Which of the following health care issues do you think is the most important for the President and Congress to

deal with? (Please rank)

Protecting patients’ rights in HMOs and managed care plans

Making Medicare more financially sound for future generations

Helping people age 65 and over pay for prescription medicines

Increasing the number of Americans covered by health insurance

All equally important None are very important

Which of the following health care issues do you think is the most important for the President and Congress to

deal with? KFF 11/2002

Protecting patients’ rights in HMOs and managed care plans – 10%

Making Medicare more financially sound for future generations – 21%

Helping people age 65 and over pay for prescription medicines – 23%

Increasing the number of Americans covered by health insurance – 35%

All equally important – 5% None are very important – 4% Don’t know/Refused – 1%

“There is abundant evidence

that serious and extensive quality problems exist throughout American

medicine.”Institute of Medicine,

1999

Opportunities to Improve Quality are Ubiquitous

Only 28-36% of elderly receive pneumococcal vaccines when they should.

Only 41-54% of hypertensives have their blood pressure controlled.

Only 21%-55% of patients with acute myocardial infarction (AMI) received Beta Blocker therapy.

Failure to provide proven therapies for AMI results in 18,000 preventable deaths annually.

Opportunities to Improve Quality are Ubiquitous

25% greater chance of dying if that person does not have health insurance.

In a 1981 sample of Medicare patients:

17% of coronary angiographies32% of carotic endarterectomies17% of upper gastrointestinal tract

endoscopies

were preformed for inappropriate reasons.

The new treatment, called aggressive rehabilitation, goes well beyond traditional physical therapy, taking the "no pain, no gain" approach to an excruciating level. After years of tentatively guarding their backs for fear of injury, back-pain sufferers who can barely walk or stand are subjected to grueling exercise, using their back muscles to stretch and push weight… Intensive exercise has been slow to catch on.

[resulting in unnecessary procedures such as spinal-fusion surgery for degenerating disks???]

The therapy is far less lucrative than the pain pills, injections and surgical treatments that are the cornerstone of the back-pain industry. And patients, too, are reluctant to pursue the treatment, which takes more time and effort than passive therapies. But now, with growing evidence that spinal-fusion surgery doesn't work for most people, more patients are looking for nonsurgical options. [Please don’t try this on your own!!]

WSJ: Patients Hit the Weights in New Back-Pain Cure Nov 12, 2002

Overuse of Health Services

Widespread: from the simplest to the most complex services

Does harm because patients are exposed to unnecessary risks

How much of health care is overuse?

At least 20% (Source: Mark Chassin’s Congressional Testimony -

Washington, D.C. - September 20, 2002

Classifying Quality Problems

1. Overuse

2. Underuse

3. Misuse

“Quality of care is the degree to which health services for the

individuals and populations increase the likelihood of desired health

outcomes and are consistent with current professional knowledge.”

Health Services: This phrase refers to services which affect both physical and mental health

Individuals: Concerned with the quality of care that individual physicians and clinicians deliver to individuals in specific episodes of care

Populations: Attention must be paid to the quality of care across the entire system and whether or not all parts of the populations have access to needed and appropriate services and whether their health status is improving

Increases likelihood of beneficial outcomes: Quality is not identical to positive outcomes

Desired health outcomes: Are these the outcomes that a patient desires???

Current professional knowledge: HC professionals must maintain an up-to-date knowledge of the research in the field and be able to implement it.

In Big Step for Patient Education,California Will Score Health PlansBy MITCHEL BENSON Staff Reporter of THE WALL STREET JOURNAL – Sept 18, 2002

The 323 Walgreens drug stores in California will soon have a new "product" on the pharmacy counter: an official report card that rates the state's 10 largest health-maintenance organizations and 81 of its biggest physician groups.

A BOSTON GLOBE EDITORIAL 11/14/2002

Bonus for better care

AT FIRST GLANCE, the notion can only prompt head-shaking. In Massachusetts, which already has the highest health care costs of any state in the country, doctors are going to have to be paid bonuses to get them to provide quality care to patients with chronic diseases like diabetes? The explanation for this madness is that too much of the $45 billion spent on health in this state is for hospitalization of patients who could have been kept on their feet if problem signs had been more closely monitored. Such monitoring, though, is labor-intensive and sometimes requires doctors to invest in new computer programs. So some Massachusetts employers and managed care organizations are offering or planning financial incentives for doctors who create systems in their practice to keep better track of patients with diabetes, asthma, or other chronic conditions. It is an idea worth trying.

CABG Mortality By State19

92 M

ort

alit

y (%

)

Annual Rate of Decline 1987-92 (%)

NY

Awareness, Knowledge, and Use of the

Consumer Guide By 474 CABG Surgery Patients in Pennsylvania

N (%)

Aware of Consumer Guide 93 (20)

Aware prior to surgery 56 (12)

Report knowledge of hospital ratings 18 (4)

Report that information was a major or

moderate influence in choice of hospital 11 (2)

Report correct rating of hospital 4 (1)

Source: Schneider and Epstein. JAMA 1998.

Barriers to Use of Performance Reports Reported by CABG Surgery

Patients in Pennsylvania

Barrier N (%) “Cost” affected choice 8 (2) “Managed care or insurance restriction” 19 (4)

affected choice Time < 3 days between decision to operate 178 (38)

and operation

“Less than enough” time to learn about provider 58 (12)

No other hospital in “reasonable distance” 157 (33)

Source: Schneider and Epstein. JAMA, 1998.

Interest in Mortality Outcomes Among

CABG Surgery Patients in Pennsylvania

N %

Interest in Obtaining the Consumer Guide

Very interested 158 33

Somewhat interested 106 22

Not very interested 106 22

Not at all interested 133 28

Don’t know 26 6

Willingness to Change Surgeons

Definitely would change 146 31

Probably would change 127 27

Probably would not change 72 15

Definitely would not change 51 11

Don’t know 78 17Source: Schneider and Epstein. JAMA 1998.

HEDIS 2001 -- 52 Measures across 7

Domains

Effectiveness of care (e.g. mammography screening) Access (translators, timeliness of prenatal care) Satisfaction (CAHPS survey) Health plan stability (practitioner turnover) Use of services (e.g. well child visits, frequency of

selected procedures) Informed health care choices (e.g. management of

menopause) Health plan descriptive information (e.g. board

certification, practitioner compensation)

HEDIS 2001 -- Effectiveness of Care

Childhood immunizationsAdolescent immunizationInfluenza vaccination for elderlyPneumonia vaccination for elderlyBreast cancer screeningCervical cancer screeningChlamydia screening

HEDIS 2001 -- Effectiveness of Care

(cont’d)

Antidepressant medication management

Followup after hospitalization for mental illness

Advising smokers to quitMedicare health outcomes survey

HEDIS 2001 -- Effectiveness of Care

(cont’d)

Controlling high BPBeta blockers after AMICholesterol management after AMI Appropriate meds for asthmaticsComprehensive diabetes care

Health Plans Have Voluntarily Reported Poor Performance on

HEDIS Beta Blocker use after myocardial infarction

varied from 15-100% with an average of 62% (Quality Compass 1997)

Breast cancer screening varied from 30-90% with a national average of 70% (Quality Compass 1997)

Diabetic eye exams varied from 28-66% with a national average of 45% (Quality Compass 2000)

HEDIS Has Been Associated with Increasing Quality of

Care

1998 1999

Beta Blocker after MI 80% 85%

Antidepressant Tx 54% 59%

Cholesterol Screening 59% 69%

Diabetic Eye Exams 41% 45%

F/U after Mental Illness 67% 70%

Adolescent Immunization 52% 59%

Source: Quality Compass 1999, 2000

Problems With Report Cards

HEDIS contains no risk adjustment» Incentives to avoid the sick and those of lower

socioeconomic status Quality measures: structure, process, &

outcomes. Most report cards focus on process measure.

Problems With Report Cards (cont’d)

Information needs are heterogeneousPurchasers, providers and consumers

often want different information Information can mislead consumers if

it magnifies clinically unimportant differences

Complex patterns of quality data may confuse consumers

Quality Measurement in the Competitive Marketplace

Will quality report cards become an important component of

quality assurance and quality improvement as we move into the 21st Century or will they

fade away?

Waypoints in Performance

Measurement Today -- Data from computer

surveys on access and satisfaction clinical data on preventive services, process for chronic diseases

Future -- Broader range of indicators, special populations, outcome measures

Controversy About What to Measure and How Precise the Measurements

Must Be

Employers want a range of data including measures of utilization and administrative function as well as quality

Physicians more concerned with technical aspects of quality and highly accurate measurements

Consumers concerned with care by specific doctors and specific hospitals for their individual problems

Persisting Efforts to Focus on Medical Groups and

Physicians

Prompted by consumers, health plans, provider organizations

Limited by information systems, political sensitivities, concerns about confidentiality, sample size and risk adjustment