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Cathy Schoen Senior Vice President, The Commonwealth Fund

Aiming High: Towards a High Performance, High Value U.S. Health System Performance Reporting to Inform and Stimulate Action. Cathy Schoen Senior Vice President, The Commonwealth Fund AHRQ Annual Meeting: Improving Health Care, Improving Lives

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Cathy Schoen Senior Vice President, The Commonwealth Fund

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  1. Aiming High: Towards a High Performance, High Value U.S. Health SystemPerformance Reporting to Inform and Stimulate Action Cathy Schoen Senior Vice President, The Commonwealth Fund AHRQ Annual Meeting: Improving Health Care, Improving Lives National Performance Measurement & Reporting Session Bethesda, MD September 28, 2007 www.commonwealthfund.org

  2. Performance Reporting to Inform and Stimulate Action • Importance of AHRQ Quality and Disparities reports and efforts to develop performance indicators: supporting efforts to improve • Need for focus on whole system and how dimensions interact: Access, Quality, Efficiency and Equity • Examples from Fund sponsored work that builds on AHRQ • Composites and benchmarks • Geographic and care system variations • Efficiency (quality/cost) indicators • Where performance reporting in going • U.S. and international examples • Future directions: critical role of public performance information & analysis to guide and drive change

  3. HIGH QUALITY CARE • Getting the right care • Coordinated care • Safe care • Patient-centered care Commonwealth Fund Commission:Goals for A High Performance Health System ACCESS & EQUITY FOR ALL • Universal participation • Affordable • Equitable LONG, HEALTHY, AND PRODUCTIVE LIVES EFFICIENCY SYSTEM CAPACITY TO INNOVATE & IMPROVE

  4. U.S. National Scorecard: Why Not the Best?Commonwealth Fund Commission National Scorecard • 37+ Indicators • U.S. compared to benchmarks Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, September 2006.

  5. Aiming Higher: Commonwealth Fund Commission State Scorecard on Health System Performance • State ranks • 32 indicators Source: Commonwealth Fund State Scorecard on U.S. Health System Performance, 2007

  6. Composites, Benchmarks and Geographic Variation • AHRQ development of indicators of key concepts critical to inform efforts to improve performance • Composites: • A limited number of key indicators enables view of overall patterns • Can “drill down” to understand variation • Benchmarks: • Top percentiles (hospitals; nursing homes; geographic areas; systems) provide targets • Goal: Improve and narrow the distribution between leading/lagging • Geographic variations and cross-cutting analyses

  7. Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* International variation, 1998 U.S. State variation,2002 Percentiles * Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. See Technical Appendix for list of conditions considered amenable to health care in the analysis. Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  8. Having an Accessible Primary Care Provider, by Age Group, Family Income, and Insurance Status, 2002 Percent of adults with a usual source of care who provides preventive care, care for new and ongoing health problems, and referrals, and who is easy to get to Elderly adults Nonelderly adults Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  9. Receipt of All Three Recommended Services for Diabetics,by Race/Ethnicity, Income, Insurance, and Residence, 2002 Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year * ** * Insurance for people ages 18–64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  10. Medicare Admissions for Ambulatory Care Sensitive Conditions,Rates and Associated Costs, by Hospital Referral Regions, 2003 Rate of ACS admissions per 10,000 beneficiaries Costs of ACS admissions as percent of all admission costs, average in region groups Percentiles Percentiles Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files (SAF) 5% Inpatient Data. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  11. State Variation: Potentially Preventable Hospital Admissions Indicators Percent DATA: Medicare readmissions – 2003 Medicare SAF 5% Inpatient Data; Nursing home admission and readmissions – 2000 Medicare enrollment records and MedPAR file; Home health admissions – 2004 Outcome and Assessment Information Set SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007

  12. Medicare Hospital 30-Day Readmission Rates and Associated Costs, by Hospital Referral Regions, 2003 Rate of hospital readmission within 30 days Readmission reimbursement as percent of total reimbursement for all admissions Quartile of regions ranked by readmission rates Percentiles Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files (SAF) 5% Inpatient Data. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  13. Where Performance Reporting Is Going: U.S. and International • United States • Multi-payer initiatives • Quality and value: cost and price reporting • Physician level reporting • Patient experiences: H-CAHPS + ambulatory • Effort to define/assess/measure outcomes • Development of episode of care quality/cost and better measures of care coordination • International • Expanded set of indicators and public reporting • System and financial incentives to support/reward improvement

  14. MHQP Setting the Stage for Public Reporting: Commonwealth Fund/RWJ Project Massachusetts first state to publicly report hospital and medical group patient-centered care survey data – Massachusetts Health Quality Partners Source: Melinda Karp, “Reporting Patients’ Experiences with Their Doctors Process, Politics and Public Reports in Massachusetts,” Presentation March 31, 2006.

  15. Patient-Centered Hospital Care: Staff Managed Pain, Responded When Needed Help, and Explained Medicines, by Hospitals, 2005 Percent of patients reporting “always” *Patient’s pain was well controlled and hospital staff did everything to help with pain **Patient got help as soon as wanted after patient pressed call button and in getting to the bathroom/using bedpan ***Hospital staff told patient what medicine was for and described possible side effects Data: CAHPS Hospital Survey for 254 hospitals submitting data in 2005. National CAHPS Benchmarking Database SOURCE: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

  16. Size of the project: 2,000 German Hospitals (> 98%) 5,000 medical departments 3 Million cases in 2005 20% of all hospital cases in Germany 300 Quality indicators in 26 areas of care 800 experts involved (national and regional) Ideas and goals:  define standards (evidence based, public)  define levels of acceptance  document processes, risks and results  present variation  start structured dialog  improve and check National Quality Benchmarking in Germany Source: Christof Veit, “The Structured Dialog: National Quality Benchmarking in Germany,” Presentation at AcademyHealth Annual Research Meeting, June 2006.

  17. German Hospital Quality Improvement Hamburg: Antibiotic Prophylaxes in Hip-Replacement. 2003: 95,6% 2004: 98,5% 2005: 99,3% % Hospitals Source: Christof Veit, “The Structured Dialog: National Quality Benchmarking in Germany,” Presentation at AcademyHealth Annual Research Meeting, June 2006.

  18. Improve Quality Transparency: The Netherlands Death-rate after stroke in bottom-20 hospitals • Collect comparative data: (quality indicators) • Inspectorate examines care providers with different quality indicators • Make quality differences visible through the internet Source: Hans Hoogervorst, Minister of Health, Netherlands,, “A Vision for Health Care in the 21st Century,” Presentation to the Commonwealth Fund International Symposium, November 2, 2006.

  19. The Impact of Public Reporting:the U.S. NCQA Experience • Ten years of measuring data: measurement and public reporting leads to improvement: • U.S. children today nearly three times more likely to have had all immunizations as in 1997 • U.S. diabetics today twice as likely to have cholesterol controlled (<130 mg/dL) as in 1998 • More than 96% of U.S. cardiac patients prescribed beta-blockers after a heart attack (up from 62% in 1997); NCQA retired the beta-blocker/post hospital measure this year* BETA-BLOCKER TREATMENT AFTER A HEART ATTACK Score = 97 2005 Score = 71 1996 Source: National Committee for Quality Assurance; *Thomas Lee, “Eulogy for a Quality Measure,” New England Journal of Medicine, September 20, 2007.

  20. Aiming High: Future Directions? • Critical role of public information and analysis to guide and drive change • AHRQ potential • Public repository and public data • Composites and benchmarks: enable focus on variation, high/low performance areas and care systems • Quality, access and cost analysis: High Value • Research and collaboration • Linking quality-related research to performance indicators • “E-indicators”: potential with electronic health records* • Collaborative efforts to understand key drivers of high performance • Whole system view: primary and specialized care *Commonwealth Fund/RWJF project with Jinnet Fowles, Park Nicollet and Jonathan Weiner, Johns Hopkins.

  21. Related Commonwealth Fund Reports and Newsletters REPORTS: • Why Not the Best? Results from a National Scorecard on U.S. Health System Performance (Sept. 20, 2006). The Commonwealth Fund Commission on a High Performance Health System. • Aiming Higher: Results from a State Scorecard on Health System Performance (June 13, 2007). The Commonwealth Fund Commission on a High Performance Health System. NEWLETTERS • Quality Matters • States in Action Download at: www.commonwealthfund.org/publications/

  22. Thank You! Acknowledgments Karen Davis, President kd@cmwf.org Stephen Schoenbaum, M.D., Executive Vice President and Executive Director, Commission on a High Performance Health System scs@cmwf.org Tony Shih, M.D., Senior Program Officer for Quality Improvement and Efficiency ts@cmwf.org Sabrina How, Senior Research Associate skh@cmwf.org

  23. Visit the Fund’s website atwww.commonwealthfund.org

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