1. The Alliance — Madison, Wisconsin Separate But Unequal: Unmasking Variations in Quality Cheryl DeMars, Director of Quality

2. The Alliance — Madison, Wisconsin Presentation Overview Cost of poor quality in health care Quality measurement and reporting as a purchaser strategy The impact – On consumers – On providers Today…the importance of staying the course

3. The Alliance — Madison, Wisconsin Employer-owned and directed not-for-profit cooperative Value-based purchasing Competitive advantage is freedom of choice 105,000 employees and family members – Approximately 20% of the commercial market About The Alliance

4. The Alliance — Madison, Wisconsin Types of Quality Problems Overuse – when the risk of harm exceeds the potential benefit 21% of antibiotic prescriptions for viral infections (50 million rx annually for kids alone) Underuse – failure to provide an effective service that would produce a favorable outcome 60% of patients diagnosed with depression are not given medication 25 – 40% of patients receive beta blockers post heart attack

5. The Alliance — Madison, Wisconsin Types of Quality Problems (cont.) Misuse - avoidable complications or death from appropriate care – 1999 Institute of Medicine Report, “To Err is Human” AIDS = 16,516* Breast cancer = 42,297* Car accidents = 43,458* Medical errors in hospitals = up to 98,000 ** * in America, 1999 ** Institute of Medicine, 1999

6. The Alliance — Madison, Wisconsin The Cost of Poor Quality 1/3 of premium costs are wasted on poor quality – $4000 per year - $1300 is wasted – Company with 150 employees = $200,000 - Midwest Business Group on Health and The Juran Institute (mbgh.org)(juran.com)

7. The Alliance — Madison, Wisconsin Past Attempts … 1991 – present: The Quality Forum …a rising tide raises all boats Collaborative approach Blinded data, aggregate comparisons of local averages to national norms 1998: Patient Satisfaction Report …incentives to publicly disclose information Providers owned the data % of excellent responses No commitment to continue

8. The Alliance — Madison, Wisconsin New Approach… Make good use of available data Measure what matters to consumers Use most effective methods to convey information to consumers Evaluate and improve: – How we measure – How we communicate

9. The Alliance — Madison, Wisconsin QualityCounts …Walking the Walk QualityCounts Report on the Safety of Hospital Care (2001) – A sustainable strategy independent of voluntary provider cooperation – Risk-adjusted rates of complications and death

10. The Alliance — Madison, Wisconsin Basic Components Wisconsin Bureau of Health Information – Administrative (billing) data – All hospital discharges AHRQ Quality Indicators (version 1.3) Risk adjustment – The Medstat Group—Disease Staging™ and Complications of Care Software Broad indexes made up of complications and mortality

11. The Alliance — Madison, Wisconsin Report Contents Broad indices of care – mortality and complication rates – Surgery and non surgery – Hip/Knee, Maternity, Cardiac care Performance ratings: + = better than expected - = worse than expected o = as expected

12. The Alliance — Madison, Wisconsin Process Highlights Consumer input – Focus groups re: interest in measures – Cognitive testing of report design Provider input – Concept testing – Input on measures – Review and comment period (July – August 2001) Alliance Board and membership

13. The Alliance — Madison, Wisconsin Report Design Literature review—what works? Judith Hibbard, PhD, Professor, University of Oregon – Research on consumer use and understanding of health care ratings – Design principles that impact “evaluability” Performance ordering, negative framing Cognitive testing with consumers

14. The Alliance — Madison, Wisconsin Distribution Strategy Alliance members—from employers to employees Newspaper insert AARP Public libraries www.qualitycounts.org

15. The Alliance — Madison, Wisconsin Provider Reaction Meetings, phone calls, emails Letters from hospital CEOs and attorneys Letters to the editor and op ed pieces Lobbied Alliance members to forego distribution of report to employees Provider “dialogues” to move past talking points

16. The Alliance — Madison, Wisconsin The Employer Response Some erosion of support – Conflicting roles Alliance member CEOs on hospital boards Hospital CEOs on Alliance member boards – Disagreement between two trusted sources (The Alliance and providers) – Uncomfortable with tension Identified new allies, champions

17. The Alliance — Madison, Wisconsin Consumer Response Over 60% awareness among Alliance members 25% awareness among general public Source: Consumer Telephone Survey Judith Hibbard, PhD, University of Oregon

18. The Alliance — Madison, Wisconsin How much of the QualityCounts Report did you read? Data Source: post cards

19. The Alliance — Madison, Wisconsin How easy was it to understand? Data Source: post cards

20. How will you use the QualityCounts Report? Data Source: post cards

21. The Alliance — Madison, Wisconsin …and care is improving in our local market Judith Hibbard, PhD, University of Oregon “Does Making Hospital Performance Public Increase Quality Improvement Efforts?” Experimental design – Public report (Alliance network hospitals) – Private report – No report

22. The Alliance — Madison, Wisconsin Research Questions Does making performance public increase: – Concerns about public image and market share? – QI efforts within areas reported upon? Are QI efforts greatest among those with lower performance scores? To what degree do “private reports” stimulate public QI activities?

23. The Alliance — Madison, Wisconsin Response Rates by Experimental Condition Public Report Private Report No ReportTotal Hospitals (At least one respondent) 100% N = 24 98% N = 39 85% N = 39 94% N=102 Individuals 75% N = 51 65% N = 67 52% N = 65 62% N=183

24. Best practices around c-sections Best practices around v-bacs Reducing 3rd or 4th degree laceration Average Number of QI Projects to Reduce Obstetrical Complications Reducing hemorrhage Reducing pre-natal complications Reducing post-surgical complications Other (p <.01, n = 93) Public report group is investing more in OB QI activities (p <.01, n = 93)

25. Average Number of OB QI Activities: (n = 93) Main effect, p <.01, interaction, p <.05 Scores: Low scoring hospitals in public report group had significantly more QI activities

26. Hospitals with Poor OB Score: % of Hospitals w/ QI Projects to Reduce Hemorrhage (p <.001, N=34) Public report hospitals have more efforts underway to reduce post partum hemorrhage (p <.001, N=34)

27. The Alliance — Madison, Wisconsin Next Steps Refine current measures – Quality Measurement Advisory Panel Integrate additional measures, as data become available

28. The Alliance — Madison, Wisconsin National Disclosure Efforts Leapfrog – Purchaser lead – employers, labor, coalitions – Standards proven to reduce medical errors – www.leapfroggroup.org National Quality Forum – Multi-stakeholder group formed by Presidential Advisory Commission on Quality in Managed Care – Establishing national standards for quality measurement of providers and conditions

29. The Alliance — Madison, Wisconsin National Disclosure Efforts (cont.) CMS/AHA Quality Initiative – 10 condition specific measures – Voluntary participation – 242 hospitals have signed up thus far, plus 5 states – Hospitals will be given chance to review and withdraw prior to public disclosure – Posted on www.cms.hhs.gov in August, 2003www.cms.hhs.gov – “Consumer-friendly” reporting in 2004

30. The Alliance — Madison, Wisconsin Final Thoughts We cannot rely on providers to disclose performance absent regulatory or legislative mandates or compelling and sustained market pressure from purchasers and consumers Quality measurement and reporting is the most effective strategy to: – Stimulate improvement among providers – Focus public attention on quality and safety issues Purchasers and consumers need to set the agenda We must put our money where our measures are