Transcript Presentation - Virginians Improving Patient Care and Safety

Achieving Quality and
Affordability
William Rollow, MD MPH
Deputy Director, Quality Improvement Group
Centers for Medicare & Medicaid Services
May 15, 2003
1970’s View of US Healthcare Issues
• Excellent care, but:
– Costly
– Treatment- rather than prevention- oriented
– Inequitably distributed
Today’s View of Quality
• “Exhaustive research documents that today,
in America, there is no guarantee that any
individual will receive high-quality care for
any particular health problem.”
– Advisory Commission on Consumer Protection
and Quality, 1998
More
• “Americans should be able to count on
receiving care that meets their needs and is
based on the best scientific knowledge. Yet
there is strong evidence that this is
frequently not the case.”
– Institute of Medicine, 2001
1990’s Strategies For Managing Cost
• Capitation/alternate payment models
• Price control
• Utilization management
Managed Care Premium/Cost Increases
18.2%
18.0%
17.7%
Annual
premium
increases
Figure 1: Premium versus Cost Increases
13.5%
Source: Salomon
Smith Barney Research estimates based on data from CMS, Milliman USA, AAHP, and KPMG. As of February 27, 2003.
13.2%
13.0%
Medical
cost
trends
11.7%
10.4%
14.0%
12.0%
11.0%
10.0%
9.0%
8.1%
8.0%
8.0%
6.5%
Physician
Previous
forecast
5.7%
Hospital
3.2%
2.1%
3.0%
-0.4% -0.5%
Drug
-2.0%
1988
1989
1990
1991
1992 1993
1994
1995
1996
1997
1998
1999
2000 2001E 2002E 2003E 2004E 2005E 2006E
Source: Salomon Smith Barney Research estimates based on data from CMS, Milliman USA, AAHP, KPMG.
Source: Salomon Smith Barney Research estimates based on data from CMS, Milliman USA, AAHP, and KPMG. As of February 27, 2003.
2000’s Strategies For Managing Cost
• Improve effectiveness/efficiency
– Disease management
– Quality Improvement
• Mitigate technology and preference drivers
– Evidence-based coverage decisions and
payment determinations
– Shared cost responsibility
– Shared decision-making
Disease Management Strategies
• Identify patients with chronic illness
• Make disease-specific information available to the
patient
• Interactively support patients in self-management
• Prompt patients to obtain services based on a
regular schedule or as needed in relation to
outcomes
• Prompt physicians to implement a medical
regimen which is consistent with best practice
Approaches to Disease Management
• Vendor-based
• Physician-based
• Mixed
Typical Vendor-Based Approach
• Analysis of medical and pharmacy claims, often
supplemented with information requested from a physician
office or from the patient, to identify and risk-stratify patients
with chronic illness
• Provision of newsletters, brochures, etc via regular mail or
email with disease information
• Provision of reminders regarding services needed to a
physician office or to the patient, via written or telephonic
communication
• Telephonic, or sometimes internet-based, interaction with a
patient on how to better self-manage diet, exercise, meds, etc
• Written or telephonic communication with a physician
regarding medical regimen when there are opportunities for
improvement
Disadvantages
• Cost reduction
–
–
–
–
Still a research question
Selected diseases
Savings largely offset by vendor cost
One-time impact on trend – no long term creation of ongoing
efficiencies
• Impact on physician office
– Additional work without reward
– Multiple vendors, each with a different approach
– Does not improve care process
• Impact on patients
– Generally look to the physician for direction
– Multiple sources of information – conflicting vendor messages and
external sources
Physician-Based Approach
• The office builds its own database (through registry or
EHR) for identification and management of patients
• The database offers decision support (reminders, evidencebased options, etc) available to the practitioner during the
office visit and which also generates reminders which are
pushed out via regular or email
• Interactive support is provided by a member of the
physician office staff, by referral to specialists or
community resources, or online
• Performance is assessed systematically by reports
generated by the database for use in improvement and
external reporting
Mixed Approach
• Recruit as many physicians as possible to implement
systems and redesign care process to improve
quality/efficiency and provide disease management
• Seek to improve physician office care by providing
feedback to the physician on how well care corresponds to
guidelines, and offering assistance in improvement
• Supplement physician office-based disease management as
needed with vendor-based activity
• Reduce as much as possible the complexity of multiple
vendors and sources of information
• Engage patients in disease management through invitation
by the physician office and route communications to the
patient as much as possible through the physician office
• Reimburse physicians for participation in such programs
Disease Management Demonstration
Projects
• BIPA – determine impact of dm/drugs:
vendor and provider/etc -based in 3
geographic areas
• Case Management – impact in N Mexico
• Coordinated care – 15 sites, provider- and
vendor- based
• PGP – 6 physician groups will be selected
Quality Improvement
• Improve process
– Better clinical outcomes
– Better patient experience
– Efficiency through elimination of non-valueadded process and rework
Medicare’s Quality Improvement
Organizations
• Previously known as the Peer Review
Organizations (PROs)
• Mission: to improve quality of care for
Medicare beneficiaries
• $1+ billion budget for current 3-year contract
• 53 QIOs – 1 in each state
• Confidentiality of information assured by
statute
QIO Program
th
7
SOW
• Clinical quality improvement/information promotion
–
–
–
–
–
Nursing homes – publicly reported measures
Home health – publicly reported measures
Hospitals – measures in voluntary public reporting pilot
Physician offices
Disparities
• Beneficiary protection
– Complaints
– Hospital payment monitoring
– Appeals/EMTALA
NHQI Quality Measures
Quality Measures
Baseline Measurement
ADL Decline
Pressure Ulcers—No FAP
Pressure Ulcers—with FAP
Chronic Pain
15.4%
8.5%
8.6%
10.7%
Physical Restraints
Infections
PAC Delirium—No FAP
9.7%
14.6%
3.8%
PAC Delirium—with FAP
3.7%
PAC Pain
PAC Walking Improvement
25.4%
30.3%
HHQI Publicly Reported Measures
•
•
•
•
•
•
•
•
•
•
•
Acute Care Hospitalization
Improvement in Ambulation/Locomotion
Improvement in Bathing
Improvement in Management of Oral Medications
Improvement in Transferring
Improvement in Upper Body Dressing
Improvement in Toileting
Improvement in Pain Interfering with Activity
Stabilization in bathing
Improvement in Confusion Frequency
Any Emergent Care Provided
Improving Care in Hospitals:
th
7 SOW MI Measures
100%
90%
80%
70%
60%
6th SOW Baseline
50%
6th SOW
Remeasurement
40%
30%
20%
10%
0%
ASA - 24H BB - Disch Smoking
HEDIS Quality Compass
Beta Blocker/MI Rate –
Commercial Plans
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
1996
1997
1998
1999
2000
2001
Improving Care in Hospitals:
7th SOW CHF Measures
100%
90%
80%
70%
60%
6th SOW Baseline
50%
6th SOW
Remeasurement
40%
30%
20%
10%
0%
LVEF
ACE-I
Improving Care in Hospitals:
7th SOW Pneumonia Measures
100%
90%
80%
70%
60%
50%
6th SOW Baseline
40%
30%
20%
6th SOW
Remeasurement
10%
0%
Antibiotic Antibiotic
Time
Choice
Flu
Screen
Improving Care in Physician Offices:
7th SOW Preventive Measures
100%
90%
80%
70%
60%
50%
6th SOW Baseline
40%
30%
20%
6th SOW
Remeasurement
10%
0%
Flu Vacc
Pneumo
Vacc
Mammo
HEDIS Quality Compass
Mammography Rate –
Commercial Plans
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
1996
1997
1998
1999
2000
2001
Improving Care in Physician Offices:
7th SOW Diabetes Measures
100%
90%
80%
70%
60%
50%
40%
30%
6th SOW Baseline
6th SOW
Remeasurement
20%
10%
0%
Glyc Hgb Eye Exam
Lipid
Screen
HEDIS Quality Compass
Diabetic Eye Exam Rate Commercial Plans
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
1996
1997
1998
1999
2000
2001
HEDIS Quality Compass
HbA1c Exam Rate Commercial Plans
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
1998
1999
2000
2001
How Successful Has QI Been?
• Impact on quality
– Menu of measures is limited and not patientfocused
– At current rate of improvement, will be 2020
before we reach 95% performance level for QIO
measures
– Most providers/practitioners only work on a
limited number of measures/topics
– Most practitioners are skeptical/resistant
• Impact on cost
What Has Limited the Impact of QI?
• On quality
– Process changes have been largely within
existing systems
– Provider/practitioner buy-in has been limited
• On cost
– Effect overwhelmed by other cost drivers: new
technology, patient demand, practitioner
preferences, supply
How Can Improvement Accelerate
and Widen?
• Promote adoption of transformative systems
and care model, such as eRx, eLab, eCare
reminders, EHR, PHR, health information
exchange
• Increase motivation of providers and
practitioners to improve and adopt such
systems and care models
Rationale: E-Prescribing
• Medication errors are common, affecting as
many as 9% of prescriptions. E-prescribing
systems have the potential to improve quality and
safety by
– Eliminating legibility problems
– Reducing the occurrence of drug interactions, dosage
errors, and other adverse effects by guiding
prescribing based on patient age, weight, allergies, lab
results, diagnoses and concurrent medications
Rationale: E-Laboratory Mgmt
• Lab results-related errors are common. Elab results management systems have the
potential to improve quality and safety by
– Making a practitioner aware if lab test results which
have been received have not been reviewed
– Reducing unnecessary test ordering by giving a
practitioner easier access to previous lab test results
Rationale: E-Care Reminders
• Preventive services, or services recommended for
chronic conditions, are underutilized. E-care
reminder systems have the potential to improve
quality and safety by
– Prompting a practitioner to remind a patient to make an office
visit
– Prompting a practitioner to remind a patient to obtain needed lab
tests or other services
– Identifying patients in need of special monitoring or services
How Can Improvement Accelerate
and Widen?
• Promote adoption of transformative systems
and care model: eRx, eLab, eCare
reminders, EHR, PHR, health information
exchange
– Promote IT standards
– Promote systems availability, affordability,
functionality
– Support redesign of care processes
• Increase motivation of
providers/practitioners to improve and
adopt such systems and care models
Promote IT Standards
• Need IT standards to assure that systems can
exchange information and that newer systems can
extract information from those they replace
• Consolidated Health Informatics group (HHS, VA,
DOD) is adopting standards for federal agencies
and recommending their use in private sector
• First set of standards has been adopted in the areas
of lab test results, imaging, prescriptions, devices,
and data transmission
Promote Systems Availability
• Need availability of high quality, affordable
systems
– EHRs
– e-Rx, e-Lab, e-Reminder systems
Promote Redesign of Care Processes
• Chronic care model
• Idealized design project
Increase Motivation of
Providers/Practitioners
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Confidential results reporting – electronic data
Public reporting – electronic data
CME
Malpractice premium reduction
Financial incentives - payor and patient
Billing/participation requirements burden
reduction
• QI projects inconsistency reduction
Opportunities for Improvement –
Payors/MCOs and QIOs
• Providers/practitioners want consistency in
interventions
– Performance measures – should be consistent
across payors and ideally should come from
electronically available information generated
by the provider/practitioner
– Guidelines/tools/improvement assistance
should be consistent across payors
Arizona Managed Care Quality
Enhancement Program
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19 MCOs, the QIO, practice groups
Diabetes collaborative
Consistent measures at practice level
Aiming at unified data collection
Common interventions
– Flowsheet
– Member information
Doctor’s Office Quality (DOQ)
Project
• Topics: Preventive care, DM, HTN, CAD,
CHF, Osteoarthritis, Depression
• Measures
– Clinical – developed with expert panel
– Patient experience
• Process improvements
– Care reminders
– Other
Achieving Quality and Affordability
• Some cost is driven by rework
(complications, unnecessary exacerbations)
and inefficiency
– Improve effectiveness/efficiency of care
through QI/disease management
• Enhance patient self-management
– Get provider participation by public reporting
and financial incentives (can be linked)
Achieving Quality and Affordability
• Some cost is driven by supply, technology,
and physician preference
– Evidence based coverage decisions and
payment rules
– Enrollee cost-sharing and information which
supports use of benefits
– Shared decision-making