Health Care in the US Exam #3, Healthcare in the US Exam #2, Healthcare in the US Exam #1

Risk Adjustment

*creates fair comparisons!, account for socioeconomic factors

Issues with Measuring Outcomes

-"Hard", objective, outcomes like death rates are often irrelevant (i.e., in any situation where mortality is rare) -Functional outcomes -Objective measures: stress test, 6-minute walk Self-reported physical functioning, or return to work -Good measures for functional outcomes exist, but they are less intuitive to providers -Cost (an outcome, but not a health outcome)

Summary: Measuring Quality

--Measurement science continues to develop, for structure, process, and outcome -Science of risk adjustment relatively well developed for some outcomes, but imperfect -Drive for standardization of measurement -Examples of organizations that review and certify measurement tools

What is Quality in Health Care?

-Abstract, multi-faceted concept that relates to the improvement of patient health outcomes -Perspectives vary *Patient: Subjective outcomes: experience of care; being treated with respect, dignity, courtesy Objective outcomes: BP control, survival, reassurance Other objective outcomes: functioning, safety *Provider: technical skills, knowledge, training, reputation, how their patients fare *Payer: different payers answer to different communities; value proposition, efficiency

Take Home Messages for gov. regulation

-As costs rise issues related to regulation will only become more prominent and complex -Government is involved in virtually every domain of regulation ... but so is the private sector State governments have responsibility for professional licensing, but they give physicians permission to design and implement the process State governments have responsibility for hospital and institutional licensing, but JCAHO actually does it (most of the time) Employer based insurance and tax expenditures

Supply Sensitive Care

-Care whose frequency of use is not determined by well-articulated medical theory, much less by scientific evidence -Supply-sensitive services include physician visits, diagnostic tests, hospitalizations and admissions to intensive care among patients with chronic illnesses -Overuse of supply-sensitive care is particularly apparent in the management of chronic illness (such as admitting patients with chronic conditions such as diabetes to the hospital, rather than treating them as outpatients) -The cause is an overdependence on the acute care sector and a lack of the infrastructure necessary to support the management of chronically ill patients in other settings

Measuring Technical Care

-Claims databases (if it is something that is reimbursed) NB: all FFS reimbursement requires that claims be filed Also called "administrative data" If no bill for this, there is no record Foot exam in a diabetic patient Poor recording of things like race/ethnicity "Errors" such as family history of diabetes being confused with history of diabetes -Medical records What you can find in medical records Smoking cessation discussions Obesity discussions Screening for depression Medical records can be incomplete and if not electronic can be difficult to review Expensive and time consuming, even if they are electronic *Strong evidence of process-outcome linkage

Framework for health care regulation

-Complexity -Confrontation State-federal balance: Supreme Court decisions on ACA Population vs. individual health Acute vs. chronic diseases Public vs. private sector role -Compromise National industry requires some national oversight State-level regulation Private professional organizations

Take Home Messages: Variation

-Examining variations, and learning how to reduce inappropriate or unnecessary variation, can simultaneously improve outcomes and reduce cost -The concepts of supply sensitive and preference sensitive care are potentially helpful ways to better understand the sources of variation -If you create incentives to cut costs in high spending areas, how do you insure that they reduce spending on the right things?

Process vs. Outcome

-Goal of health care is to improve health outcomes -It follows that the ultimate goal of quality measurement and quality improvement is to improve health outcomes -Then why don't we forget structure and process and focus on outcomes? (know now to discuss/answer this question)

Value in Health Care

-Intuitively, value has to do with paying a fair or reasonable amount for something -Understanding value, and producing value, requires that we understand and measure quality -Example: buying a phone or a camera -Think of it as a ratio: dollars per unit of quality -Research area: decision analysis, cost effectiveness analysis

Evidence Based Medicine

-Is there such a thing as non-evidence based medicine? -Refers to a set of methods, developed in the last 20 years, that are used to evaluate and summarize the information in the published literature -Ranking the quality and generalizability of evidence

Ways to Regulate

-Many different types of consequences, or ways to induce behavior change Hassle and costs Taxes Fines Public embarrassment Initiated administrative or legal actions Revocation of license, e.g. of a provider, hospital, nursing home, etc.

Technical Care Measurement

-Many processes contribute to any outcome: think of hospitalization for heart attack or treatment of lung cancer; or the cervical cancer screening example -Quality of evidence about process-outcome links varies -For any process measure there are practical issues related to the cost, convenience, and validity of the measurement process

The ________ provides health care to veterans, Native Americans, and military personnel

federal government

Is Regulation Necessary?

-Markets can "fail" in a variety of ways Development of monopoly or oligopoly power Collective action or public good: e.g., highways or national defense Inadequate information: e.g., food labeling, drug or device quality, or hospital quality; no info on prices (as we have discussed previously) Unseen externalities*: e.g., water pollution, global warming; or cost-shifting in health insurance

TQM/CQI in US Health Care

-Medicare Peer Review Organizations (PROs), created in 1982 to review outlier cases in Medicare program Quality Improvement Organizations (QIOs), created in 1992 to improve care of all patients in Medicare program -Malcolm Baldridge National Quality Award mid 1980s -Joint Commission for Accreditation of Healthcare Organizations (JCAHO) has used QI approaches for 20 years -Practice improvement module in American Board of Internal Medicine (ABIM) recertification process -Medical schools and house staff training increasingly teaching principles of teamwork, root cause analysis

Spectrum of scientific rigor: strong to weak

-Meta analyses of randomized trials -Individual randomized clinical trials -Observational studies -Case reports -Conventional wisdom -"In my experience ..."

Take Home Messages: Misuse

-Modern medicine and safety problems -Patients: complex, chronic illnesses -Hospitals: can be dangerous places -Treatments: often highly effective, but with risks -Systems are evolving to handle these risks, but there remains lots of room for improvement -Accountability: inpatient, outpatient, across care spectrum

Porter paper

-Nicely makes the argument against process measures, and for outcome measures -Argues that risk adjustment methods are mature and ready for prime time ... some would debate this -Basic premise - that assessing value requires a focus on outcomes - is correct -Debate is about technical problems of measuring and risk adjusting the outcomes

Case 1

-October 22, 2009 a state health department fined a hospital $150,000 for operating on the wrong finger -Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and the state Dept. of Health (DOH) disagreed about how the hospital should be asked to respond DOH required that the hospital -Adopt the statewide protocol for safety checklists, surgical marking, and develop a plan to revise protocols and update staff -Shut down surgery for a day and conduct a mandatory training and review of surgical procedures -Install audio and video equipment in every ER and, with patient consent, review 2 surgical events each year for each surgeon -Prepare a summary of every surgical error from 2005 to the present, and send it to 4 government and accrediting agencies THEN -August 4, 2010 a small piece of drill bit broke off and was left in a patient's scalp during neurosurgery -It was discovered the day after surgery and removed without incident -The hospital suspended the surgeon and apologized to the patient -The event was reported to the DOH on Aug 6 On Tuesday Oct 14, 2010 the DOH fined the hospital $300,000 for the drill bit incident for failure to follow its own policies, which require x-rays whenever equipment is not accounted for THEN -On Oct 15, 2010 a surgical instrument was discovered in the abdomen of a patient who had had a surgery 3 months prior -Against the recommendations of the Director of the DOH, CMS ordered a survey to determine whether they would keep their Certificate of Participation (COP) -The hospital passed the survey One clear take home message from this case: safety is an important dimension of quality that the public want carefully regulated

Technical vs. Interpersonal Care

-One could argue, at least for the care of chronic diseases, that this is an artificial distinction -High quality interpersonal care, at least for chronic care, is required for good technical care to be implemented

Patient Safety Movement

-Origins of errors Human factors Medical Complexity System failures -A new patient safety discipline has developed -Role of technology such as electronic medical records and computerized physician order entry -Tremendous opportunities in these areas

Preference Sensitive Care

-Preference-sensitive care comprises treatments that involve significant tradeoffs affecting the patient's quality and/or length of life -Decisions about these interventions - whether to have them or not, which ones to have - ought to reflect patients' personal values and preferences, and ought to be made only after patients have enough information to make an informed choice -Misuse of preference-sensitive care refers to situations in which there are significant tradeoffs among the available options. Treatment choices should be based on the patient's own values (such as the choice between mastectomy and lumpectomy for early-stage breast cancer); but often they are not.

NCQA

-Private regulatory entity -Created by plans to regulate plans -Has become a trusted entity -Taking a leadership role in quality measurement and reporting -Producing information so that markets can work

Quality Assurance Approach

-Quality assurance is the concept of inspection or culling, throw out defective products or "bad apples" -Focus on the "tail" of a distribution that does not meet standards -Find the individual that is the source of the mistake

Underuse

-Random sample of adults in 12 communities -Phone call followed by request to review medical records -Review of the medical records for adherence to standards of care for multiple conditions

Drivers of Health Care Regulation

-Regulation generally focuses on 3 inter-related domains of health care Cost Quality Access -Cost has historically been the most important driver of regulation

What is Regulation?

-Regulation is "controlling human or societal behavior by rules or restrictions."* -Many forms, examples include Government imposed legal restrictions Self-regulation by a trade organization Social regulation (social norms) Market regulation -Health care: heavily regulated

Managed Care: State Regulation

-Remember: HMOs have both financing and delivery system features -Insurance is (mostly) regulated by states -Remember that self-insured companies, often with employees in many states, come under the aegis of ERISA* -RI has an Office of the Health Insurance Commissioner -HMO Act of 1973: stimulated growth of HMOs Over ruled some state laws First direct federal intervention in health insurance -National Committee on Quality Assurance (NCQA), 1990 Private accreditation organization created by the managed care industry to supervise quality -NCQA: what do they measure? Structural features of HMOs: how providers selected, size of provider network Patient satisfaction type measures: ease of enrollment, responsiveness to enrollee inquiries Health Employer Data Information Set (HEDIS): clinical performance

Quality Improvement Approach: TQM/CQI

-Shewart introduced idea that any production process, when examined using statistical methods, had a predictable and constant number of errors -Error rate is a function of the production process or system (NB: not of the system operators, but of the system itself) -Don't over react to individual defects, analyze and fix the production system that created them -Shift the whole curve (in this case upward, toward higher % on time) MOVE MEAN UPWARD MOVING TOWARD THIS IN HEALTHCARE

Advantages of Measuring Technical Processes

-Some measures can be relatively simple: All women between 50 and 75 should have a mammogram every 2 years All diabetics should be screened yearly for diabetic retinopathy All patients who have had a heart attack should be on daily aspirin (absent counter indications) -This makes comparisons relatively simple -Most accepted quality measures are measures of technical processes

Hospitals: State Regulation

-State licensure, in theory, is primary oversight mechanism for hospitals and other health organizations -Joint Commission on the Accreditation of Healthcare Organizations (JCAHO or the "Joint Commission") -JCAHO certification can satisfy requirements for state licensure: 80% of hospitals choose this route The other 20% choose state mechanisms

framework take homes

-Theory: independence of regulators and regulated -Practice: interdependence, "the most knowledgeable people are also the most conflicted" -In health care in the US, regulation and oversight can have federal, state, and private components Think about regulation as necessarily fluid, responsive to many forces

Hospitals: Federal Regulation

-Through Medicare Certification of Participation required Can come through JCAHO certification EMTALA (1986): hospitals that participate in Medicare must provide appropriate emergency care Clinical Laboratory Improvement Amendments (CLIA, 1988): quality standards for laboratories that bill Medicare -Economic regulation: hospital supply and rates Hill-Burton construction funding (1946); goal was expansion Certificate of Need (CON) programs (1974); hospitals had to get permission to build or expand

Summary Comments on Overuse

-Variations can be seen in all dimensions of care: diagnosis and treatment -Seen more often in when there is lack of consensus about what is appropriate -In general, areas in which spending is higher do not show higher quality care, better patient outcomes, or more satisfied patients

Take Home Messages: Underuse

-We underuse many diagnostic and treatment modalities that have a strong evidence base -Question: what would happen to costs if we didn't underuse these?

Measuring Interpersonal Care

-You have to ask the patient -Ask about things they are uniquely qualified to answer -What do you ask them about? Service quality: office and telephone wait times Communication quality: information exchange about medications, diagnostic testing, diagnosis, prognosis More complex concepts: trust, respect, overall satisfaction with care, willingness to recommend -How do you ask them? Surveys in the office Telephone surveys Mail surveys Internet surveys **Triple Aim Improving experience of care Improving quality of care Reducing cost of care

NEJM Quality article

-average age 45, 44% with at least 1 chronic conditions -55% of reccomended care recieved

overkill article

-everyone now doing overtesting and having wasted money on nonbeneficial medicine

standardizing patient outcomes measurement article

-healthcare shifting focus from volume to value but outcomes that matter to patients are hard to measure -quality is adherence to compliance, not improvement in outcomes -limited outcomes measurement led by specialty societies -outcomes focused on the objective like survival

Healthcare-associated infections

-infections acquired during a hospital stay are among the most common complications of hospital care -1 in 25 hospital patients have at least one hospital associated infection -CAUTI are going up (Catheter associated urinary tract infections) -obstetric traumas going down

National Healthcare Quality and Disparities Report GOALS

-making care safer by reducing harm caused in the delivery of care -reduce preventable hospital admissions and readmissions -reduce the incidence of adverse health care-associate conditions -reduce harm from inappropriate or unnecessary care -in patient safety, 21 measures improving, 9 no change and 2 worsening

The cost conundrum article

-medicine now about racking up expenses for unnecessary test -macallen has highest medical costs because of this

Why is health care regulation so complex? article

-regulatory structure is necessary to govern, but it is not consistent or uniform currently -most things controlled federally -private regulators entered in early 20th century -people must turn to multiple competing authorities for guide on complying with regulations -private regulators more interested in protecting financial interests -regulation has nurtured progress of healthcare

Kaiser Family Foundation Report

3 types of reforms medical homes - PRIMARY CARE ORGANIZERS - management fees in addition to fee for service - mixed evidence about it working accountable care organizations - groups of providers working together to insure share responsibility of patient - gain or losses based on quality of care bundled payments - overall budget for all services used for patient treatment - incentives for quality of care to come under budget

According to the IOM 2010 report, what percentage of health care spending goes to waste?

30%

To err is human book

44,000 to 98,000 preventable deaths in the US annually due to errors in hospital care 7000 due to medication errors Similar efforts to quantify adverse events all over the world

The Centers for Medicare and Medicaid Services administer

A and B (Medicare and Medicaid, CHIP)

Unwanted Variation

A more nuanced look -Underuse of effective care -Overuse of supply sensitive care -Misuse of preference sensitive care

ACO Jama Article

ACO Challenges: Conflicting financial incentives, inadequate and discordinat quality measures,, shifting population

Health Affairs Website

ACOs growing, particularly in northeast, low dropout rate

Outcome Elements

Acute recovery, restoration of function, survival, efficiency

What is one issue with measuring health care quality according to Porter?

All of the above (The US medical system overemphasizes process measures which has limited effect on quality, Outcome measurements are mainly performed among specialists and specialty societies, Outcome measurements traditionally focus on clinical status rather than functional status)

Which of the following is the responsibility of state governments?

B and C (Licensing, Collecting health statistics)

What treatment did doctors provide for Gawande's mother when she fainted in a grocery store?

Cardiac catherization

What is the main reason for the lack of success of health care cost control efforts in the United States according to Shi & Singh?

Cost shifting by providers

Stats

Critical trend: using market forces to drive quality improvement Public reporting Pay for performance (P4P) Who is driving this evolution? AHRQ: collecting and disseminating data BOTH private and public payers New private organizations that have developed to meet the needs of payers, often formed by purchasers (employers) -Intense focus on quality and disparities -Some real progress -Many challenges remain -Quality improvement does not mean that disparities lessen

Following the Atul Gawande article on McAllen, Texas, health care costs and overutilization in the town

Declined

Cervical Cancer Screening Example

Design: Cross sectional study of data abstracted during an evaluation of an initiative to improve quality of care for people with HIV. Data: Medical records CASE: Cervical cancer screening in women with HIV care (60%) Chain of events that has to happen in order for this relatively simple even to occur Single weak link breaks the chain Thus the emphasis on teamwork and systems Accountability & systems: QI approach

Hospitals: Private Quality Oversight

Joint Commission on Accreditation of Healthcare Organizations (JCAHO); organized and funded by American College of Surgeons American Medical Association American Dental Association American Hospital Association American College of Physicians -Surveys every 3 years Formerly very process oriented: look at many things including completeness of medical records, minutes of medical staff committees, quality assurance and improvement processes, operating room procedures, etc. Last 10-20 years: focus on outcomes and quality improvement JCAHO surveys not considered "friendly visits" by most hospitals

framework challenges

External: Increasing complexity of issues and problems faced by the US: toxic waste, globalization, terrorism, new infectious diseases (Ebola) Internal: Increasing complexity of financing and delivery systems in health care, and serious cost problems

Structure Elements

Facilities, Equipment, Staffing, Qualification, Licensing, Accreditation

True or False: Managed care increased the rate of growth in health spending between 1993 and 2000?

False

True or False: there are standardized outcome measures and definitions for quality healthcare among providers and payers

False

What does the Consumer Price Index measure?

General inflation

Doctors Hospital at Renaissance is known for

Incentivizing physicians to send their patients there for procedures and tests which are probably unnecessary

What is one major benefit of having multiple competing interests in the regulation of health care according to Robert Field?

It ensures that no one regulatory power becomes too powerful

The town of McAllen in Texas is distinctive because

It is the town with the highest health care expenditure in the nation

True or False: Since 1975, the rates of change in medical inflation have remained consistently and continuously above the rates of change in the CPI?

True

Case Mix or Risk Adjustment

Medical care is, if anything, more complex than educational achievement Outcome measurement, to be fair, should take account of or adjust for patient characteristics related to their baseline risks for the outcome in question Comparing apples to apples, "all other things being equal" Risk adjustment can be technically complex and expensive Critical in public reporting and pay-for-performance

_________ is the erroneous diagnosis of a disease while __________ is the correct diagnosis of a disease that will not bother you in your lifetime.

Misdiagnosis; overdiagnosis

3 Kinds of Quality Problems

Misuse: errors, mistakes Underuse: not doing things that you should Overuse: doing more than you should

Regulation in the US

Occurs in 3 places or at 3 levels State Federal Private

What is the cause of high health care costs in McAllen, Texas?

Overutilization

True or false: Most thyroid microcarcinomas are not life threatening

True

The American Medical Association is a _______ regulator of healthcare

Private

Which of the following is the most reported issue faced by the newly insured?

Provider capacity

Quality Assurance vs. Quality Improvement in Health Care

Quality assurance: measures compliance with standard by means of inspection, defensive attitude, focus on few outliers, scope is medical providers Quality Improvement: continuously improves processes to meet standard by means of prevention, proactive attitude, focus on all in the system, scope is patient care

TQM/CQI Take Home Points

Regulation is necessary, and there are many forms Regulation in healthcare has evolved as the business of health care has become more complex Biggest driver of regulation in health care is cost increases, with quality and access generally taking a secondary role Modern theories and practice of quality improvement have come to medicine (finally)

What is one major downside of having multiple competing interests in the regulation of health care according to Robert Field?

Some regulatory bodies do not have an interest in protecting the public

What is ICHOM attempting to do?

Standardize risk factors and outcome measures for disease on a global scale

Donabedian's Model

Structure: physical and organizational resources contributing to healthcare delivery Process: Activities that constitute care delivery Outcome: results of care processes; recovery, restoration of function, and survival

Process Elements

Technicial care (screening, diagnosis, prevention) and interpersonal care (respect, communication, knowledge)

Which amendment to the constitution outlines the concept of federalism?

Tenth Amendment

Which federal agency is the most important for the provision of health services?

The Department of Health and Human Services

A service is cost efficient when:

The benefit received is greater than the cost incurred to provide the service

According to Robert Field, which level of government has the most power to regulate health care?

The state level

According to Robert Field, what is the primary reason health care regulation is so complex?

There are a variety of regulatory bodies with competing interests

How did the Mayo Clinic control health care costs according to Gawande?

They paid all doctors a salary

What is the primary purpose of certificate-of-need statutes?

To control capital expenditures by health facilities

What is the health care function of the judicial branch?

To handle disputes arising from the provision of health services

True or False: Elements of the Donabedian model include outcomes, structure, and process?

True

True or False: In order to successfully implement an ACO, a significant amount of data must be collected and compiled about a population

True

True or False: McAllen, Texas health care costs are high because the population is extremely unhealthy

True

True or False: More patients die from complications in surgery than from car crashes in America

True

True or False: Physician decision-making is highly dependent on what city the physician works in.

True

The US is moving from a _______ health care system to a ________ health care system

Volume-based; Value-based

What is information asymmetry?

When doctors know more about the value of a medical treatment than their patients

National Healthcare Quality and Disparities Report

annual report to congress mandated in the healthcare research and quality act of 1999 -provides comprehensive overview of quality of healthcare recieved by general US population and disparities in care experienced by different racial and socioeconomic groups