Quality of Health Care in the U S

Quality of Health Care in the U. S. : How Good Is It & What Have We Learned About How to Improve It? Stephanie Teleki, Ph. D. Cheryl Damberg, Ph. D. Robert Reville, Ph. D. Research Colloquium on Workers’ Compensation Medical Benefit Delivery and Return-to-Work May 1, 2003 1

What Is Health Care Quality? “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ” -- Institute of Medicine 2

Key Components of High Quality Health Care Safe Effective Patient-centered Timely Efficient Equitable -- Institute of Medicine, 2001 3

Current State of Health Care Quality in the U. S. • At best, care is outstanding Cutting edge technologies Innovative pharmaceutical industry Superbly trained clinicians • Often, care is sub-optimal to alarmingly poor 4

Current State of Health Care Quality in the U. S. (continued) Problems are well-documented and widespread across all regions of U. S. within states between cities in the same state or region in all types of patient populations in all types of medical specialties across all types of care delivery systems & settings 5

Problem: Unwarranted Practice Variations Carotid Endarterectomy per 1, 000 Medicare Enrollees (1995 -96) 8. 0 7. 0 Example: Carotid Endarterectomy Napa 5. 2 Bakersfield 4. 7 Los Angeles 2. 7 6. 0 5. 0 4. 0 3. 0 2. 0 1. 0 San Francisco 1. 7 -- J. Wennberg, 2003 0. 0 6

Problem: Unwarranted Practice Variations (continued) The bottom line Geography matters most in terms of the care one is likely to receive, even over medical appropriateness or evidence 7

Problem: Unwarranted Practice Variations (continued) Troubling implications for cost Medicare study (Fisher et al, 2003) More is not necessarily better 8

Problem: Overuse About 30% of procedures performed in the U. S. are of questionable health benefit relative to their risks. -- RAND: Schuster, Mc. Glynn, Brook, 1998 9

Problem: Underuse • Over 40 million Americans lack health insurance • Even with comprehensive coverage, many fail to receive services recommended for prevention acute and chronic conditions 10

Problem: Misuse Overall, between 44, 000 and 98, 000 Americans die each year from medical errors. -- Institute of Medicine, 2000 11

Problem: Patient Dissatisfaction • Nationally problems getting needed care: 15 to 27% physician only sometimes or never communicated well: 6 to 14% -- CAHPS, 2000 • In California problems with timely access to care: 30% difficulties getting treatment/specialty care: 30% -- CAS, 2002 12

Quality: Where Are We Today? • Acknowledgement that there are serious problems Widespread System-wide • Mandate for change Institute of Medicine reports First National Quality Report in 2003 13

Lessons Learned: #1 In order to improve health care quality, it is necessary to measure it. It is hard to improve what you don’t know 14

Lessons Learned: #2 Measuring health care quality is a complex task. Health care is not a single product needs to be measured at many different levels system/structural patient-provider interaction end-product/outcome 15

Lessons Learned: #3 Measuring health care quality takes time. Many organizations involved in quality measurement and improvement; for example NCQA AHRQ National Quality Forum FACCT RAND Much has been done, but much remains to do 16

Lessons Learned: #4 It is important to establish explicit, transparent, standardized measures. Success at national level NCQA Success in California PBGH CCHRI Clear measures reduce resistance understand process increase participation 17

Lessons Learned: #5 It is important to publicly report performance results. Why? Public reports positive change NCQA experience Wisconsin hospital study (Hibbard, 2003) 18

Lessons Learned: #6 It is important to hold parties accountable. Clearly define who is responsible for what Leverage where money/contracting is involved Make accountability part of doing business Focus on different levels Purchasers hold plans accountable HEDIS and CAHPS ® Plans hold providers accountable “Rewarding Results” 19

Lessons Learned: #7 Quality improvement efforts must cover the entire system. In last 10 -15 years, focus has been on plan level Today, focus expanded to include other levels: hospitals, provider groups, individual clinicians Examples of new focus Doctors’ Office Quality (DOQ) Project H-CAHPS® 20

Lessons Learned: #8 It is important to align financial incentives with quality goals. Conflicting messages Capitation Fee-for-service Lower reimbursement for more appropriate options Today, seeing shift from utilization-based to quality-based incentives, especially at physician level “Rewarding Results” 21

Lessons Learned: #9 For employers, there is a business case for quality. Strong case if view health care spending as investment in workforce productivity and organization’s future NCQA: Reclaiming absentee days 22

Lessons Learned: #10 For providers, we need to build the business case. In the past, limited business case for individual providers and provider groups to focus on quality measurement and improvement Today, there is a growing emphasis on measurement and accountability at the provider level “Rewarding Results” Doctors’ Office Quality Pilot in Bay Area Central Florida Health Care Coalition 23

Lessons Learned: #11 The involvement of key stakeholders is critical. To assure credibility and increase odds of success, need key players at the table their buy-in them to demand high quality them to leverage collective interests of purchasers, especially through contract requirements Examples of success NCQA CCHRI 24

Lessons Learned: #12 Start small. Secure some “wins” early in process by focusing on important-- but also do-able-- tasks NCQA 25

Lessons Learned: #13 Minimize the burden of data collection. To the extent possible, use existing data to begin documenting the problems Once have some sense of the problems, seek more support for larger data collection efforts Acknowledge deficiencies of using existing data 26

Next steps for Workers’ Compensation in California No need to re-invent the wheel Build on past knowledge and experience Focus on quality is well-placed given known quality deficiencies evidence that efforts can improve care save lives reduce burden of injury and illness in human and financial terms 27

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