1 Quality of Health Care in the U.S.: How Good Is It & What Have We Learned About How to Improve It? Stephanie Teleki, Ph.D. Cheryl Damberg, Ph.D. Robert Reville, Ph.D. Research Colloquium on Workers’ Compensation Medical Benefit Delivery and Return-to-Work May 1, 2003

2 What Is Health Care Quality? “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” -- Institute of Medicine

3 Key Components of High Quality Health Care  Safe  Effective  Patient-centered  Timely  Efficient  Equitable -- Institute of Medicine, 2001

4 Current State of Health Care Quality in the U.S. At best, care is outstanding  Cutting edge technologies  Innovative pharmaceutical industry  Superbly trained clinicians Often, care is sub-optimal to alarmingly poor

5 Current State of Health Care Quality in the U.S. (continued) Problems are well-documented and widespread  across all regions of U.S.  within states  between cities in the same state or region  in all types of patient populations  in all types of medical specialties  across all types of care delivery systems & settings

6 Problem: Unwarranted Practice Variations Example: Carotid Endarterectomy Carotid Endarterectomy per 1,000 Medicare Enrollees ( ) Napa 5.2 Bakersfield 4.7 Los Angeles 2.7 San Francisco J. Wennberg, 2003

7 Problem: Unwarranted Practice Variations (continued) The bottom line  Geography matters most in terms of the care one is likely to receive, even over medical appropriateness or evidence

8 Problem: Unwarranted Practice Variations (continued) Troubling implications for cost  Medicare study (Fisher et al, 2003)  More is not necessarily better

9 Problem: Overuse About 30% of procedures performed in the U.S. are of questionable health benefit relative to their risks. -- RAND: Schuster, McGlynn, Brook, 1998

10 Problem: Underuse Over 40 million Americans lack health insurance Even with comprehensive coverage, many fail to receive services recommended for  prevention  acute and chronic conditions

11 Problem: Misuse Overall, between 44,000 and 98,000 Americans die each year from medical errors. -- Institute of Medicine, 2000

12 Problem: Patient Dissatisfaction Nationally  problems getting needed care: 15 to 27%  physician only sometimes or never communicated well: 6 to 14% -- CAHPS, 2000 In California  problems with timely access to care: 30%  difficulties getting treatment/specialty care: 30% -- CAS, 2002

13 Quality: Where Are We Today? Acknowledgement that there are serious problems  Widespread  System-wide Mandate for change  Institute of Medicine reports  First National Quality Report in 2003

14 Lessons Learned: #1 In order to improve health care quality, it is necessary to measure it.  It is hard to improve what you don’t know

15 Lessons Learned: #2 Measuring health care quality is a complex task.  Health care  is not a single product  needs to be measured at many different levels  system/structural  patient-provider interaction  end-product/outcome

16 Lessons Learned: #3 Measuring health care quality takes time.  Many organizations involved in quality measurement and improvement; for example  NCQA  AHRQ  National Quality Forum  FACCT  RAND  Much has been done, but much remains to do

17 Lessons Learned: #4 It is important to establish explicit, transparent, standardized measures.  Success at national level  NCQA  Success in California  PBGH  CCHRI  Clear measures understand process reduce resistance increase participation

18 Lessons Learned: #5 It is important to publicly report performance results.  Why?  Public reports positive change  NCQA experience  Wisconsin hospital study (Hibbard, 2003)

19 Lessons Learned: #6 It is important to hold parties accountable.  Clearly define who is responsible for what  Leverage where money/contracting is involved  Make accountability part of doing business  Focus on different levels  Purchasers hold plans accountable  HEDIS and CAHPS ®  Plans hold providers accountable  “Rewarding Results”

20 Lessons Learned: #7 Quality improvement efforts must cover the entire system.  In last years, focus has been on plan level  Today, focus expanded to include other levels: hospitals, provider groups, individual clinicians  Examples of new focus  Doctors’ Office Quality (DOQ) Project  H-CAHPS®

21 Lessons Learned: #8 It is important to align financial incentives with quality goals.  Conflicting messages  Capitation  Fee-for-service  Lower reimbursement for more appropriate options  Today, seeing shift from utilization-based to quality-based incentives, especially at physician level  “Rewarding Results”

22 Lessons Learned: #9 For employers, there is a business case for quality.  Strong case if view health care spending as investment in workforce productivity and organization’s future  NCQA: Reclaiming absentee days

23 Lessons Learned: #10 For providers, we need to build the business case.  In the past, limited business case for individual providers and provider groups to focus on quality measurement and improvement  Today, there is a growing emphasis on measurement and accountability at the provider level  “Rewarding Results”  Doctors’ Office Quality Pilot in Bay Area  Central Florida Health Care Coalition

24 Lessons Learned: #11 The involvement of key stakeholders is critical.  To assure credibility and increase odds of success, need  key players at the table  their buy-in  them to demand high quality  them to leverage collective interests of purchasers, especially through contract requirements  Examples of success  NCQA  CCHRI

25 Lessons Learned: #12 Start small.  Secure some “wins” early in process by focusing on important-- but also do-able-- tasks  NCQA

26 Lessons Learned: #13 Minimize the burden of data collection.  To the extent possible, use existing data to begin documenting the problems  Once have some sense of the problems, seek more support for larger data collection efforts  Acknowledge deficiencies of using existing data

27 Next steps for Workers’ Compensation in California  No need to re-invent the wheel  Build on past knowledge and experience  Focus on quality is well-placed given  known quality deficiencies  evidence that efforts can  improve care  save lives  reduce burden of injury and illness in human and financial terms

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