1 quality of health care in the u.s.: how good is it & what have we learned about how to improve...
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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
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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
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Key Components of High Quality Health Care
Safe
Effective
Patient-centered
Timely
Efficient
Equitable-- Institute of Medicine, 2001
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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
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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
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Problem: Unwarranted Practice Variations
Example: Carotid Endarterectomy
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1.01.0
2.02.0
3.03.0
4.04.0
5.05.0
6.06.0
7.07.0
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Car
oti
d E
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arte
rect
om
y p
er 1
,000
Car
oti
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nd
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om
y p
er 1
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Med
icar
e E
nro
llees
(19
95-9
6)M
edic
are
En
rolle
es (
1995
-96) Napa 5.2
Bakersfield 4.7
Los Angeles 2.7
San Francisco 1.7
-- J. Wennberg, 2003
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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
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Problem: Unwarranted Practice Variations(continued)
Troubling implications for cost Medicare study (Fisher et al, 2003) More is not necessarily better
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Problem: Overuse
About 30% of procedures performed in the U.S. are of questionable health benefit relative to their risks.
-- RAND: Schuster, McGlynn, Brook, 1998
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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
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Problem: Misuse
Overall, between 44,000 and 98,000 Americans die each year from medical errors.
-- Institute of Medicine, 2000
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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
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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
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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
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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
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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
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Lessons Learned: #4
It is important to establish explicit, transparent, standardized measures.
Success at national level NCQA
Success in California PBGH CCHRI
Clear measures understand process
reduce resistance increase participation
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Lessons Learned: #5
It is important to publicly report performance results.
Why? Public reports positive change
NCQA experience Wisconsin hospital study (Hibbard,
2003)
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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”
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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®
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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”
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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
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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
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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
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Lessons Learned: #12
Start small.
Secure some “wins” early in process by focusing on important-- but also do-able-- tasks NCQA
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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
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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