Perfect Care

1. Perfect Care • When is performance good enough? • For you; for your family • Near-perfection is attainable even in health care • The question we all should be asking: • How soon can we achieve perfect care? • Within our organization • Across the entire health care system

2. An Organized Delivery System that Emphasizes Primary and Preventive Care and Is Patient-Centered 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements

3. Expand Primary Care and Preventive Services • Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care. • Barbara Starfield, MD

4. Expand Primary Care and Preventive Services • Health is better in areas where there are more primary care physicians or more primary care services • People who receive care from a primary care physician are healthier • Costs of care are lower in areas where there are more primary care physicians or more primary care services • More primary care is associated with more equitable care Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.

7. Shared Decision-Making:An Important Aspect of Patient-Centered Care

8. Why Is Shared Decision Making Important • Combines evidence-based practice with patient preferences • Many clinical decisions involve value judgments • Interventions have different benefits/ risks that patients value differently • There is no single right answer for everyone • Ethical principle of patient autonomy and legal requirement of informed consent • Health care providers cannot automatically infer what patients value, nor can they assume what care decisions are in patients' best interest. • Uncertain nature of clinical information

9. Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center • Provides evidence-based tools to help patients understand trade-offs of medical vs. surgical treatment given their preferences • Assists with health care decisions (e.g., videotapes, booklets, websites) • Provides follow-up counseling with skilled staff • Generally results in lower rates of invasive procedures once the patient understands the trade-offs Kate Clay, BA, MSN, Program Director

10. Being There For The Patient • The importance of continuity • “After-hours” care

11. Practice Has Arrangement for After-Hours Care to See Nurse/Doctor Percent 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

12. Increase Transparency and Reporting on Quality and Costs 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 4. Increase Transparency and Reporting on Quality and Costs

13. NCQA/HEDIS Experience • Ten years of measuring data has shown that measurement and public reporting leads to improvement: • Children today nearly three times more likely to have had all immunizations as in 1997 • Diabetics today twice as likely to have cholesterol controlled (<130 mg/dL) as in 1998 • More than 96% of cardiac patients prescribed bet-blockers after a heart attack (up from 62% in 1997) Source: NCQA, “The State of Health Care Quality 2006,” 2006.

14. Improvements in Use of Beta BlockersAfter a Heart Attack Source: National Committee for Quality Assurance, TheState of Health Care Quality: 2006, Washington, D.C.: NCQA, 2006.

15. Expand the Use of Interoperable Information Technology 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs

16. Electronic Medical Records and Information Systems • Reduce duplicate tests • Reduce hospital admissions by having information accessible to emergency room physicians • Improve patient care • Provide decision support for physicians and patients • Facilitate “referrals,” secure transfer of responsibility • Reduce medical errors • Promote better management of chronic conditions and care coordination • Registries • Performance information • Facilitated by interoperability

17. Over 80% Medication Errors Prevented with Computerized Order Entry System Source: Adapted with permission from D.W. Bates et . al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.

18. U.S. Adoption of Health Information Technology Source: Presentation by Ashish Jha. “Health IT Adoption: a cross-national comparison.” June 26, 2006.

19. Primary Care Practices with Advanced Information Capacity Percent reporting 7 or more out of 14 functions* *Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care. Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

20. Network Prescriptions 1289023 = 87% GP´s with EDI : 2150 = 98 % Specialists with EDI: 639 = 80 % Hospitals with EDI : 63 = 100% Pharmacies with EDI: 331 = 100 % Doctors on Call : 15 = 100 % Health Insurance : 17 = 100 % 79 messages /min Referrals Referrals Referrals Referrals 115597 = 60 % Reimbursement 21049 = 92 % THE COMMONWEALTH FUND MedCom – The Danish Health Data Network Prescriptions 1039105 = 73% Disch Disch . Letters . Letters 682923 = 85 % 1054314 = 88 % Lab. Lab. reports reports 844528 = 98 % 543040 = 82 % Lab Requests 44385 = 15 % Source: I. Johansen, “What Makes a High Performance Health Care System and How Do We Get There? Denmark,” Presentation to the Commonwealth Fund International Symposium, November 3, 2006.

21. Reward Performance for Quality and Efficiency 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 6. Reward Performance for Quality and Efficiency

22. Medicare/Premier Hospital Quality P4P Demonstration • First year results showed significant improvement; composite score increased – • AMI: 87% to 91% • Heart Failure: 65% to 74% • Pneumonia: 69% to 79% • CABG: 85% to 90% • Hip/knee replacement: 85% to 90% • Patients receiving better care showed lower mortality (AMI, CHF) • Cost savings for hospitals (AMI, Pneumonia, CABG, Hip/Knee) and Medicare

23. Primary Care Doctors’ Reports of Any Financial Incentives Targeted on Quality of Care Percent reporting any financial incentive* *Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

24. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 3. Emphasize Primary, Preventive, and Patient-Centered Care 1. Guarantee Affordable Health Insurance Coverage 2. Implement Major Quality and Safety Improvements 7. Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change 5. Expand the Use of Interoperable Information Technology 4. Increase Transparency and Reporting on Quality and Costs 6. Reward Performance for Quality and Efficiency

25. There Has To Be Leadership • Federal laggership • Collaborating public-private groups can lead • IHA (California) • MHQP (Massachusetts) • HQA, AQA • IHI’s new 5 million lives campaign

26. IHA (Integrated Healthcare Association) - California • Collaboration of multiple stakeholders with a neutral convener • Purchasers – Pacific Business Group on Health • California Association of Physician Groups (225) • California health plans (7) • Consumer Groups • State of California Department of Managed Health Care & Office of the Patient Advocate • California HealthCare Foundation – Rewarding Results grant • NCQA (National Committee on Quality Assurance)

27. IHA - California Agreement on measures (technical quality, patient experience, use of health information technology) • Competitive stakeholders can collaborate on aligning incentives Agreement to tie P4P to the common measures; but no attempt to agree on payment formulae Results • Year over year improvement • Scatter in performance • This isn’t sufficient to achieve perfection

28. Massachusetts Health Quality Partners (MHQP) • MHQP • A broad-based coalition of physicians, hospitals, health plans, purchasers, and government agencies • Seeks to improve health care through collaboration among all stakeholders • Common quality agenda, including shared guidelines and tools, as well as becoming a source for comparative health quality information • Public Reporting • In 2006, started Medical Group level reporting of 15 quality measures and patient satisfaction measures • Moving forward, will incorporate Medicare/Medicaid data (designated as one of the 6 Ambulatory Quality Alliance pilots) • Beginning to explore new efficiency measures and their role in public reporting

29. Achieving a High Performance Health System: What You Can Do

30. What You Must Do • Take An Active Role In Improving Your Own Care • Take An Active Role In Improving Care In Your Health System • See The Positive Side To Change • What We All Must Stop Doing • Protect Our Turf (there is still a lot of turf to go around)

31. Achieving a High Performance Health System: What You Can Do • Advocate for affordable health insurance for all • Establish and publicize policy on discounted care for uninsured and low-income • Invest in chronic care improvement, transitional care • Share and help spread best practices; join collaboratives to implement proven quality and patient safety measures • Improve patient-centered care; survey and respond to patient concerns • Support transparency; public reporting of clinical quality, patient-centered care, and efficiency • Accelerate adoption of IT; ensure patient access to an integrated personal health record • Participate in demonstrations that reward high quality and efficient care; be actively involved in design of incentivized payment systems • Consider options for better coordination and integration of care delivery; shared accountability for patient care through physician-hospital organizations; accountable medical homes

32. Thank You! Karen Davis, President, The Commonwealth Fund Anne Gauthier, Senior Policy Director, Commission on a High Performance Health System, The Commonwealth Fund Tony Shih, MD, Senior Program Officer, Quality Improvement and Efficiency, The Commonwealth Fund Elizabeth Sturla, Executive Assistant, The Commonwealth Fund

33. Visit the Fundwww.cmwf.org