation
  • WHITE COAT NOTES NEWS FROM BOSTON'S MEDICAL AND
    SCIENTIFIC COMMUNITY A NEW WAY TO RANK HOSPITAL
    QUALITY
  • Boston Globe, March 2, 2004
  • Tops in Heart Attack Care
  • Winchester Hospital
  • Melrose-Wakefield Hospital
  • South Shore Hospital
  • Brockton Hospital
  • Massachusetts General Hospital (5)
  • Beth Israel Deaconess (23)
  • New England Medical Center
  • Brigham and Women's Hospital (3)
  • Boston Medical Center
  • Beverly Hospital

it's enough to get a patient thinking Am I
going to an outlier hospital?" -Manager Health
Share Technology
38
Pressure for Transparency
Stakeholder Perspectives
Implementation Challenges
Incentives to Promote Information Transparency
The Future How To Use This Information
39
Leapfrog Quadrants
Incentives for Transparency
The Leapfrog methodology gives some credit just
for reporting
40
Bridges to Excellence Program
Incentives for Transparency
Clinical Information System Patient Education Support Care Management Total for meeting all measures
Level A Y1 20 10 15 50
Level A Y2 15 5 10 35
Level A Y3 10 5 5 25
Level B Y1 20 10 15 50
Level B Y2 20 5 10 40
Level B Y3 15 5 5 30
Level C Y1 20 10 15 50
Level C Y2 20 10 15 50
Level C Y3 20 10 15 50
Year 1 total based on 200 patients Year 1 total based on 200 patients 4,000 2,000 3,000 10,000
Bridges to Excellence pays physicians based on
meeting certain criteria.
41
Pay for Performance Contracting
Incentives for Transparency
  • CMS has agreed with Premier Hospital System
  • Incentive payments of 1-2 on Medicare members
    for hospitals in top 10-20iles for quality
    measures
  • Blue Shield of California
  • Incentive payments for hospitals with top quality
    rankings
  • Harvard Pilgrim Health Care
  • Incentive payments for delivery systems with high
    HEDIS scores
  • Tufts Health Care
  • Incentive payments for delivery systems with high
    HEDIS scores and improvements in Leapfrog measures

42
Pressure for Transparency
Stakeholder Perspectives
Implementation Challenges
Incentives to Promote Information Transparency
The Future How To Use This Information
43
Tiering of consumer copayment or health care
premium by quality and efficiency
Future Uses of Information
  • Already in place in some health plans
  • HealthNet
  • Pacificare
  • Harvard Pilgrim
  • Aetna
  • Likely to increase as part of consumer directed
    health care

44
More robust credentialing, especially for
volume-sensitive procedures
Future Uses of Information
HMO Rates Hospitals Many Don't Like It, But They
Get Better --- Heart-Care Assessment Finds
Reputation and Reality Don't Necessarily Match
WSJ April 22, 1999 Anthem uses the survey to
eliminate all but the top 15 such units from its
million-member health-maintenance organization in
Ohio, the state's largest. That gives them all an
incentive to do what it takes to rate well.
-- UnitedHealth Creates New Premium Network(SM)to
Expand Patient Access to Better Health Outcomes
through Program PR Newswire, April 22,
2004 UnitedHealth Group (NYSEUNH
ltstock_info.asp?tickerUNHgt), citing significant
gains in health outcomes and affordability, today
announced the expansion of its long -established
Centers of Excellence programs for complex health
conditions.
45
Future Uses of Information
Health Plan Leadership in Identifying E2 MDs
E2 efficient and effective Source The Leapfrog
Group
46
Purchasers will be better able to shop for value
Future Uses of Information
  • But providers will also have a greater sense of
    their value, and will charge for it

Carotid Endarterectomy Volume
These hospitals perform 24 of all CEAs for a
commercial health plan
Beth Israel Deaconess 227 Brigham and
Women's 216 Lahey Clinic 110 Mass.
General 382 Saint Vincent 118 St.
Luke's 119 U. of Mass. Med. Cr. 168 U. of Mass.
Memorial 109
47
Elements that are publicly reported will garner
the lions share of resources for improvement
Future Uses of Information
Quality improvement programs aimed at issues not
subject to public reporting
Quality improvement projects aimed at issues that
ARE subject to public reporting
48
Doctor 'Scorecards' Are Proposed In a
Health-Care Quality Drive March 25, 2004 Page A1
In one of the most ambitious efforts yet to
provide health-care quality ratings for
consumers, 28 large employers, including Sprint
Corp., Lowe's Cos., BellSouth Corp., J.C. Penney
Co. and Morgan Stanley are teaming up to develop
"scorecards" to help employees choose doctors
based on how well they care for patients -- and
how cost-efficient they are.
49
  • .claims data remains the only reliable source
    to verify the treatments doctors use and the
    drugs they prescribe. "It's imperfect, but it's
    better than being totally blind"
  • Arnold Millstein Mercer Consulting
  • "This is a very hard issueThe more quality
    measures, the better, but we don't want the
    information to be misleading. Without the
    appropriate statistical models, every time you
    start ranking doctors or putting a number of
    stars next to their name people are going to be
    misclassified
  • Bruce Landon MD MBA
  • Harvard Medical School

Quoted in Landro, L Doctor 'Scorecards' Are
Proposed In a Health-Care Quality Drive Wall
Street Journal March 25, 2004
50
Resources
  • www.talkingquality.gov
  • www.ncqa.org
  • www.medicare.gov/Dialysis/Home.asp
  • www.medicare.gov/NHCompare/Home.asp
  • www.myhealthfinder.com
  • http//www.wicheckpoint.org/
  • Rosenstein, AH Hospital Report Cards, Friend or
    Foe? JCOM 1198 (2004)
  • Krumholz, HM et al Evaluation of a
    Consumer-Oriented Internet Health Care Report
    Care JAMA 27810 (2002)
  • Landro, L Doctor 'Scorecards' Are Proposed In a
    Health-Care Quality Drive Wall Street Journal
    March 25, 2004
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