Achieving Quality and Affordability

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Achieving Quality and Affordability

• William Rollow, MD MPH
• Deputy Director, Quality Improvement Group
• Centers for Medicare Medicaid Services
• May 15, 2003

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1970s View of US Healthcare Issues

• Excellent care, but
• Costly
• Treatment- rather than prevention- oriented
• Inequitably distributed

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Todays View of Quality

• Exhaustive research documents that today, in
  America, there is no guarantee that any
  individual will receive high-quality care for any
  particular health problem.
• Advisory Commission on Consumer Protection and
  Quality, 1998

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More

• Americans should be able to count on receiving
  care that meets their needs and is based on the
  best scientific knowledge. Yet there is strong
  evidence that this is frequently not the case.
• Institute of Medicine, 2001

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1990s Strategies For Managing Cost

• Capitation/alternate payment models
• Price control
• Utilization management

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Managed Care Premium/Cost Increases
Figure 1 Premium versus Cost Increases   Source
Salomon Smith Barney Research estimates based on
data from CMS, Milliman USA, AAHP, and KPMG. As
of February 27, 2003.  
Source Salomon Smith Barney Research estimates
based on data from CMS, Milliman USA, AAHP, and
KPMG. As of February 27, 2003.
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2000s Strategies For Managing Cost

• Improve effectiveness/efficiency
• Disease management
• Quality Improvement
• Mitigate technology and preference drivers
• Evidence-based coverage decisions and payment
  determinations
• Shared cost responsibility
• Shared decision-making

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Disease Management Strategies

• Identify patients with chronic illness
• Make disease-specific information available to
  the patient
• Interactively support patients in self-management
• Prompt patients to obtain services based on a
  regular schedule or as needed in relation to
  outcomes
• Prompt physicians to implement a medical regimen
  which is consistent with best practice

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Approaches to Disease Management

• Vendor-based
• Physician-based
• Mixed

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Typical Vendor-Based Approach

• Analysis of medical and pharmacy claims, often
  supplemented with information requested from a
  physician office or from the patient, to identify
  and risk-stratify patients with chronic illness
• Provision of newsletters, brochures, etc via
  regular mail or email with disease information
• Provision of reminders regarding services needed
  to a physician office or to the patient, via
  written or telephonic communication
• Telephonic, or sometimes internet-based,
  interaction with a patient on how to better
  self-manage diet, exercise, meds, etc
• Written or telephonic communication with a
  physician regarding medical regimen when there
  are opportunities for improvement

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Disadvantages

• Cost reduction
• Still a research question
• Selected diseases
• Savings largely offset by vendor cost
• One-time impact on trend no long term creation
  of ongoing efficiencies
• Impact on physician office
• Additional work without reward
• Multiple vendors, each with a different approach
• Does not improve care process
• Impact on patients
• Generally look to the physician for direction
• Multiple sources of information conflicting
  vendor messages and external sources

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Physician-Based Approach

• The office builds its own database (through
  registry or EHR) for identification and
  management of patients
• The database offers decision support (reminders,
  evidence-based options, etc) available to the
  practitioner during the office visit and which
  also generates reminders which are pushed out via
  regular or email
• Interactive support is provided by a member of
  the physician office staff, by referral to
  specialists or community resources, or online
• Performance is assessed systematically by reports
  generated by the database for use in improvement
  and external reporting

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Mixed Approach

• Recruit as many physicians as possible to
  implement systems and redesign care process to
  improve quality/efficiency and provide disease
  management
• Seek to improve physician office care by
  providing feedback to the physician on how well
  care corresponds to guidelines, and offering
  assistance in improvement
• Supplement physician office-based disease
  management as needed with vendor-based activity
• Reduce as much as possible the complexity of
  multiple vendors and sources of information
• Engage patients in disease management through
  invitation by the physician office and route
  communications to the patient as much as possible
  through the physician office
• Reimburse physicians for participation in such
  programs

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Disease Management Demonstration Projects

• BIPA determine impact of dm/drugs vendor and
  provider/etc -based in 3 geographic areas
• Case Management impact in N Mexico
• Coordinated care 15 sites, provider- and
  vendor- based
• PGP 6 physician groups will be selected

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Quality Improvement

• Improve process
• Better clinical outcomes
• Better patient experience
• Efficiency through elimination of non-value-added
  process and rework

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Medicares Quality Improvement Organizations

• Previously known as the Peer Review Organizations
  (PROs)
• Mission to improve quality of care for Medicare
  beneficiaries
• 1 billion budget for current 3-year contract
• 53 QIOs 1 in each state
• Confidentiality of information assured by statute

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QIO Program 7th SOW

• Clinical quality improvement/information
  promotion
• Nursing homes publicly reported measures
• Home health publicly reported measures
• Hospitals measures in voluntary public
  reporting pilot
• Physician offices
• Disparities
• Beneficiary protection
• Complaints
• Hospital payment monitoring
• Appeals/EMTALA

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NHQI Quality Measures
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HHQI Publicly Reported Measures

• Acute Care Hospitalization
• Improvement in Ambulation/Locomotion
• Improvement in Bathing
• Improvement in Management of Oral Medications
• Improvement in Transferring
• Improvement in Upper Body Dressing
• Improvement in Toileting
• Improvement in Pain Interfering with Activity
• Stabilization in bathing
• Improvement in Confusion Frequency
• Any Emergent Care Provided

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Improving Care in Hospitals 7th SOW MI Measures
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HEDIS Quality CompassBeta Blocker/MI Rate
Commercial Plans
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Improving Care in Hospitals7th SOW CHF Measures
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Improving Care in Hospitals 7th SOW Pneumonia
Measures
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Improving Care in Physician Offices 7th SOW
Preventive Measures
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HEDIS Quality CompassMammography Rate
Commercial Plans
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Improving Care in Physician Offices 7th SOW
Diabetes Measures
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HEDIS Quality CompassDiabetic Eye Exam Rate -
Commercial Plans
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HEDIS Quality CompassHbA1c Exam Rate -
Commercial Plans
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How Successful Has QI Been?

• Impact on quality
• Menu of measures is limited and not
  patient-focused
• At current rate of improvement, will be 2020
  before we reach 95 performance level for QIO
  measures
• Most providers/practitioners only work on a
  limited number of measures/topics
• Most practitioners are skeptical/resistant
• Impact on cost

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What Has Limited the Impact of QI?

• On quality
• Process changes have been largely within existing
  systems
• Provider/practitioner buy-in has been limited
• On cost
• Effect overwhelmed by other cost drivers new
  technology, patient demand, practitioner
  preferences, supply

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How Can Improvement Accelerate and Widen?

• Promote adoption of transformative systems and
  care model, such as eRx, eLab, eCare reminders,
  EHR, PHR, health information exchange
• Increase motivation of providers and
  practitioners to improve and adopt such systems
  and care models

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Rationale E-Prescribing

• Medication errors are common, affecting as many
  as 9 of prescriptions. E-prescribing systems
  have the potential to improve quality and safety
  by
• Eliminating legibility problems
• Reducing the occurrence of drug interactions,
  dosage errors, and other adverse effects by
  guiding prescribing based on patient age, weight,
  allergies, lab results, diagnoses and concurrent
  medications

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Rationale E-Laboratory Mgmt

• Lab results-related errors are common. E-lab
  results management systems have the potential to
  improve quality and safety by
• Making a practitioner aware if lab test results
  which have been received have not been reviewed
• Reducing unnecessary test ordering by giving a
  practitioner easier access to previous lab test
  results

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Rationale E-Care Reminders

• Preventive services, or services recommended for
  chronic conditions, are underutilized. E-care
  reminder systems have the potential to improve
  quality and safety by
• Prompting a practitioner to remind a patient to
  make an office visit
• Prompting a practitioner to remind a patient to
  obtain needed lab tests or other services
• Identifying patients in need of special
  monitoring or services

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How Can Improvement Accelerate and Widen?

• Promote adoption of transformative systems and
  care model eRx, eLab, eCare reminders, EHR,
  PHR, health information exchange
• Promote IT standards
• Promote systems availability, affordability,
  functionality
• Support redesign of care processes
• Increase motivation of providers/practitioners to
  improve and adopt such systems and care models

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Promote IT Standards

• Need IT standards to assure that systems can
  exchange information and that newer systems can
  extract information from those they replace
• Consolidated Health Informatics group (HHS, VA,
  DOD) is adopting standards for federal agencies
  and recommending their use in private sector
• First set of standards has been adopted in the
  areas of lab test results, imaging,
  prescriptions, devices, and data transmission

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Promote Systems Availability

• Need availability of high quality, affordable
  systems
• EHRs
• e-Rx, e-Lab, e-Reminder systems

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Promote Redesign of Care Processes

• Chronic care model
• Idealized design project

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Increase Motivation of Providers/Practitioners

• Confidential results reporting electronic data
• Public reporting electronic data
• CME
• Malpractice premium reduction
• Financial incentives - payor and patient
• Billing/participation requirements burden
  reduction
• QI projects inconsistency reduction

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Opportunities for Improvement Payors/MCOs and
QIOs

• Providers/practitioners want consistency in
  interventions
• Performance measures should be consistent
  across payors and ideally should come from
  electronically available information generated by
  the provider/practitioner
• Guidelines/tools/improvement assistance should be
  consistent across payors

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Arizona Managed Care Quality Enhancement Program

• 19 MCOs, the QIO, practice groups
• Diabetes collaborative
• Consistent measures at practice level
• Aiming at unified data collection
• Common interventions
• Flowsheet
• Member information

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Doctors Office Quality (DOQ) Project

• Topics Preventive care, DM, HTN, CAD, CHF,
  Osteoarthritis, Depression
• Measures
• Clinical developed with expert panel
• Patient experience
• Process improvements
• Care reminders
• Other

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Achieving Quality and Affordability

• Some cost is driven by rework (complications,
  unnecessary exacerbations) and inefficiency
• Improve effectiveness/efficiency of care through
  QI/disease management
• Enhance patient self-management
• Get provider participation by public reporting
  and financial incentives (can be linked)

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Achieving Quality and Affordability

• Some cost is driven by supply, technology, and
  physician preference
• Evidence based coverage decisions and payment
  rules
• Enrollee cost-sharing and information which
  supports use of benefits
• Shared decision-making