Which of the following health care issues do you think is the most important for the President and Congress to deal with? (Please rank) q Protecting patients’ rights in HMOs and managed care plans q Making Medicare more financially sound for future generations q Helping people age 65 and over pay for prescription medicines q Increasing the number of Americans covered by health insurance q All equally important q None are very important

Which of the following health care issues do you think is the most important for the President and Congress to deal with? KFF 11/2002 q Protecting patients’ rights in HMOs and managed care plans – 10% q Making Medicare more financially sound for future generations – 21% q Helping people age 65 and over pay for prescription medicines – 23% q Increasing the number of Americans covered by health insurance – 35% q All equally important – 5% q None are very important – 4% q Don’t know/Refused – 1%

“There is abundant evidence that serious and extensive quality problems exist throughout American medicine.” Institute of Medicine, 1999

Opportunities to Improve Quality are Ubiquitous  Only 28-36% of elderly receive pneumococcal vaccines when they should.  Only 41-54% of hypertensives have their blood pressure controlled.  Only 21%-55% of patients with acute myocardial infarction (AMI) received Beta Blocker therapy.  Failure to provide proven therapies for AMI results in 18,000 preventable deaths annually.

Opportunities to Improve Quality are Ubiquitous q 25% greater chance of dying if that person does not have health insurance.

In a 1981 sample of Medicare patients: q 17% of coronary angiographies q 32% of carotic endarterectomies q 17% of upper gastrointestinal tract endoscopies were preformed for inappropriate reasons.

The new treatment, called aggressive rehabilitation, goes well beyond traditional physical therapy, taking the "no pain, no gain" approach to an excruciating level. After years of tentatively guarding their backs for fear of injury, back-pain sufferers who can barely walk or stand are subjected to grueling exercise, using their back muscles to stretch and push weight… Intensive exercise has been slow to catch on. [resulting in unnecessary procedures such as spinal-fusion surgery for degenerating disks???] The therapy is far less lucrative than the pain pills, injections and surgical treatments that are the cornerstone of the back-pain industry. And patients, too, are reluctant to pursue the treatment, which takes more time and effort than passive therapies. But now, with growing evidence that spinal-fusion surgery doesn't work for most people, more patients are looking for nonsurgical options. [Please don’t try this on your own!!] WSJ: Patients Hit the Weights in New Back-Pain Cure Nov 12, 2002

Overuse of Health Services q Widespread: from the simplest to the most complex services q Does harm because patients are exposed to unnecessary risks q How much of health care is overuse? At least 20% (Source: Mark Chassin’s Congressional Testimony - Washington, D.C. - September 20, 2002

Classifying Quality Problems 1. Overuse 2. Underuse 3. Misuse

“ Quality of care is the degree to which health services for the individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

q Health Services: This phrase refers to services which affect both physical and mental health q Individuals: Concerned with the quality of care that individual physicians and clinicians deliver to individuals in specific episodes of care q Populations: Attention must be paid to the quality of care across the entire system and whether or not all parts of the populations have access to needed and appropriate services and whether their health status is improving

q Increases likelihood of beneficial outcomes: Quality is not identical to positive outcomes q Desired health outcomes: Are these the outcomes that a patient desires??? q Current professional knowledge: HC professionals must maintain an up-to-date knowledge of the research in the field and be able to implement it.

In Big Step for Patient Education, California Will Score Health Plans By MITCHEL BENSON Staff Reporter of THE WALL STREET JOURNAL – Sept 18, 2002 The 323 Walgreens drug stores in California will soon have a new "product" on the pharmacy counter: an official report card that rates the state's 10 largest health-maintenance organizations and 81 of its biggest physician groups.

A BOSTON GLOBE EDITORIAL 11/14/2002 Bonus for better care AT FIRST GLANCE, the notion can only prompt head- shaking. In Massachusetts, which already has the highest health care costs of any state in the country, doctors are going to have to be paid bonuses to get them to provide quality care to patients with chronic diseases like diabetes? The explanation for this madness is that too much of the $45 billion spent on health in this state is for hospitalization of patients who could have been kept on their feet if problem signs had been more closely monitored. Such monitoring, though, is labor-intensive and sometimes requires doctors to invest in new computer programs. So some Massachusetts employers and managed care organizations are offering or planning financial incentives for doctors who create systems in their practice to keep better track of patients with diabetes, asthma, or other chronic conditions. It is an idea worth trying.

CABG Mortality By State 1992 Mortality (%) Annual Rate of Decline (%) NY

Awareness, Knowledge, and Use of the Consumer Guide By 474 CABG Surgery Patients in Pennsylvania N (%) Aware of Consumer Guide 93 (20) Aware prior to surgery 56 (12) Report knowledge of hospital ratings 18 (4) Report that information was a major or moderate influence in choice of hospital 11 (2) Report correct rating of hospital 4 (1) Source: Schneider and Epstein. JAMA 1998.

Barriers to Use of Performance Reports Reported by CABG Surgery Patients in Pennsylvania Barrier N (%) r “Cost” affected choice 8 (2) r “Managed care or insurance restriction” 19 (4) affected choice r Time < 3 days between decision to operate 178 (38) and operation r “Less than enough” time to learn about provider 58 (12) r No other hospital in “reasonable distance” 157 (33) Source: Schneider and Epstein. JAMA, 1998.

Interest in Mortality Outcomes Among CABG Surgery Patients in Pennsylvania N% Interest in Obtaining the Consumer Guide Very interested15833 Somewhat interested10622 Not very interested10622 Not at all interested13328 Don’t know 26 6 Willingness to Change Surgeons Definitely would change14631 Probably would change12727 Probably would not change 7215 Definitely would not change 5111 Don’t know 7817 Source: Schneider and Epstein. JAMA 1998.

HEDIS Measures across 7 Domains q Effectiveness of care (e.g. mammography screening) q Access (translators, timeliness of prenatal care) q Satisfaction (CAHPS survey) q Health plan stability (practitioner turnover) q Use of services (e.g. well child visits, frequency of selected procedures) q Informed health care choices (e.g. management of menopause) q Health plan descriptive information (e.g. board certification, practitioner compensation)

HEDIS Effectiveness of Care q Childhood immunizations q Adolescent immunization q Influenza vaccination for elderly q Pneumonia vaccination for elderly q Breast cancer screening q Cervical cancer screening q Chlamydia screening

HEDIS Effectiveness of Care (cont’d) q Antidepressant medication management q Followup after hospitalization for mental illness q Advising smokers to quit q Medicare health outcomes survey

HEDIS Effectiveness of Care (cont’d) q Controlling high BP q Beta blockers after AMI q Cholesterol management after AMI q Appropriate meds for asthmatics q Comprehensive diabetes care

Health Plans Have Voluntarily Reported Poor Performance on HEDIS q Beta Blocker use after myocardial infarction varied from % with an average of 62% (Quality Compass 1997) q Breast cancer screening varied from % with a national average of 70% (Quality Compass 1997) q Diabetic eye exams varied from 28-66% with a national average of 45% (Quality Compass 2000)

HEDIS Has Been Associated with Increasing Quality of Care Beta Blocker after MI 80% 85% Antidepressant Tx 54% 59% Cholesterol Screening 59% 69% Diabetic Eye Exams 41% 45% F/U after Mental Illness 67% 70% Adolescent Immunization 52% 59% Source: Quality Compass 1999, 2000

Problems With Report Cards q HEDIS contains no risk adjustment »Incentives to avoid the sick and those of lower socioeconomic status q Quality measures: structure, process, & outcomes. Most report cards focus on process measure.

Problems With Report Cards (cont’d) Information needs are heterogeneous q Purchasers, providers and consumers often want different information q Information can mislead consumers if it magnifies clinically unimportant differences q Complex patterns of quality data may confuse consumers

Quality Measurement in the Competitive Marketplace Will quality report cards become an important component of quality assurance and quality improvement as we move into the 21st Century or will they fade away?

Waypoints in Performance Measurement q Today -- Data from computer surveys on access and satisfaction clinical data on preventive services, process for chronic diseases q Future -- Broader range of indicators, special populations, outcome measures

Controversy About What to Measure and How Precise the Measurements Must Be q Employers want a range of data including measures of utilization and administrative function as well as quality q Physicians more concerned with technical aspects of quality and highly accurate measurements q Consumers concerned with care by specific doctors and specific hospitals for their individual problems

Persisting Efforts to Focus on Medical Groups and Physicians q Prompted by consumers, health plans, provider organizations q Limited by information systems, political sensitivities, concerns about confidentiality, sample size and risk adjustment