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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

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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

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Key Components of High Quality Health Care

Safe

Effective

Patient-centered

Timely

Efficient

Equitable-- Institute of Medicine, 2001

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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

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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

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Problem: Unwarranted Practice Variations

Example: Carotid Endarterectomy

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Bakersfield 4.7

Los Angeles 2.7

San Francisco 1.7

-- J. Wennberg, 2003

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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

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Problem: Unwarranted Practice Variations(continued)

Troubling implications for cost Medicare study (Fisher et al, 2003) More is not necessarily better

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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

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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

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Problem: Misuse

Overall, between 44,000 and 98,000 Americans die each year from medical errors.

-- Institute of Medicine, 2000

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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

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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

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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

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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

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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

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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

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Lessons Learned: #5

It is important to publicly report performance results.

Why? Public reports positive change

NCQA experience Wisconsin hospital study (Hibbard,

2003)

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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”

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Lessons Learned: #7

Quality improvement efforts must cover the entire system.

In last 10-15 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®

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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”

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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

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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

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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

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Lessons Learned: #12

Start small.

Secure some “wins” early in process by focusing on important-- but also do-able-- tasks NCQA

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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

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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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