1. 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

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

3. 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

4. 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

5. 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

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

7. 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

8. Transparency Drives Improvement
Beta-Blocker Treatment Rates, 8

9. 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

10. 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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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