Patient Safety: A Keystone of NCQA’s Value Agenda The Quality Colloquium August 26, 2003 Welcome, thanks for coming Insert Topical message of the day... Those of you who are familiar with the report will notice that it has a new name this year. We’ve changed the title to reflect the fact that we’ve expanded the report--Medicaid and Medicare averages appear for the first time, along with physician-level performance results, which we’ll discuss in a few moments. I’d also like to note that as was the case last year, the expanded academic version of the report (more analysis, more background, more charts), which will be available at our Web site within the next few days. This is a huge annual project, so some acknowledgements are in order: Research & Analysis -- Greg Pawlson Sarah Shih, who really managed the report development process this year. Data Collection -- Pete Frawley Margaret E. O’Kane President

Presentation Overview Who is NCQA? How is NCQA’s agenda evolving? How can we advance patient safety? 2

Private, non-profit health care quality oversight organization Measures and reports on health care quality Unites diverse groups around common goal: improving health care quality Points to mention: NCQA has a wide range of programs relevant to different parts and levels of the system. Core part of our mission is providing information. Much of the information we have is available free of charge on our Web site. We give more of it away free to the media so the HMO report cards you see are usually based on our data. As previously indicated, we build consensus. We believe that it is critical for our programs to reflect the input, needs, desires of all the affected parties. That means consumers, employers, providers, policy makers, health plans, etc. Achieving consensus among these groups is a hallmark of our work and the reason for our success. 3

NCQA’s Programs Quality measurement through HEDIS and CAHPS 2.0H Accreditation of health care organizations Recognition of physicians for quality Reporting to the public, employees and employers, professionals 4

NCQA’s Mission To improve the quality of health care delivered to people everywhere Re: the mission -- “Everywhere” might sound ambitious, but it just indicates that we’re thinking ahead. Right now we’re just in the U.S. . Note: some people think measuring and reporting on quality is our mission, but the truth is that that’s just a means to an end. The end is quality and achieving quality is our mission. Re: the vision -- so how do we achieve our mission? By measuring and reporting and becoming the most widely trusted source of information about HC quality improvement. 5

M.O.: Making Quality Count Quality Measurement Public Reporting Performance-based Accreditation Provider Recognition Pay-for-Performance 6

The Goal: Manage Population Health & Costs How do different product types accomplish this? 20% of people generate 80% of costs Costs and diseases best managed by intervening early Need to identify efficiency at each stage Opportunity to link quality and cost VALUE AGENDA High Risk Early Symptoms Active Disease Healthy/low Risk At-Risk Source: HealthPartners 7

Transparency Drives Improvement Beta-Blocker Treatment Rates, 1996 - 2002 8

Transparency Drives Improvement Much of the system still is not accountable - PPOs, FFS, many HMOs We don’t know what the rates are in these other parts of the system, but evidence indicates that they are probably lower. 9

Recognizing Excellence at the Provider Level Physicians Achieving Recognition ADA/NCQA Diabetes Physician Recognition Program % of adult patients with Participation currently limited to 1800 MDs; Stronger leverage needed 10

We Began With A Quality Agenda In 1990s Large employers looked to HMOs Capitation would control cost Economically motivated underuse was considered the major threat to quality The extent of other quality problems was poorly understood To summarize, we’ve talked about five keys to quality today -- five characteristics that are essential to the “ideal” health care system that’s still out there waiting to be realized. And they’re all interrelated by the way. Those things are: Measurement and reporting -- every organization, institution, group practice and individual physician needs to be tracking their performance on key indicators. The last 22 slides just showed why that is so important. Information -- there’s a big difference between data and information. Doctors need patient specific information about who needs a mammogram, who missed their immunization. Patients need information about their care. Employers need information.… Systems -- There is no doctor in the world that won’t become a better doctor if she works in an environment where there are systems to support her. That’s true because systems can do what an individual cannot -- track and coordinate care from multiple databases, detect contraindications, or simply be familiar with recently updated treatment protocols for any given illness or condition. Every doctor needs those reminder systems, clinical decision support systems... Rewards -- let’s reward quality. It works in every single other sector of the economy. If you reward quality, people compete based on quality and quality gets better. With that I’m going to turn things over to our panel 11

Health Care Cost Increases to Employers (by Percentage), 1988-2002 % Source: 2002 National Survey of Employer-Sponsored Health Plans 12

A Crossroads: Moving from Quality to Value Accreditation and HEDIS are based on an accountable health plan model Demand has shifted the predominant model—in the post-capitation world Future evaluation needs to be based on value and evolve to provider level Patient safety is part of a value agenda 13

We Are At a Crossroads Two Choices Drive a Safety and Do Nothing Value Agenda Measure value and reduce under-use, misuse (unsafe) and overuse Reduce inefficiency and waste Push system to reward safety, effectiveness and efficiency Do Nothing More malpractice and higher payouts Lower payments to providers Fewer insured and more limited coverage for those insured 14

The Reasons for a Value Strategy Are More Compelling Than Ever Costs out of control Quality not what it should be Potential for greater ROI for our health care expenditures 15

Overuse Non-evidence based care Care appropriate under some circumstances, inappropriately applied – wrong patients Inefficient use patterns New HEDIS Measures Appropriate Treatment for Children with URI No antibiotic within first 3 days Appropriate Treatment for Children with Pharyngitis No antibiotic without strep test Other opportunities: use of generic drugs; inappropriate use of imaging; unnecessary surgery 16

Misuse Medication errors (est. cost $9 billion/year) Preventable hospital acquired infections (est. cost $18 billion/year) Poorly executed care (surgical failures, badly read mammograms) Failure to coordinate complex cases Redundant tests Non-value added visits Providers working at cross-purposes 17

How Plans Add Value Directly Indirectly Health promotion DM, risk reduction Shared decision-making Case management Indirectly Steerage to high value providers How do we get there? Standardized information? Information for consumers 18

Opportunities to Add Value Shared decision-making Case management Health Promotion DM, risk reduction High Risk Early Symptoms Active Disease Healthy/low Risk At-Risk Source: HealthPartners 19

NCQA’s Approach to Patient Safety Accredit the health plan for its role in systems that produce safety Encourage the health plan to channel to safer providers Evaluate systems that produce safety at the physician practice level—Physician Office Link 20

1. NCQA Accreditation Standards: The Health Plan’s Role in Safety Pharmaceutical safety: system for checking drug interactions at point of care and alerting providers Management: a QI plan that covers patient safety Management: systems to promote continuity and coordination of care 21

2. Health Plans Channeling to Safer Providers – New Standard First step: collection of information on hospital safety such as Leapfrog Next step: distribution of safety and quality information to health plan members, covering institutions and physicians Future: incentives for members to choose safer, higher quality providers 22

3. Physician Office Link: Safety Systems at the Practice Level Pharmaceutical safety: CPOE Preventing errors of omission: Systems for follow-up of abnormal test results Care Management: Coordination of care for patients with chronic illness and complex problems 23

Some examples of requirements: A registry to track patients with the top 3 chronic diseases treated Evidence-based prompts for treating chronic conditions Decision support embedded in CPOE systems to check drug interactions Patient support for reversing risk factors and managing chronic conditions A process for following up on abnormal test results Use of case management for people with complex, high-risk conditions 24

Safety in the Outpatient Setting: What’s at Stake 1 billion annual ambulatory visits 631 million visits providing medication therapy 3 billion prescriptions dispensed annually from ambulatory care pharmacies 6.2 million ambulatory visits were the result of adverse events in health care Outpatient adverse drug events (ADE) drive one million hospital events per year Other issues – failure to follow up, coordination of care, inadequate informed consent Point out – 3 Billion prescriptions dispensed annually, but only 631 million office visits – dispensing w/o seeing pt can lead to communication gaps “Outpatient” and “Ambulatory” are interchangeable – for consistency, we’ll use “Outpatient” 757 million physician office visits1 25

What Systems Can Accomplish Evidence linking specific system (for example use of registry) to effectiveness and safety Medline and Cochrane Reviews Use of similar audits of practices by several malpractice insurers (COPIC, CRICO) Potential Benefits of Systems Implementation More patients seen-higher revenue Enhanced satisfaction with practice Better outcomes in safety, chronic illness and prevention 26

Malpractice: A Modest Proposal Problem: Debate on malpractice is stuck on issue of caps on damages Regardless of outcome-will not reduce “risk factors” for malpractice or improve patient safety Modest proposal: link willingness to participate in reporting of errors, and implementation of systems for patient safety to use of arbitration in cases of adverse patient outcomes-could be done as state level demonstrations 27