Transcript No Slide Title

The Evolution of Healthcare
Quality and the Marketplace
Patient Safety Center of Expertise
February 2009
What type of evolutionary era are we in?
•
Gradualism?
OR
•
Punctuated Equilibrium?
2
What type of evolutionary era are we in?
•
•
Gradualism versus punctuated equilibrium
• Environmental assessment as the key to what we will look like

Technical Revolution and Cultural Revolution
Are the global financial crisis and the election of 2008 the punctuators?
3
IOM 2: Crossing the Quality Chasm
•
“The Rest of the Iceberg”
•
There are serious problems in quality

•
The problems come from poor systems…not bad
people

•
Between the health care we have and the care we could
have lies not just a gap but a chasm.
In its current form, habits, and environment, American
health care is incapable of providing the public with the
quality health care it expects and deserves.
We can fix it… but it will
require changes
4
VARIATIONS ARE WIDESPREAD
5
VARIATIONS ARE WIDESPREAD – Intensity of Care
6
Expanding the Quality Compass: Unwarranted Variation
Effective Care
Percent of Medicare Diabetics Receiving
Blood Lipids Testing
Preference-Sensitive Care
Back Surgery Rate per 1,000
Medicare Enrollees
Supply-Sensitive Care
Physician Visits During the Last Six Months
of Life Among Patients Assigned to Selected
Academic Medical Centers
7
And nationally…
McGlynn, et al: The quality of health care delivered to adults in the United
States. NEJM 2003; 348: 2635-2645 (June 26, 2003)
•
•

439 indicators of clinical quality of care

30 acute and chronic conditions, plus prevention

Medical records for 6712 patients

Participants had received 54.9% of scientifically indicated care
(Acute: 53.5%; Chronic: 56.1%; Preventive: 54.9%)
Conclusion: The “Defect Rate” in the technical quality of American
health care is approximately
45%
8
The Problem
•
A healthcare system badly out of
balance:

Call it the 'Partners Effect:'
Elite hospitals are paid much
more for care that is often no
better than average. It is the
best kept secret in
Massachusetts medicine -
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Quality v. Cost
The Relationship Between Quality and Medicare Spending
Source: Baicker, K and Chandra, M : Medicare spending, the Physician Workforce and
Beneficiary Quality of Care, Health Affairs, April 7, 2004
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Who Cares?
Patients? Providers? Policymakers? Plans? Our
New President?
Purchasers!
Variation = Cost (& quality)
The 2 ½
Percent Rule
“The American healthcare sector expects its
revenue to grow 2-1/2
percentage points
faster than the GDP as
a whole, year after
year.”
- Uwe Reinhardt
Source: Reinhardt, U, “Sailing Into the Perfect Storm” Presented at the 12th Princeton Conference May
19 – 20,, 2005
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The Purchaser’s dilemma
•
The cost of health benefits for employees > the cost of steel in American cars

Starbucks spends more on health insurance for employees than on coffee

We are not immune!
• MGH/MGPO pay over $85 million for healthcare for employees
•
For other inputs purchasers are used to getting more when they pay more (value added)

Not transparent in healthcare
BUT, Levers for demanding “added value” have not existed

Purchasers are asking and now demanding payers to develop such levers

Citing healthcare as a driver of global non-competitiveness
•
Optimal
Quality
Effective
and
Efficient
Utilization
Value
Added
12
The Provider’s dilemma
Utilization of High Cost Imaging Tests at PCHI
160
134
Procedures/1000
140
113
120
100
98
85
75
80
2000
2001
2002
2003
82
65
55
60
40
15
20
21
27
33
-
CT
MRI
Nuc-Card
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One Model of the Evolution of Healthcare
The Long View
High
Chasm Crossing
Value of
Health
Benefits
Consumerism
& P4P
Performance
Disclosure
Performance
comparisons
for hospitals,
MDs & Tx
 Market
sensitivity to
hospital/MD
quality &
TCO
2002
50 ppts
$
40 ppts
Clinical reengineering by
MDs, hospitals
& suppliers
Q = compliance with guidelines
$=
Low
Q
annual health benefits cost
Key Evolutionary Steps
Reproduced with permission of Arnold Milstein, MD (Mercer)
2012
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Transparency
Transparency – the public
reporting of cost and outcomes
information – will lead to
improved value in health care.
The “T word” is now political
Mom and apple pie.
Consumers of healthcare, made
price sensitive by appropriate
product design and informed by
detailed outcomes and price
information, will shop for value
and bring market forces to bear
on both cost and quality. (a
hypothesis!)
15
Mounting Pressures For Transparency and
Accountability (a sample!)
AQA/HQA
National:
US News and World Report
NSQIP
QASC
JCAHO
AMA and
Specialty Societies
NCQA/HEDIS
National Quality Forum
AHRQ
Leapfrog
CMS (including serious
reportable events and P4P)
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Mounting Pressures For Transparency and
Accountability (a sample!)
Regional:
Tiered Regional Networks
Regional
Publications
Commercial website vendors
(Subimo, Healthshare,
HealthGrades, MD rating sites)
National Insurers
(United, Aetna)
UHC
17
Mounting Pressures For Transparency and
Accountability (a sample!)
State:
Dept of Public Health
Regional
Magazines
(Boston)
Board of
Registration
GIC Insurance Data
MHQP
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Mounting Pressures For Transparency and
Accountability (a sample!)
Payors:
Tiered Networks
Payor Websites
Payor Open-Enrollment
Materials
P4P Data
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Mounting Pressures For Transparency and
Accountability (a sample!)
Within MGH/MGPO/PHS:
CPM
PHS High Performance Medicine Close
PCAC
Departmental Quality
Work
Credentialing
PHS Quality Close
MGPO Quality Incentive Program
Quality and Safety Dashboard
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Mounting Pressures For Transparency and
Accountability
CPM
AQA/NQA
Dept of Public Health
Tiered
Regional
Tiered
Networks
Networks
JCAHO
US News
and
World
Report
PHS High Performance Medicine Close
NSQIP
Regional
Regional
AMA and
National
Board
of Insurers
PCAC
Magazines
Publications
Specialty
(United,
Registration
Aetna)
Societies
PHS
Quality
Close
Payor
Websites
(Boston)
Payor Open-Enrollment
NCQA/HEDIS
Materials
Leapfrog
Departmental Quality
National Quality Forum
MGPO Quality Incentive Program
Work
GIC Insurance Data
CMS (with P4P coming soon) UHC
Commercial website vendors
P4P Data
MHQP
(Subimo, Healthshare,
Quality and Safety Dashboard
HealthGrades
AHRQ
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Credentialing
C. P. Snow Redux: The Two Worlds
….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 Milstein
Mercer Consulting
"This is a very hard issue…The
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
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The Johns Hopkins Example
JOHNS HOPKINS HOSPITAL
• Ranked #1 overall, #2 in
the nation for neurology
and neurosurgery, #3 in
cancer, #4 in heart and
heart surgery
• No other Maryland
hospital made the top 50
2005
Ratings
JOHNS HOPKINS HOSPITAL
• Did not earn clinical
excellence award – 4 other
Baltimore hospitals did
• Only award for specialty
excellence was for stroke
care
• One of the lowest rated
hospitals in Baltimore
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The “5 Stages” of Getting Involved in Quality
Measurement
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Denial
•
Anger
•
Bargaining
•
Depression
•
Acceptance
•
We need help getting through the stages
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The Important “W” Question
What is the purpose of quality measurement?
.
The stakes get higher as the purpose moves towards accountability
Improvement
RESEARCH/
IMPROVEMENT
PAYMENT
PUBLIC
REPORTING
ACCOUNTABILITY
ality
Qu
Data
R
Administrative
Data
Clinical
Data
tment
s
u
j
d
isk A
Cost
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Consumer effects of public reporting
•
Is information available at the right time?
•
Is information readily understandable?
•
Is information presented in a manner which is statistically appropriate?
Public reporting of quality alone may not do it and now cost
reporting ($, $$, $$$, $$$$) is getting greater attention…
Source: Harris Poll, 2002, http://www.harrisinteractive.com.
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The Realities of Reporting
Adjusted in-hospital mortality rates by center 1987-2000 N=37,599
8
Mortality Rate (%)
7
6
5
4
3
2
1
0
1988
1990
1992
1994
Year
1996
1998
2000
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Uses of Quality
Measurement
Purpose
Goals
Selection
Results
(Performance)
Measurement
for
Selection &
Accountability
•
•
•
Process Improvement
New Design
Process Control
Improvement
Knowledge About
Performance
Consumers
Purchasers
Regulators
Patients
Contractors
Referring Clinicians
Etc.
Change
Knowledge About
Processes and
Results
Motivation
MOTIVATION
THE NEW YORK STATE EXPERIENCE
Organizations
Care Deliver
Teams and
Practitioners
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The Long View
High
Chasm Crossing
Value of
Health
Benefits
P4P &
Consumerism
Performance
Disclosure
Performance
comparison
s for
hospitals,
MDs & Tx
 Market
sensitivity to
hospital/MD
quality &
TCO
2002
50 ppts
$
40 ppts
Clinical reengineering by
MDs, hospitals
& suppliers
Q = compliance with guidelines
$=
Low
Q
annual health benefits cost
Key Evolutionary Steps
Reproduced with permission of Arnold Milstein, MD (Mercer)
2012
29
Why Payment for Performance Is So Important
•
•
There is a “quality chasm” between what is and what ought to be in
healthcare
We have programs that we know work to improve quality

Patients have improved outcomes and quality of life (win)

The savings accrue to the payers (win)

The costs of the program are borne by the providers (lose)
•
Payment for performance could make it a win – win – win
•
This is a key additional motivator for improvement

CMS sees this as its key tactic (becoming an “active purchaser”
• Payment for reporting
• Payment for performance (or withholding payment – e.g. SREs)
• ? Condition of Participation
30
What is Payment for Performance?
Payment for Performance = Concrete financial incentives (either “bonuses” or “return of
withholds”) for meeting negotiated targets on quality and efficiency
Goals include:
1.
Efficiency (managing utilization and costs)
–
–
–
–
–
2.
Quality (improving patient safety and quality care)
–
–
–
–
–
3.
Inpatient days or admissions
High cost imaging utilization
Pharmacy costs
Emergency Room utilization
Management of High Risk Patients
Pediatric asthmatic use of controller medications
Adult diabetes population HbA1c testing and control
Chlamydia testing in young adult women
Cardiac Care
Reporting of healthcare acquired infections
Infrastructure
–
–
–
Electronic Medical Record (EMR) implementation by PCPs and Specialists
Computerized Physician Order Entry (CPOE) implementation
Safety system implementation
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P4P Adds Focus To Monitoring and Improvement
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But is P4P Delivering the Value?
To Date Most Experts Would Say That The Impact Of “P4P” On Quality
Has Been Modest At Best And The Impact On Costs Negligible
Health Care Consumerism
3 combinable flavors and a cone
•
Hollowed-out insurance coverage
•
Portable spending accounts
•
Performance-tiered out-of-pocket costs
•
Wizard-style consumer (and MD) decision support
N.B. This will extend, not replace, managed competition among plans
33
Workers contributions to health coverage are growing
rapidly
Average Monthly Worker Contribution
$250
$226
$222
$201
$200
$149
$150
$129
$122
$100
$50
$37
$27
$30
$42
$47
$51
$0
1996
1999
2001
Individual
2003
2004
2005
Family
Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2005,
KPMG Survey of Employer-Sponsored Health Benefits, 1996.
34
Price Transparency
•
•
•
Built on the premise that exposing patients to price will influence their
decisions upon where to get care
 Unproven hypothesis
• But, potential effect of higher out of pocket costs (HSAs, high
deductibles, etc.) may not yet be apparent in data – WILL THIS
BE THE DISRUPTIVE INNOVATION IN HEALTHCARE?
Usually presented in quartiles or significant above/below mean
 Often represented as $ v $$ v $$$
Key question is whether the financial data is based on costs (usually
using a standard cost/charge ratio) or charges (i.e. price)
 Most efforts to date use price
• No good deed (or fair deal) goes unpunished
• Most consumers do not understand prices versus their own
costs and this is exploited in the marketplace (e.g. “THIS IS
NOT A BILL” notices)
35
The new face of transparency
36
Minnesota Experiment With Tiering
37
Are Consumers Finally Voting With Their Feet?
38
What the Consultants Are Showing the Purchasers
PostChasm
Suppliers
MD Quality Index
(outcomes or % adherence to EBM)
Lower
Higher
50th %ile
Low Efficiency
High Quality
High Efficiency
High Quality
(Dream Suppliers)
50th %ile
Low Efficiency
Low Quality
High Efficiency
(Nightmare
Suppliers)
Lower Efficiency/
Higher Cost
Low Quality
Cost
MD Longitudinal Cost-Efficiency Index
Higher Efficiency/
Lower Cost
(total cost per case mix-adjusted treatment episode)
Adapted from Regence Blue Shield
Turning Up the Heat: Selective Contracting
“If a doctor
“If a has
doctor
opened
has opened
Example: Aetna Aexcel with a bronze
with a lancet
bronzean
lancet an
abscessabscess
of the eye
of the
of aeye of a
gentleman
gentleman
and hasand has
cured the
caused
eye, he
theshall
loss of the
take teneye,
shekels
the doctor’s
of
hands
silver” shall be cut off”
Projected savings vary from
1.6 % to 4.5% depending on
the region, specialties
involved and other factors.
This product has grown
rapidly
40
The Long View
High
Chasm Crossing
Value of
Health
Benefits
P4P &
Consumerism
Performance
Disclosure
Performance
comparison
s for
hospitals,
MDs & Tx
 Market
sensitivity to
hospital/MD
quality &
TCO
2002
50 ppts
$
40 ppts
Clinical reengineering by
MDs, hospitals
& suppliers
Q = compliance with guidelines
$=
Low
Q
annual health benefits cost
Key Evolutionary Steps
Reproduced with permission of Arnold Milstein, MD (Mercer)
2012
41
Iron Laws of Improvement
•
B Teams with A Systems always beat A Teams with B
Systems


•
It’s not the seed, it’s the soil




•
Culture trumps all
Innovation must be balanced with Spread
The political is much more challenging than the technical
TPS Order of change: leaders -> professionals -> staff
Data + Anecdote = Action

•
It’s the systems stupid (studies of VA care)…
We need an A team, not A individuals and we need to provide that
team A systems
You need both
• E.g. VA and bar-coding implementation
Proven Tools From Industry (e.g. LEAN and 6 Σ) Are Being Applied
 TJC and others are now focusing on the use of these tools
42
Improving Care for Patients with Pneumonia
43
Improving Care for Patients with Pneumonia
Pneumovax intervention Winter 2004
44
Pneumovax Sticker Intervention
MGH 2004
# Pneumovax Orders in POE at MGH
150
~150 total patients estimated eligible/week
125
100
75
50
25
28
25 8
20
14
13
19
12
1/
15
/0
5
1/
8/
05
1/
1/
05
12
/2
5/
04
12
/1
8/
04
12
/1
1/
04
12
/4
/0
4
11
/2
7/
04
0
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It takes a real system, not science projects…
High reliability QI tactics or interventions
•
Level 1 (1 error in 10) prevent errors by standardizing care with
algorithms, guidelines

•
Design the implementation tactic to be as error proof as possible
Level 2 (1 error in 100) mitigate errors by identifying failures; promoting
use of opt-out orders, making the best choice the default choice

Even the best designed implementation plans have failures
Level 3 (1 error in 1000) redesign the system in which the intervention
operates; eliminate work-arounds, use electronic records,

Systems should perform 24-7 and be as error-proof as possible
Adapted from Institute of Healthcare Improvement Innovation Series 2004: Improving the Reliability of Health Care 46
Pneumovax “opt-out” intervention 2005
Patient will be screened for and given pneumovax
unless you opt out below
(Nursing will screen for patient / family
agreement and contraindications)
Literature suggests this should improve compliance to 98%
but it took time to prepare the “soil”
47
PROMETHEUS Payment Model: Targeting Waste
Incentive To Go After Potentially Avoidable Costs
48
Going Beyond The Simple – The Unmentionables
To Lower Total Cost of Care,
What Sacred Cows External to Care
Delivery Processes Must be Sacrificed?
Efficiency
Measures and Measurements Must Meet
Rigorous Standards of Scientific Acceptability
If Efficiency Measures are not Produced by EHRs,
Providers’ Data Collection Cost Must be Reimbursed
Performance-Reward Formulas Must Sustain the
Livelihoods of All Current Providers
Tacit Complicity in Patient Self-Management Failures
MD as Primary Performance Lever (Rather Than Teams
and Systems)
100% In-Country Health Care Workforce
The R word
Under the intermediate assumptions the HI
trust fund is projected to be exhausted in
2019, the same year as in last year’s report
but at an earlier point within the year, due to
slightly lower projected payroll tax income and
slightly higher projected benefits than
previously estimated.” CMS Actuary 3/25/2008
•
Public Policy and Politics

Currently Medicare is projected to “bankrupt” in 2018 or 2019
• “Deficit spending will begin at least 5 years earlier
– Some projections put that date as early as 2011
» President Obama will not finish their first term
without hitting this “milestone”
» “We can’t afford not to fix the healthcare cisis…”
» Are there enough forces for healthcare reform?
50
Conclusions
•
•
•
•
•
Quality reporting to date has been a failure as a driver of selection (? If this may
change with more out of pocket cost at risk), but clearly focuses attention and
fosters improvement
 Focus on reporting is rapidly shifting to quality and cost
Integrity in measurement, choosing targets wisely, and providing additional
motivation (P4P) is a requisite balance to a plethora of reporting requirements
Payment for performance has been a rapidly growing mechanism for valuebased purchasing but leading edge purchasers are getting more aggressive and
patients are taking on greater financial risk
 Increased out of pocket costs with tiering
 Selective contracting
 Emergence of cost as dominant factor
Promoters of transformative quality improvement motivation would do well to
keep in mind the “Iron Laws of Improvement” and employ the tools of industry to
help meet the demands of a more discriminating marketplace
We are likely to experience a period of punctuated equilibrium in the evolution of
the healthcare marketplace in the next few years – can fundamental healthcare
reform continue to wait?
51