Measuring What Counts

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Measuring What Counts - AND - Making it Count
for Quality
Constance Horgan Brandeis University Panel on
Quality and Financing of Co-Occurring
Services Complexities of Co-Occurring Conditions
Conference Washington, DC June 24, 2004
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Overview of Presentation

• Background on quality and performance measurement
• Measuring performance
• Using performance measures the role of
  stakeholders

3
Historical Perspective

• 1930-1960
• Physicians defined quality
• 1970s
• Cost containment focus
• 1980s
• Rise of managed care
• 1990s
• Debate over legislating standards for managed
  care organizations
• Emergence of organizations focused on quality
  NCQA, FAaCt
• Standardized measurement approaches

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Historical Perspective (continued)

• 2000
• Influential Institute of Medicine Report
  Crossing the Quality Chasm A New Health System
  for the 21st Century (2001)
• National Initiatives (e.g. National Quality Forum
  , National Quality Measures Clearinghouse)
• Continued development of quality report cards
  nationally (e.g. NCQA) and at state level (e.g.
  New York State Health Accountability Foundation)
• New approaches to quality measurement with
  multiple data sources and at provider or provider
  group level
• Use of incentives to providers to improve quality

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What is Performance Measurement?

• Health care performance measurement is the
  process of using a tool based on research
  (performance measure) to evaluate a managed care
  plan, health plan or program, hospital, or health
  care practitioner
• Performance implies that the responsible health
  care providing entity can be identified, held
  accountable, has control over the aspect of care
  being evaluated.

Source Understanding Performance Measurement
www/ahcpr.gov/chtoolbx
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Classic Framework for Quality Measures

• Structure
• Access
• Process
• Outcomes
• Patient Experience

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Data Sources

• Claims/Encounter Data
• 2. Patient Surveys
• 3. Medical Record

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So How Are We Doing?

• Percentage of Recommended Care Received
• Alcohol Dependence 10.5
  
• (5 indicators)
• Depression
  57.7
• (14 indicators)
• Total all conditions 54.9
• Source McGlynn et el, NEJM (2003)

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Selected Behavioral Health Initiatives

• New IOM study Crossing the Quality Chasm
  
• An Adaptation to Mental Health and Addictive
• Disorders
• Join Together National Policy Panel
• Rewarding Results
• SAMHSA e.g. National Registry of Effective
• Programs (NREP), Performance Partnerships
• The Forum on Performance Measurement
• Washington Circle

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Measuring Performance The Case of
Washington Circle

• Develop a core set of performance measures for
  substance abuse treatment for public and
  private-sector health plans
• Collaborate with a broad range of stakeholders to
  ensure widespread adoption of substance abuse
  performance measures by private employers, public
  payers and accrediting organizations

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Washington Circle Performance Measures
(see www.washingtoncircle.org)
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Three Administrative Measures

• Identification Rates -- Percent of adult
  enrollees with an AOD claim, defined as
  containing a diagnosis of AOD abuse or dependence
  or a specific AOD-related service, on an annual
  basis.
• Initiation of Plan-Provided Substance Abuse
  Services -- Percent of adults with an inpatient
  AOD admission or with an outpatient claim for AOD
  abuse or dependence and any additional AOD
  services within 14 days.
• Treatment Engagement -- Percent of adults
  diagnosed with AOD disorders that receive two
  additional AOD services within 30 days of the
  initiation of care.

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Washington Circle Testing Results

• Identification is extremely low (0.46-1.45)
• Drop off is high
• Initiation (26-46)
• Engagement (14-19)

Source Garnick et al (2002)
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Distribution of Adult SA/MH Claimants by Type of
Diagnoses
Mental Health
Alcohol and Other Drugs
4,183 (2.7)
147,620 (95.0)
3,550 (2.3)
Note Percents are of all 155,353 claimants with
any behavioral health services. Source Medstat.
2001 MarketScan
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Adult Enrollees with SA or MH diagnoses receive
services from both specialty and medical
providers.
Source Medstat, 2001 MarketScan
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Challenges to Performance Measures for
Co-Occurring Conditions

• Co-occurring represents a substantial proportion
  
• of substance abuse claimants
• Substantial proportion of co-occurring claimants
  
• use both medical and specialty setting
• If specialty, is it mental health or substance
  abuse
• setting?

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Making Performance Measures Count the role of
stakeholders

• Purchasers
• Health Plans
• Clinicians/Provider Group
• Consumers
• Policy Makers
• Researchers

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Call for Action

• Recommendation 10 Crossing the Quality Chasm
• Private and public purchasers should examine
  their current payment methods to build in
  stronger incentives for quality enhancements.

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Purchasers

• Use performance measures in contracting
  requirements
• Work with health plans to improve performance
  measure scores
• Seek plans that have higher adherence to
  performance measures
• Pay physician groups for achieving certain goals

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Conclusion

• Measure what counts, BUT having a measure is not
  sufficient
• How measures are used is key, SO seek solutions
  from multiple stakeholders