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Transparency in health care

Transparency in Health Care Quality What you need to know about public reporting Elizabeth Mort, MD, MPH Vice President Quality & Safety, MGH Associate Chief Medical Officer, MGH Team Leader for Uniform High Quality, Partners HealthCare Inc. Transparency in health care

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Transparency in health care

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  1. Transparency in Health Care QualityWhat you need to know about public reporting Elizabeth Mort, MD, MPHVice President Quality & Safety, MGHAssociate Chief Medical Officer, MGHTeam Leader for Uniform High Quality,Partners HealthCare Inc.

  2. Transparency in health care • Transparency involves being open about what you do, how you do it, and the results that you get. • In health care, transparency encompasses • Clinical quality and safety • Service and access • Pricing and cost • Purpose: • Increase public accountability • Inform consumers’ decision-making • Rationalize resource use (costs) in health care • Inspire providers to improve

  3. Outline • How did we get here? • What information is out there? • A short primer on quality measurement, ranking, tiering • Landmark litigation • Current initiatives in MA • Discussion

  4. How did we get here? • Rising cost of health care • Longstanding problem, now in crisis • Gaps in quality • Striking variation in quality and service delivery • Consumerism • Consumer empowerment driving transparency and accountability • Consumer directed health plans as a new tactic to reduce costs

  5. RISING COSTS 5 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 International Comparison of Spending on Health, 1980-2005 Average spending on healthper capita ($US PPP*) Total expenditures on healthas percent of GDP * PPP=Purchasing Power Parity. Data: OECD Health Data 2007, Version 10/2007. 5

  6. GAPS IN QUALITY 6 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 Mortality Amenable to Health Care Deaths per 100,000 population* * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See report Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

  7. GAPS IN QUALITY 7 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 Recommended Screening & Preventive Care for Adults Percent of adults (ages 18+) who received all recommended screening and preventive care within a specific time frame given their age and sex* U.S. Average U.S. Variation 2005 * Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See report Appendix B for complete description. Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

  8. Emerging models of payment reform: new combinations of old ideas • Incremental reforms such as nonpayment for never events • Primary care payment reform, medical home, tiered case-management fees, capitation • Episode-based payments, global case rates • Shared savings models, providers share in savings, quality monitored • Consumer directed plans Rosenthal MB, NEJM 359;12 Sept 18, 2008

  9. Consumer-directed health plans are emerging • Rationale: patients with more out of pocket expenses will drive more rationale use of resources (hopefully data-driven) • Several varieties • Higher co-payments and deductibles • Health savings accounts • Tax credits • Tiering of physicians • Tiering has been the tactic of choice in MA used by the Group Insurance Commission

  10. “For Your Benefit,” Group Insurance Commission Newsletter, Fall 2008

  11. So, what’s at issue? • “The appropriate way to measure physicians’ (quality and) efficiency is a matter of disagreement between those that pay for (use) health care and those who provide it.” Arnold Milstein, MD Thomas Lee, MD NEJM 357:26 December 27, 2007

  12. Providers worry about… • Poorly designed performance reporting can lead to risk aversion • The risk of misclassifying a physician threatens their reputation and livelihood • There are more effective ways to address cost of care • There are more accurate ways of measuring quality

  13. Consumers and purchasers • Consumers want more information about the quality of care their doctor’s provide • Consumers want more information about the value they are purchasing

  14. Our challenge • Not measuring MD competency in some way is simply not an option • Not controlling costs in some way is simply not an option • Goal this afternoon: • Review the current measurement initiatives • Discuss what we can get behind in terms of assessing the quality of care of MDs

  15. What’s out there?

  16. Sources of MD-specific information • Word of mouth • BORIM physician profiles • Health grade profiles • MHQP profiles • Health plan products tiers • Angie’s list • Vitals.com • Consumers checkbook • Rate MD • Google

  17. BORIM

  18. DPH specialty profiles: CABG

  19. DPH specialty profiles: CABG

  20. http://www.mhqp.org

  21. Healthgrades

  22. Vitals.com

  23. Benefits manager • Husband and wife have just moved to Boston and are employed by the state and covered through the GIC • They’re signing up for a health plan and need access to: Cardiology

  24. What is GIC?

  25. GIC members pick a plan

  26. A short primer on quality measurement Measures of quality and efficiency Physician profiling Tiering methodologies

  27. Defining quality is a challenge • Donabedian: structure, process, outcome • IOM six aims: safe, effective, patient-centered, timely, efficient, equitable • FACCT domains: staying healthy, getting better, living with illness or disability, coping with end of life • Internal vs. External audience

  28. What we need for a good system • Standardized performance measures representing all relevant domains • Access to pt level data • Data verification and auditing • Comparative analyses and reporting Performance Measurement Accelerating Improvement IOM 2007

  29. Health care settings are not equally covered • Hospitals - most mature • Groups - somewhat developed • Provider-level - very spotty • Systems – nascent • Health plans – NCQA led the way • States - spotty • Community - undervalued

  30. Service line coverage is spotty Confidential and Proprietary © March 2008 Sg2

  31. Steps toward transparency: where are we on this steep climb? Confidential and Proprietary © March 2008 Sg2

  32. Meanwhile….on-line tools are proliferating… Source: The Advisory Board Company. Drivers of Consumer Choice Implications from the 2007 Consumer

  33. Loose talk about accuracy • Accuracy of measurement • Reliability • Validity • Misclassification of physicians • Reliability and validity • Cut-off points

  34. Reliability • Reliability speaks to the consistency of a measure • Internal consistency, (Cronbach’s Alpha) usually measured between 0-1.0) • Test-retest • Inter-rater • Reliability is a prerequisite for validity!!!

  35. Validity • Face validity (sounds good) • Content (are all dimensions of the construct measured, assumes this is possible) • Construct (considered with that which is being measured cannot be operationally defined) • Predictive (cholesterol and CAD risk) • Concurrent (high scores on safety culture and low rates of SREs)

  36. Risk of mis-classification Score Significantly below Significantly above 0.7 0.8 0.9 50th percentile Risk of misclassification is low <2.5 % with sample size of 45 and measurement reliability of 0.7 Dana Safran. et al; J Gen Intern Med 20-06; 21:13-21 = area of uncertainty

  37. Efficiency measures • Currently, the majority of efficiency measures rely on the MD as the unit of analysis • Data sources: encounter and claims data • Risk adjustment relies on same source

  38. Efficiency measures • Episode of treatment groupers (ETGs) • Pooled claims data are used to derive the total cost for a particular episode • Care is then attributed to a physician • Physicians average cost is determined for each ETG • Cost per ETG is averaged across all ETGs that relate to that doc • Proprietary

  39. Commentary on ETG validity • We have reason to be concerned Elizabeth McGlynn, PhD Associate Director, RAND Health; Distinguished Chair in Health Quality

  40. Measure cost efficiency via “ETG” methodology Measure quality via HEDIS, etc. Squeeze quality and cost scores from claims data Incent patient and physician behavior via differentials in co-payments Implemented in 2006 Tiering

  41. GIC’s rules for 2008-2011 • Must individually rate MD’s in six specialties Cardiology Endocrinology Orthopedics Gastroenterology Rheumatology OB-GYN • Three tiers for all plans predetermined Tier 1: 20% Tier 2: 65% Tier 3: 15% • Must use GIC’s data • Standardized reports to make the rankings interpretable for the physicians (developed collaboratively with MMS input)

  42. Tufts Navigator (GIC): Tiering Explanation

  43. Tufts Navigator (GIC): Tiering Explanation continued

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