1999 CAS Seminar on Health and Managed Care Hilton Head Island, SC October 18-19, 1999

1. 1999 CAS Seminar onHealth and Managed CareHilton Head Island, SCOctober 18-19, 1999

2. Intro - Shevlin Benchmarking Measures and Quality ControlHilton Head Island, SCOctober 18-19, 1999

3. Overview on Healthcare Benchmarks • What? • Why? • Examples • Sources • Classifications • Planning • Limitations • Analysis • Application • Discussion

4. Healthcare Benchmarks- What are they? - • “Gold standards”; target results • Easily and reproducibly measured • Pertaining to Financial or Clinical Outcomes • Typically involve ratios

5. Healthcare Benchmarks- Why Do We Need Them? - • Used for Comparison and Quality Improvement • “If you cannot measure, you cannot improve” • To provide objective measures that will drive performance to a new level of excellence

6. Healthcare Benchmarks- Why Do We Need Them Today? - History of Efforts in Healthcare Quality • Early years - physician esteem/ethics/peers • 1980s - Utilization Management (UM) • 1990s - Case/Care Management • Now - Disease/Health Management

7. Healthcare Benchmarks- Why Do We Need Them? - • Apply evidence-based medicine • Establish “Best Practice” • Monitoring results: “Report Cards” • Target “Intervention Strategies” • Establish Value

8. Healthcare Benchmarks- Why Do We Need Them? - Improving healthcare: • Services • Process • Outcomes • Resources

9. Healthcare Benchmarks- Clinical Examples - • Mortality - Unequivocal? • - Clinical v.s. cost implication • - Certain diseases and surgeries • - Must be severity risk adjusted • Morbidity - Tests (lab) • - Vitals signs • - Physical findings (disease classes) • - Trends • - Manual records extraction is expensive

10. Healthcare Benchmarks- Clinical Examples - • Prevention • Primary • - Screenings/Immunizations • Secondary • - Drugs/Services • Clinical Guidelines • - Diagnostics/Therapeutics • - Inappropriate • Complications • - Medical/Surgical

11. Healthcare Benchmarks- Other Examples - • Financials - Dollars • - Resources • Perception / Satisfaction / Patient Self-Assessment • - Functional status • - Access to care • - Waiting times, time to return calls • - Quality of life • - In areas of concern to the patient • Proxy Measures - Length of stay • - Number of visits/services/readmissions

12. Asthma Intro - Shevlin

13. Healthcare Benchmarks- Sources: for Data - • Medical & pharmacy claims data • Laboratory data • Electronic medical records • Hospital information systems • Utilization review & incident reports • Surveys & direct observation • Proxy Measures: LOS, visits (billing)

14. Healthcare Benchmarks- Sources: Market Characteristics - % Cost % Claims

15. Healthcare Benchmarks- Sources: Accreditation/Measurements - Drivers • Purchasers • Comparatives among suppliers • Financial and quality objectives • Lacking knowledge and/or resource for measures and outcomes

16. Healthcare Benchmarks- Sources: The Accreditation Industry - • Organizations • The “Joint Commission” on Accreditation of Healthcare Organizations (JCAHO) • National Committee for Quality Assurance (NCQA) • Accreditation Association for Ambulatory Health Care (AAAHC) • Utilization Review Accreditation Commission (URAC)

17. Healthcare Benchmarks- Sources: The Measurement Industry - Organizations • Foundation for Accountability (FACCT) • University of Wisconsin • University of California • Association for Healthcare and Policy Research (AHCPR)

18. Healthcare Benchmarks- Sources - Review • Customers care about “value” • Suppliers care about customers • Third parties make it happen

19. Healthcare Benchmarks- Classifications - • Codes • ICD • CPT • DRG • Groupers • MDCs • ACGs • DCGs

20. Healthcare Benchmarks- Planning: Choosing the Right Ones - • Relevant Outcomes (desirable or not) • Measurable (reproducibly) • Impact Sensitive • Achievable • Return on Investment

21. Healthcare Benchmarks- Planning: Achievability - • Time Requirements • Volume Requirements • Scope Management • Buy-In • Realistic, Incremental Goals

22. Healthcare Benchmarks- Planning: Controls - • General • Case matched • Temporal issues • Internal • Most similar • Randomized • External • Availability/Quality • Industry ‘Best Practice’ • Improvement priorities • Historical perspective

23. Don’t Forget to Plan Don’t Forget to Update Intro - Shevlin

24. Healthcare Benchmarks- Planning: Reevaluation - • Regularly (annually) • New measurement or coding procedures • New technology or diagnostics • New therapeutic modalities or interventions

25. Healthcare Benchmarks- Data Limitations - • Population drift/differences • Environmental issues • Collection process/irregularity • Storage process/irregularity • Integrity indicators

26. Healthcare Benchmarks- Analysis - • Data limitations • Barriers • Be suspicious • Skewed or broken axes • Missing data • Sub-populations • Undisclosed methods

27. Healthcare Benchmarks- Application: How to make it work - • Physicians do not need more medical school • Practice Guidelines and Outcomes Data • Benchmarks and Peer Profiling • Physicians do not like to be outliers • Physicians are uncomfortable with change

28. “If You Can Not Measure, You Can Not Improve” Intro - Shevlin