Use of Outcome Measures in Payment Reform: Rationale Patrick S. Romano, MD MPH UC Davis Center for...

Use of Outcome Measures in Use of Outcome Measures in Payment Reform: RationalePayment Reform: Rationale

Patrick S. Romano, MD MPHPatrick S. Romano, MD MPHUC Davis Center for Healthcare Policy and ResearchUC Davis Center for Healthcare Policy and Research

AHRQ Annual ConferenceAHRQ Annual ConferenceBethesda, MD; September 14, 2009Bethesda, MD; September 14, 2009

OverviewOverview

Variation in quality and outcomes is Variation in quality and outcomes is substantial and is driven (at least substantial and is driven (at least somewhat) by provider behaviorsomewhat) by provider behavior

Suboptimal health care quality and Suboptimal health care quality and outcomes contribute to excess costsoutcomes contribute to excess costs

Higher quality is not generally associated Higher quality is not generally associated with higher overall costs, but improving with higher overall costs, but improving quality often reduces provider revenue quality often reduces provider revenue under current payment systemsunder current payment systems

Questions and answersQuestions and answers

Variation in quality and Variation in quality and outcomes is substantial and outcomes is substantial and is driven (at least somewhat) is driven (at least somewhat)

by provider behaviorby provider behavior

Chronic disease proxy outcomes: Chronic disease proxy outcomes: Managed care plan distribution, 2006Managed care plan distribution, 2006

70 73

49

81

88

68

6056

30

0

25

50

75

100

Private Medicare Medicaid

Mean 90th %ile 10th %ile

Note: Diabetes includes ages 18–75; hypertension includes ages 18–85.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 4

6057

53

68 67 66

4946

39

0

25

50

75

100

Private Medicare Medicaid


Percent of adults with hypertension whose blood pressure <140/90 mmHg

9691

87

99 9895

88

7176

Heart Attack Heart Failure Pneumonia

Median 90th %ile 10th %ile

84

99

91

75

90

10096

78

0

25

50

75

100

Median Best 90th %ile 10th %ile

2004 2006

Hospitals: Quality of care for heart attack, Hospitals: Quality of care for heart attack, heart failure, and pneumoniaheart failure, and pneumonia

* Composite for heart attack care consists of 5 indicators; heart failure care, 2 indicators; and pneumonia care, 3 indicators.Overall composite consists of all 10 clinical indicators. See report Appendix B for description of clinical indicators.Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Percent of patients who received recom-mended care for all three conditions*

Percent of patients who received recommended care for each condition*


Hospital-Standardized Mortality RatiosHospital-Standardized Mortality Ratios

101

8593 94 97 100 103 106 106

112118

8274 78 78 79 81 83 83 85 86 89

0

20

40

60

80

100

120

140

U.S. 1 2 3 4 5 6 7 8 9 10

2000-2002 2004-2006

Decile of hospitals ranked by actual to expected deaths ratios

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors.* Medicare national average for 2000=100

mean

* See report Appendix B for methodology.Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2004 to 2006 for conditions leading to 80 percent of all hospital deaths.


Nosocomial infections in Nosocomial infections in intensive care unit patients, 2006intensive care unit patients, 2006

Central line-associated Central line-associated bloodstream infection bloodstream infection rate, per 1,000 days userate, per 1,000 days use PercentilePercentile

Type of ICUType of ICUNo. of units 10% 25% 50% 75% 90%

MedicalMedical 73 0.0 0.0 2.2 4.2 6.2

Med-surg major Med-surg major teachingteaching 63 0.0 0.6 1.9 3.1 5.5

Med-surg all othersMed-surg all others 102 0.0 0.0 1.0 2.3 4.5

SurgicalSurgical 72 0.0 0.9 2.0 4.4 7.4

Neonatal–Level IIINeonatal–Level III(infants weighing (infants weighing 750 grams or less)750 grams or less) 42 0.0 2.5 5.2 11.0 15.6

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

7Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 7

Nosocomial infections in Nosocomial infections in intensive care unit patients, 2006intensive care unit patients, 2006

Ventilator-associated Ventilator-associated pneumonia rate, per pneumonia rate, per 1,000 days use1,000 days use Percentile

Type of ICUType of ICUNo. of units 10% 25% 50% 75% 90%

MedicalMedical 64 0.0 0.9 2.8 4.6 7.2

Med-surg major Med-surg major teachingteaching 58 0.0 1.3 2.5 5.1 7.3

Med-surg all othersMed-surg all others 99 0.0 0.0 1.6 3.8 6.2

SurgicalSurgical 61 0.0 1.8 4.1 6.4 10.0

Neonatal (NICU)Neonatal (NICU)(infants weighing (infants weighing 750 grams or less)750 grams or less) 36 0.0 0.0 1.7 4.1 9.5

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).


Potentially preventable adverse events and Potentially preventable adverse events and complications of care in hospitals among Medicare complications of care in hospitals among Medicare

beneficiaries across states, 2005-2006beneficiaries across states, 2005-2006

2.4

9.8

4.6

1.9

8.8

3.63.6

10.6

6.0

0

5

10

15

Postoperative

complications composite*

Adverse drug events

composite**

Pressure sores

US Average Top 10% States Bottom 10% StatesPercent


*Surgical patients with postoperative pneumonia, urinary tract infection (2005 only), or venous thromboembolic event ** Patients with serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin, or hypoglycemia associated with insulin or oral hypoglycemics.Data: M. Pineau, Qualidigm analysis of Medicare Patient Safety Monitoring System.

Suboptimal health care Suboptimal health care quality and outcomes quality and outcomes

contribute to excess costscontribute to excess costs

““Business case”:Business case”:Impact of preventing PSI on mortality, LOS, chargesImpact of preventing PSI on mortality, LOS, charges

NIS 2000 analysis by Zhan & Miller, NIS 2000 analysis by Zhan & Miller, JAMAJAMA 2003;290:1868-74 2003;290:1868-74

IndicatorIndicator ΔΔ Mort (%) Mort (%) ΔΔ LOS (d) LOS (d) ΔΔ Charge Charge ($) ($)

Postoperative septicemiaPostoperative septicemia 21.921.9 10.910.9 $57,700$57,700

Selected infections due to medical careSelected infections due to medical care 4.34.3 9.69.6 38,70038,700

Postop abd/pelvic wound dehiscencePostop abd/pelvic wound dehiscence 9.69.6 9.49.4 40,30040,300

Postoperative respiratory failurePostoperative respiratory failure 21.821.8 9.19.1 53,50053,500

Postoperative physiologic or metabolic Postoperative physiologic or metabolic derangementderangement

19.819.8 8.98.9 54,80054,800

Postoperative thromboembolismPostoperative thromboembolism 6.66.6 5.45.4 21,70021,700

Postoperative hip fracturePostoperative hip fracture 4.54.5 5.25.2 13,40013,400

Iatrogenic pneumothoraxIatrogenic pneumothorax 7.07.0 4.44.4 17,30017,300

Decubitus ulcerDecubitus ulcer 7.27.2 4.04.0 10,80010,800

Postoperative hemorrhage/hematomaPostoperative hemorrhage/hematoma 3.03.0 3.93.9 21,40021,400

Accidental puncture or lacerationAccidental puncture or laceration 2.22.2 1.31.3 8,3008,300

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

““Business case”:Business case”:Impact of preventing PSI on mortality, LOS, VA costImpact of preventing PSI on mortality, LOS, VA cost

VA PTF 2001 analysis by Rivard et al., VA PTF 2001 analysis by Rivard et al., Med Care Res RevMed Care Res Rev; 65(1):67-87; 65(1):67-87

IndicatorIndicator ΔΔ Mort (%) Mort (%) ΔΔ LOS (d) LOS (d) ΔΔ Cost Cost ($) ($)

Postoperative septicemiaPostoperative septicemia 30.230.2 18.818.8 $31,264$31,264

Selected infections due to medical careSelected infections due to medical care 2.72.7 9.59.5 13,81613,816

Postop abd/pelvic wound dehiscencePostop abd/pelvic wound dehiscence 11.711.7 11.711.7 18,90518,905

Postoperative respiratory failurePostoperative respiratory failure 24.224.2 8.68.6 39,74539,745

Postoperative physiologic or metabolic Postoperative physiologic or metabolic derangementderangement

Postoperative thromboembolismPostoperative thromboembolism 6.16.1 5.55.5 7,2057,205

Postoperative hip fracturePostoperative hip fracture

Iatrogenic pneumothoraxIatrogenic pneumothorax 2.72.7 3.93.9 5,6335,633

Decubitus ulcerDecubitus ulcer 6.86.8 5.25.2 6,7136,713

Postoperative hemorrhage/hematomaPostoperative hemorrhage/hematoma 5.15.1 3.93.9 7,8637,863

Accidental puncture or lacerationAccidental puncture or laceration 3.23.2 1.41.4 3,3593,359

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

Uncertain “business case” for some PSIsUncertain “business case” for some PSIs Zhan & Miller, Zhan & Miller, JAMAJAMA 2003;290:1868-74 2003;290:1868-74 Rosen et al., Rosen et al., Med CareMed Care 2005;43:873-84 2005;43:873-84

IndicatorIndicator ΔΔ Mort (%) Mort (%) ΔΔ LOS (d) LOS (d) ΔΔ Charge Charge ($) ($)

Birth traumaBirth trauma -0.1 (NS)-0.1 (NS) -0.1 (NS)-0.1 (NS) 300 (NS)300 (NS)

Obstetric trauma –cesareanObstetric trauma –cesarean -0.0 (NS)-0.0 (NS) 0.40.4 2,7002,700

Obstetric trauma - vaginal w/out Obstetric trauma - vaginal w/out instrumentationinstrumentation

0.0 (NS)0.0 (NS) 0.050.05 -100 (NS)-100 (NS)

Obstetric trauma - vaginal w Obstetric trauma - vaginal w instrumentationinstrumentation

0.0 (NS)0.0 (NS) 0.070.07 220220

Complications of anesthesia*Complications of anesthesia* 0.2 (NS)0.2 (NS) 0.2 (NS)0.2 (NS) 1,6001,600

Transfusion reaction*Transfusion reaction* -1.0 (NS)-1.0 (NS) 3.4 (NS)3.4 (NS) 18,900 (NS)18,900 (NS)

Foreign body left during procedureForeign body left during procedure†† 2.12.1 2.12.1 13,30013,300

* All differences NS for transfusion reaction and complications of anesthesia in VA/PTF.

† Mortality difference NS for foreign body in VA/PTF.

AHRQ Patient Safety Indicators (PSIs) were used AHRQ Patient Safety Indicators (PSIs) were used to identify selected medical and surgical injuriesto identify selected medical and surgical injuries

Thomson Reuters Projected Inpatient Data Base Thomson Reuters Projected Inpatient Data Base for federal FY 2007 (based on 21.5 million for federal FY 2007 (based on 21.5 million discharge abstracts from 2,620 acute hospitals)discharge abstracts from 2,620 acute hospitals)

Regression models were used to adjust for age, Regression models were used to adjust for age, sex, clinical category, and comorbid conditionssex, clinical category, and comorbid conditions

Model coefficients were used to estimate annual Model coefficients were used to estimate annual impact attributable to PSI eventsimpact attributable to PSI events

Total impact: Total impact: – almost 30,000 excess deathsalmost 30,000 excess deaths– 3.4 million excess hospital days3.4 million excess hospital days– $9 billion in excess hospital costs $9 billion in excess hospital costs

Thomson Reuters analysis of PSI business caseThomson Reuters analysis of PSI business caseFoster et al., AcademyHealth 2009Foster et al., AcademyHealth 2009

International evidence of “business case” from International evidence of “business case” from case control analysis of PSIs in NHS Englandcase control analysis of PSIs in NHS England

All differences were statistically significant at p<0.001 except as noted.

Raleigh VS, Cooper J, Bremner SA, Scobie S, Patient safety indicators for England from hospital administrative data, BMJ 2008, 337; a1702.

Admissions, England, 2005-6

IndicatorExcess LOS Excess LOS

(days)(days)

ExcessExcessMortalityMortality(percent)(percent)

Pressure ulcer 9.1 9.1 13.413.4

Accidental puncture of lung 4.3 4.3 10.6 10.6

Central line and device related infections 11.4 11.4 5.7 5.7

Postoperative hip fracture 17.117.1 18.2 18.2

Postoperative sepsis 15.915.9 27.1 27.1

Obstetric trauma – vaginal with instrument 0.6 0.6 * (NS)* (NS)

Obstetric trauma – vaginal without instrument 0.5 0.5 0.01 (NS)0.01 (NS)

Obstetric trauma – caesarean 0.2 (NS)0.2 (NS) * (NS)* (NS)

Quality is not generally associated Quality is not generally associated with overall costs, but improving with overall costs, but improving quality often reduces provider quality often reduces provider

revenue given current payment revenue given current payment systemssystems

Total Medicare payments vary widely Total Medicare payments vary widely across Hospital Referral Regionsacross Hospital Referral Regions

0.80

0.90

1.00

1.10

1.20

$0 $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000

Relative Resource Use**

Quality and costs of care for Medicare patients hospital-Quality and costs of care for Medicare patients hospital-ized for heart attacks, hip fractures, or colon cancer,ized for heart attacks, hip fractures, or colon cancer,

by Hospital Referral Regions, 2004by Hospital Referral Regions, 2004

* Indexed to risk-adjusted 1-year survival rate (median=0.70).** Risk-adjusted spending on hospital and physician services using standardized national prices.Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of Medicare beneficiaries.

Median relative resource use=$27,499

Qu

ali

ty o

f C

are

*(1

-Ye

ar

Su

rviv

al

Ind

ex

, M

ed

ian

=7

0%

)


Estimated excess 90-day payments due to Estimated excess 90-day payments due to AHRQ PSIs, 2001-2 MarketScan Commmercial AHRQ PSIs, 2001-2 MarketScan Commmercial

Claims Database (5.6 m enrollees)Claims Database (5.6 m enrollees)

All differences in total excess payments were statistically significant at p<0.001 except for Technical Problems and Wound Problems, after adjusting for propensity based on 92 collapsed DRGs, 20 comorbidities, and 12 other patient characteristics.

Encinosa and Hellinger, HSR 2008;43:2067-85.

Patient safety event class TotalTotal

IndexIndexhospitalhospital ReadmitsReadmits OutpatientOutpatient DrugsDrugs

Technical problems $646$646 $1,407$1,407 -$616-$616 -$97-$97 -$48-$48

Infections 19,48019,480 15,67415,674 2,5942,594 1,0471,047 165165

Pulmonary/vascular 7,8387,838 6,5336,533 659659 373373 273273

Acute respiratory failure 28,21828,218 25,82825,828 1,7021,702 631631 5757

Metabolic problems 11,79711,797 11,53611,536 288288 -117-117 9090

Wound problems 1,4261,426 1,2851,285 109109 5454 -22-22

Nursing-sensitive events 12,19612,196 11,65711,657 484484 4040 1515

Ambulatory care-sensitive hospitalizations Ambulatory care-sensitive hospitalizations (AHRQ PQI) for select conditions across states(AHRQ PQI) for select conditions across states

178

62

242

156

49

230

U.S.Average

Top 10%states

Bottom 10%states

241

137

299

240

126

293

U.S.Average

Top 10%states

Bottom 10%states

2002/2003^ 2004

Adjusted rate per 100,000 population

498

258

631

476

246

634

0

100

200

300

400

500

600

700

U.S.Average

Top 10%states

Bottom10% states

Diabetes*Heart failure Pediatric asthma

^ 2002 data for heart failure and diabetes; 2003 data for pediatric asthma. *Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations. Data: National average—Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution—State Inpatient Databases; not all states participate in HCUP (AHRQ 2005, 2007a).


Medicare admissions for AHRQ PQIs, rates and Medicare admissions for AHRQ PQIs, rates and associated costs, by Hospital Referral Regionsassociated costs, by Hospital Referral Regions

771

499

610

887

1043

700

465

558

816

926

0

300

600

900

1200

Nationalmean

10th 25th 75th 90th

2003 2005

13.4

10.0

11.8

14.7

16.3

12.6

9.811.1

13.6

15.2

0

5

10

15

20

Nationalmean

10th 25th 75th 90th

2003 2005

Rate of ACS admissions per 10,000 beneficiaries

Costs of ACS admissions as percent of all discharge costs

Percentiles Percentiles

See report Appendix B for complete list of ambulatory care-sensitive conditions used in the analysis.Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.


Extend Prevention Quality Indicators (PQIs) to EDsExtend Prevention Quality Indicators (PQIs) to EDs– Modify and test existing PQIs using State Emergency Modify and test existing PQIs using State Emergency

Department Databases (SEDD)Department Databases (SEDD)– Feed “enhanced PQIs” into the Preventable Hospitalization Feed “enhanced PQIs” into the Preventable Hospitalization

Costs Mapping Tool Costs Mapping Tool Develop AHRQ ED Patient Safety Indicators (EDPSIs)Develop AHRQ ED Patient Safety Indicators (EDPSIs) Pilot AHRQ Efficiency and Resource Use IndicatorsPilot AHRQ Efficiency and Resource Use Indicators Fully incorporate “Present on Admission” logic into the Fully incorporate “Present on Admission” logic into the

AHRQ PSIsAHRQ PSIs– Current algorithms grafted POA onto previous algorithms, Current algorithms grafted POA onto previous algorithms,

resulting in enhanced PPV/specificity but no gain in sensitivityresulting in enhanced PPV/specificity but no gain in sensitivity– Reconsider necessity and value of PSI denominator exclusions Reconsider necessity and value of PSI denominator exclusions

(i.e., nursing home transfers for Pressure Ulcer) and numerator (i.e., nursing home transfers for Pressure Ulcer) and numerator restrictions (i.e., procedures)restrictions (i.e., procedures)

Planned AHRQ QI enhancements Planned AHRQ QI enhancements to support payment reformto support payment reform

Questions and DiscussionQuestions and Discussion

Potentially inappropriate antibiotic prescribing, Potentially inappropriate antibiotic prescribing, children with sore throat:children with sore throat:

Managed care plan distribution, 2006Managed care plan distribution, 2006Percent of children prescribed antibiotics for throat infection without receiving a “strep” test*

25

4335

0

25

50

75

100

1997-2003 2004

National Average Managed Care Plan Distribution, 2006


27

44

14

23

43

74

Private Medicaid


Note: National average includes ages 3–17 and plan distribution includes ages 2–18.* A strep test means a rapid antigen test or throat culture for group A streptococcus.Data: National average—J. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distribution—Healthcare Effectiveness Data and Information Set (NCQA 2007).

Managed care health plans: Managed care health plans: Potentially inappropriate imaging studies Potentially inappropriate imaging studies

for low back pain, by plan typefor low back pain, by plan type

26

22

19

15

35

29

0

10

20

30

40

Private Medicaid


Percent of health plan members (ages 18–50) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors

25 2526

22 21 22

2004* 2005 2006

Private Medicaid

Annual averagesManaged care plans (2006)

* Denotes baseline year.Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).


Date post:	13-Jan-2016
Category:	Documents
Upload:	alfred-chandler
View:	213 times
Download:	0 times

Use of Outcome Measures in Payment Reform: Rationale Patrick S. Romano, MD MPH UC Davis Center for...

Documents