Report Cards, P4P, EMRs, and Disease Management

1. Report Cards, P4P, EMRs, and Disease Management An Analysis of Managed Care 2.0

2. The debate about quality has been corrupted in two ways • Quality problems have been exaggerated; this is usually accomplished by confusing inferior quality with access barriers. • Discussion of QI has been limited to those activities which plans can conduct (e.g., financial incentives, report cards). QI which leaves out plans (e.g., public health, ending the nurse shortage) gets less attention.

3. Example of exaggeration of the quality problem “Extensive research has documented that all three forms of clinical quality problems – underuse, overuse, and misuse – are ubiquitous in American medicine….” (p. 166). Elise C. Becher and Mark R. Chassin, “Improving the quality of health care: Who will lead?” Health Affairs 2001;20(5):164-179, 166.

4. Becher and Chassin offered this proof of “ubiquitous” inferior quality • A 1998 Rand literature review finding 30-40% underuse and 20-30% overuse, and malpractice studies finding, 1% misuse. • But a far more extensive Rand study (2003) found 46% underuse and 11% overuse. • Overuse and misuse obviously involve provider error. But underuse may not.

5. Rand reported 46% underuse and 11% overuse But Rand made no attempt to determine what caused underuse and overuse. Examples of Rand findings for diabetics: * 24% had A1c measured every six months; * 14% had annual eye exam; * 23% had urine protein checked annually; * 56% received dietary and exercise counseling; * 45% had follow-up visit every six months.

6. Researchers ignored underuse until late 1990s “Most health services research to date has been directed at identifying and reducing excessive utilization. Little attention has been given to underuse of care.” Two scholars at the RAND Corporation (R. L. Kravitz and M. Laouri, “Measuring and averting underuse of necessary cardiac procedures: A summary of results and future directions,” Joint Commission Journal on Quality Improvement 1997;23:268-76).

7. Example of misuse of the 2003 Rand study (conflating quality and access) “[D]espite the extensive investment in developing clinical guidelines, most clinicians do not routinely integrate them into their practices. In a recent study of US adults, Elizabeth McGlynn and colleagues found that more than half did not receive the recommended … care….” Dan Mendelson and Tanisha V. Carino, “Evidence-based medicine in the United States: De rigueur or dream deferred?” Health Affairs 2005;24:133-136, 134.

8. Another example of the misuse of the Rand study “Research has shown that physicians incorporate the latest medical evidence into their treatment decisions 50 percent of the time (McGlynn et al, 2003).” US Department of Health and Human Services, Office of National Coordinator for Health Information Technology, The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care, July 21, 2004, 3.

9. Another example of misuse of the Rand study “Physicians deliver recommended care only about half of the time….” (citing McGlynn et al.) Richard Hillestad et al., “Can electronic medical record systems transform health care? Potential health benefits, savings, and costs,” Health Affairs 2005;24:1103, 1110. This article, also by Rand scholars, was funded by the computer industry hailing the benefits of EMRs.

10. Rand facilitated misunderstanding: “our results need no risk adjustment” “We primarily chose measures of processes as indicators, because they represent the activities that clinicians control most directly, [and] because they do not generally require risk adjustment….” Elizabeth McGlynn et al., “The quality of health care delivered to adults in the United States,” New England Journal of Medicine 2003;348:2635-45, 37.

11. Outcome and process measures • Outcome measures reflect changes in patient health. Examples: mortality rates after surgery, cholesterol level, and ability to carry out activities of daily living. • Process measures reflect how well providers comply with standards of care. Examples: percent of children vaccinated, and percent of diabetics given eye exams.

12. Underuse is affected by factors outside physician control • No health insurance or insurance with pre-ex exclusions or out-of-pocket payments; • Other barriers (patient values, low income, illiteracy, immobility, transportation, daycare, change in residence or insurance).

13. Evidence that health insurance affects underuse by diabetics “[A]though an estimated 35 percent of those with health coverage had received a blood glucose test, a cholesterol test, eye exam, foot exam, and influenza vaccination, just 14 percent of those without health coverage received the same set of services.” US GAO, Managing Diabetes: Health Plan Coverage of Services and Supplies, February 2005, 19.

14. Evidence that patient behavior affects process measures • Three-fifths of elderly Medicare beneficiaries who receive an appropriate recommendation for cholecystectomy fail to have it done; • half of insured patients who should, according to a stress test, have an angiogram do not get it; and • a fourth of insured patients who, according to their angiogram, should have angioplasty or bypass surgery receive neither. Sources: SM Asch et al., “Measuring underuse of necessary care among elderly Medicare beneficiaries using inpatient and outpatient claims,” JAMA 2000;284:2325-2333 (cholecystectomy bullet); PP Garg et al., “Understanding individual and small area variation in the underuse of coronary angiography following acute myocardial infarction,” Med Care 2002;40:614-626, and M Laouri et al., “Underuse of coronary angiography: Application of a clinical method,” Int J Qual Health Care 1997;9:15-22 (angiogram bullet); LL Leape et al., “Underuse of cardiac procedures: Do women, ethnic minorities, and the uninsured fail to receive needed revascularization?” Ann Internal Med 1999;130:231-233, and M Laouri et al., “Underuse of coronary revascularization procedures: Application of a clinical method,” J Am Coll Cardiol 1997;29:891-897.

15. Patient refusal has been documented in studies of … • warfarin for atrial fibrillation, • aspirin for heart attack, • hypertension medication, • vaccines for influenza and pneumonia, • blood glucose tests, • colorectal cancer screens, and • radiation therapy for cancer. Sources: SD Weisbord et al., “Is warfarin really underused in patients with atrial fibrillation?” J Gen Intern Med 2001;16:743-749; J O’Neil, “A small step for women’s hearts,” New York Times, February 22, 2005, D6; BS Bloom, “Continuation of initial antihypertensive medication after one year of therapy,” Clin Ther 1998;20:671-681; PR Dexter et al., “Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: A randomized trial,” JAMA 2004;2366-2371; VS Elliott VS, “Researchers call for more diabetes testing,” American Medical News, September 22/29, 2003, 19; LC Walter et al., “Pitfalls of converting practice guidelines into quality measures: Lessons learned from a VA performance measure,” JAMA 2004;291:2466-2470; N Bickel et al., “The quality of early-stage breast cancer care,” Ann Surg 2000;220-224..

16. (Patient refusal cont.) • Patient refusal accounted for 59 percent of the underuse of colorectal cancer screens among Veterans Affairs patients. • At a 2005 meeting of the American Heart Association, investigators reported on a study which found that doctors recommended aspirin on a daily basis to about 95 percent of women who had suffered heart attacks and stroke, but that only 54 percent of the heart-attack patients and 43 percent of the stroke patients complied with the recommendation. Sources: Walter et al., op cit.(colorectal bullet); O’Neil, op cit. (aspirin bullet)

17. Thus, current research permits us to say… • Overuse occurs 11% of the time and • Misuse (malpractice) occurs <1% of the time. • Underuse due to provider failure occurs some unknown percent of the time. • These figures reveal serious problems, but they do not add up to “ubiquitous.”

18. Exaggerating the problem of inferior providers serves insurance industry • Insurance industry has used the picture of inept providers to promote managed care. • QI that does not assume inept providers and/or which insurance companies cannot do – that is, which does not fall under the rubric of “managed care” – gets much less attention.

19. Managed care is not the only way to improve quality Other methods with more substantial evidence to support them include: • Ending the nurse shortage; • ending waiting times for emergency services; • insuring the uninsured and under-insured; • conducting public education campaigns re appropriate medical care and the effects of unhealthy behavior; • rolling back the excesses of managed care; • measuring and sharing performance results privately with providers; • conducting controlled trials and other forms of traditional research to find new treatments and to evaluate the efficacy of existing treatments.

20. Managed care has gone through two stages Managed Care 1.0 relied on * financial incentives (capitation and bonuses), and * utilization review and drug formularies. Managed Care 2.0 relies on * report cards, which facilitate P4P, and * disease management.

21. Definition of terms • Report cards: Any document purporting to measure the quality of care given by particular providers which is used to reward or punish providers. • Pay for performance: Any method of paying providers based on grades on report cards.

22. (Definitions cont.) Report card advocates propose that providers be rewarded and punished by * market forces (plans, employers, and patients avoid low-scoring providers and patronize high-scoring providers), and/or * “pay for performance” (insurers pay low scorers less, high scorers more).

23. DMAA’s definition of DM Activities conducted by third parties that: * Identify people with certain diseases by examining their medical records or claims; * Rely on evidence-based practice guidelines; * Educate patients (may include surveillance); * Measure processes and outcomes and report the results to patients and providers. Source: Disease Management Association ofAmerica http://www.dmaa.org/definition.html, accessed February 9, 2006.

24. Another definition of DM “‘Disease management’ is the latest catchphrase in the ever-evolving American health care spectacle. … [D]isease management is ‘a systematic, population-based approach to identify persons at risk, intervene with specific programs of care, and measure clinical and other outcomes.’” Thomas Bodenheimer, “Disease management – Promises and pitfalls,” New Eng J Med 1999;340:1202-1205, 1202.

25. Report cards are now advocated simultaneously with … • “Interoperable electronic medical records” (EMRs) (aka, regional and national health information networks) and • “Pay-for-performance” methods of reimbursement in order to reward high scorers and punish low scorers.

26. Interoperable EMRs are advocated in order … • To facilitate collection of medical records on all Minnesotans/Americans all the time, and • To “risk adjust” scores on report cards. “Risk adjustment” refers to the process of adjusting scores on report cards to reflect differences in patient health and other factors outside of provider control.

27. In sum, Managed Care 2.0 means … (1) Report cards, which require • interoperable EMRs and • pay-for-performance methods of reimbursement; and (2) Disease management.

28. Managed Care 2.0 appeared in the wake of the failure of MC 1.0 “Events of the past year demonstrate beyond a doubt that managed care has failed – and failed dismally. The greatest single ethical crisis facing American health care as we move into new year is what to do about it.” Art Caplan, director of the Center for Bioethics at the University of Pennsylvania("In 2001, managed care our No. 1 health crisis," MSNBC, December 21, 2001 http://www.msnbc.com/news/671464.asp, accessed December 23, 2001).

29. (Failure of MC 1.0 cont.) “Managed care is basically over. People hate it, and it's no longer controlling costs. Health-care inflation is now back in the double digits. So if it's not saving money, then why should we have it? But like an unembalmed corpse decomposing, dismantling managed care is going to be very messy and very smelly, and take awhile.” George Lundberg, former editor of JAMAwho as recently as 1996 had co-authored an article defending managed care (Linda Marsa, “Former JAMA editor laments the state of medical care,” Los Angeles Times, March 26, 2001, http://www.latimes.com/print/health/200103 26/t000026016.html, accessed March 28, 2001).

30. MUHCC’s position on report cards and pay-for-performance • Quality: Report cards and P4P have not been shown to improve quality, and some research indicates they harm patients. • Cost: Report cards and P4P have not been shown to save money, and may raise costs. • Small-scale report card and P4P experiments should be conducted; report cards P4P should not implemented on a wide scale.

31. MUHCC’s position on EMRs • Quality: EMRs may enhance quality in some clinics and hospitals. Evidence does not support the claim that making EMRs interoperable will improve quality. • Cost: Evidence does not support the claim that EMRs, with or without interoperability, will reduce cost. • Providers should not be required by government, or given financial incentives financed by taxes, to buy EMR hardware and software.

32. MUHCC’s position on disease management • Quality: DM has been shown to improve quality. • Cost: The evidence does not warrant the claim that DM will save money. • Because DM can improve quality, research on effective means of DM should continue, and effective DM programs should be covered by insurance or delivered through public health agencies.

33. Report cards The following slides examine the claims made for report cards, pay-for-performance, and electronic medical records.

34. Governor claims report cards will improve quality, reduce costs “[R]ewarding providers for improved health outcomes and encouraging patients to use the best providers will not only help contain costs, it will improve the quality of care,’ Pawlenty said.”(“Governor Pawlenty unveils ‘Smart Buy’ Alliance to slow health care costs and improve quality,” press release, November 29, 2004, http://www.governor.state.mn.us, accessed November 30, 2004).

35. The Legislature claims report cards improve quality, cut costs Minnesota Statutes Sec. 62J.43, signed by Governor Pawlenty on May 29, 2004, says: “To improve quality and reduce health care costs, state agencies shall encourage the adoption of best practice guidelines…. The commissioner of health shall facilitate access to … quality of care measurement information to providers, purchasers, and consumers by … disseminating information … on adherence to best practices care by physicians and other health care providers….”

36. Governor-Legislature claims rely on three assumptions (1) Report cards improve quality more often than they damage quality; (2) Quality improvements inevitably lead to cost reductions; (3) The cost reductions achieved by report cards will outweigh the cost of producing report cards.

37. There is little evidence that report cards improve quality “Despite … extensive adoption of quality measurement and reporting, little research examines the effect of public reporting on the delivery of health care, and even less examines how report cards may improve care. …[T]he potential … negative consequences of public reporting are largely unexplored.” Rachel M. Werner and David A. Asch, “The unintended consequences of publicly reporting quality information,” JAMA 2005;293:1239-44, 39.

38. Report cards could damage quality three ways (1) By being inaccurate (steering patients to inferior doctors); (2) By inducing doctors to reject sicker patients; (3) By inducing doctors to shift resources from unmeasured to measured patients.

39. Report cards can be accurate for some things, e.g., vacuum cleaners Consumer Reports’ report card onvacuum cleaners: * Offers grades on 38 vacuum cleaners on a five-point scale (from excellent to poor). * 3 quality measures: - cleaning (carpet, bare floors, w/ tools) - other results (ease of use, noise, emissions) - features (bag, brush, manual pile adj, weight) * Kenmore (Sears) got 79 points, Sanyo Performax and Panasonic Fold N’Go got 53

40. But patients are not floors, and doctors are not vacuum cleaners • Comparisons of quality are not useful if the playing field is not level, that is, if the conditions under which quality is measured are not the same. • Keeping the playing field level is much easier to do while measuring the quality of vacuum cleaners than it is while measuring doctors and hospitals.

41. Many factors outside provider control influence health outcomes Factors that influence health outcomes that are outside of provider control include: * Patient health status prior to treatment; * Patient insurance status (presence of deductibles and co-pays; no coverage for service being measured; no coverage at all) * Patient income, education and values.

42. Failure to measure health status affects scores The next slide illustrates how scores on hospitals can be distorted when differences in patient health are measured only crudely. It shows that when “stage of illness” at admission was ignored, 18 of 65 hospital units scored above or below average, but when it was factored in, only 6 scored above or below average.

43. Hospital mortality rates vary depending on “stage of illness” Hospital mortality rates for 13 hospitals and five conditions* under HCFA and Green-Wintfeld Models** Actual Mortality RateHCFA ModelGreen-Wintfeld Model Above expected range 8 2 Within expected range 47 59 Below expected range 10 4 Total 65 65 *Low-risk heart disease, severe acute heart disease, cancer, stroke, and pulmonary disease ** HCFA adjusted mortality rates for only a few of the factors that could have affected patient mortality that were outside hospital control (risk adjustment included age, sex, diagnoses other than the principal diagnosis, number of hospitalizations in the past 12 months, referral source (physician or nursing home), and urgency of admission (emergent, urgent, or elective)). Green-Wintfeld added to the HCFA adjusters an adjustment for “stage of principal diagnosis at admission.”

44. Income affects preventive services for insured patients* “[L]ower SES [socioeconomic status] patients had lower compliance with Pap smears, mammograms, and diabetic eye exams, and were less likely to have a referral or make any office visit…. These income effects are not confined to the poorest patients but span the entire socioeconomic spectrum.” Peter Franks et al., “Effects of patients and physician practice socioeconomic status on the health care of privately insured managed care patients,” Medical Care 2003;41:842-852, 842 * Patients were all insured by the same plan, described as “the largest local managed care organization” in the ten-county area surrounding Rochester, New York.

45. “Quality-of-care” scores for diabetics vary depending on measure of quality (1) LDL cholesterol under 130 73% (2) Measure (1) + doctor has responded to high reading, + patient has contraindications to statins 87% (3) Measures (1) + (2) + other factors* 90% * “Other factors” included: patient refuses to take lipid-lowering medications; lipid management low priority or difficult to address; no primary care visit after high reading; has active care elsewhere; other interventions tried within six months of high reading (diet, exercise, or other lipid-lowering drug). Source: Eve Kerr et al., “Building a better quality measure: Are some patients with ‘poor quality’ actually getting good care?” Medical Care 2003;41:1173-1182.

46. Experts say risk adjustment of report card grades is essential “The interpretation of [medical] outcomes is further complicated by the need to make adjustments for comorbidity and the intensity and state of the patient’s illness – a far from trivial undertaking.” Paul Ellwood(“Outcomes management: A technology of patient experience,” New England Journal of Medicine1988;318:1549-1556). “[T]he importance of co-morbidity must be stressed.... If co-morbidity is not considered, there will always be the potential for individual providers … to be unjustly accused of poor quality because of patient selection….” Richard W. Asinger, MD(“Constructive use of clinical databases,” The Medical Journal of Allina, 1996(1):31-34, 32).

47. (Experts say risk adjustment is essential, cont.) “Case-mix adjustments are made in almost all profile analyses to account for the differences in provider performance attributable solely to differences in the populations served” (p. 764). “Risk adjustments contribute vitally to reducing unfair profile evaluations” (p. 765). Cindy L. Christiansen and Carl N. Morris,“Improving the statistical approach to health care provider profiling,” Ann Intern Med 1997;127:764-768. “Accurate risk adjustment is necessary for observational and health services research, including comparison of outcomes of different treatments and quality assessment.” Jay F. Piccirillo et al., “Prognostic importance of comorbidity in a hospital-based cancer registry,” JAMA 2004;291:24241-47.

48. (Experts say risk adjustment is essential, cont.) “We found that patient characteristics were 315 times more important than hospital characteristics in predicting mortality after simple surgery, so small errors in risk adjustment may loom large compared to hospital differences.” Jeffrey H. Silver and Paul R. Rosenbaum, “A spurious correlation between hospital mortality and complication rates: The importance of severity adjustment,” Medical Care 1997;35;OS77-OS92, Supplement, OS87.

49. Unadjusted report cards damage access for sicker patients “Performance-based contracting gave providers of substance abuse treatment financial incentives to treat less severe OSA [Office of Substance Abuse] clients in order to improve their performance outcomes. Fewer OSA clients with the greatest severity were treated in outpatient programs with the implementation of PBC [performance-based contracting].” Yujing Shen, “Selection incentives in a performance-based contracting system,” Health Services Research 2003;38:535-552, 535.

50. Even risk-adjusted report cards can damage access for sicker diabetics “[We found that] if those physicians with the worst profiles . . . for 1991 managed to discourage the patients with the top 5% of HbA1c levels (representing only 1-3 patients per physician) from returning to their panel, they would in most cases achieve a panel HbA1c profile in 1992 that would be substantially improved than average. . . . . Thus, the patient’s HbA1c levels from the previous year proved a far better predictor of what a patient’s HbA1c level would be in the current year, better than . . . our case-mix adjusters. Manipulating their patient pool, based on a patient’s prior year HbA1c level, is the easiest way for physicians to have a substantial improvement in their profile” Timothy P. Hofer et al., “The unreliability of individual physician ‘report cards’ for assessing the costs and quality of chronic disease,” JAMA, 1999;281:2098-2105, 2103; emphasis added.