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.
5
(No Transcript)
6
(No Transcript)
7
Shared Decision-MakingAn 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 (lt130 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,
The State 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
MedCom The Danish Health Data Network
Prescriptions
1039105 73
Disch
. Letters
Disch
. Letters
682923 85
1054314 88
Lab.
reports
Lab.
reports
543040 82
844528 98
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
• IHIs 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 isnt 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