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7/7/17
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KevinShah,MDMBA
Value and Quality in Health Care
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Define
Measure
Improve
OverviewofQuality
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Health care reform is transitioning financing from volume to value based reimbursement
Today Future
Care for individuals Manage populations
Specialty care focus Primary care focus
How do you measure value and quality?
Fee for service Value / Risk based reimbursement
Define
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A simple framework to approach health care quality
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Is the patient healthier?
• Live longer• Live healthier • Improved clinical metrics• Avoid adverse events
Outcomes Metrics
How was the patient’s experience?
• Adequate communication• Easy access to care• Patient felt needs were met
Patient Experience
Was the correct care provided?
• Appropriate Care• Timely care• Avoid unnecessary care• Avoid errors
Process Metrics
Was the care cost effective?
• Cost to patient / payer• Cost relative to appropriate benchmark• Avoidance of future cost
Cost
Define
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Variousentitiesweighparametersdifferentlyindefiningquality
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Illustrative only
Outcomes Process Pt Experience Cost
Patient
Providers
Payers
Employers
++
+
- -
++
x
+
+
- -
+
- -
x
+
+
xx
++
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Variousprivateandgovernmententitiesaredesigningandimplementingqualityprogramswithvaryingareasoffocus
Define
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There are a variety of programs that measure quality and value
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Government- Value Based Purchasing- Hospital Readmissions Reduction
Program- Hospital Acquired Conditions
Program- Medicare Advantage: STAR ratings- Medicare ACOs- Hospice Quality Initiative- Physician Quality Reporting System
PQRS)- State CABG reporting systems- Many others
Private Insurers: - ACO plans- Narrow network / high performing
network plans- Many others- Choosing Wisely
Providers- Internal quality benchmarking for QI and
compensation- Transparency of patients satisfaction and
outcomes- Choosing Wisely
Patients are increasingly having access to this quality reporting
Define
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Define
Measure: Evaluate several case studies
Improve
Measure
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Examples to study
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- CMS: Hospital Value based purchasing
- Commercial Payer: adequate clinical care.
- Health System: Patient Satisfaction
CaseStudies
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CMS’s Hospital Value Based Purchasing (VBP)
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- Legislatively endorsed by the Patient Protection and Affordable Care Act (PPACA, i.e. Obamacare)
- Budget neutral: there are winners and losers- Withholding: FY 2013 1% à FY 2017 2%
OLD SYSTEM
FFS Payments: 100%
FFS Payments: X%
VBP Payments: (1-X) %
CaseStudies:CMS
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Medicare Value Based Purchasing metrics have evolved over time
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Outcomes Process* Pt Experience Cost
2013
2014
2015
2016
None
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None
None
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Value Based Quality MetricsNumber
CaseStudies:CMS
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Value Based Purchasing FY2016 Metrics
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CaseStudies:CMS
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Value Based Purchasing FY2016 Metrics (cont)
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CaseStudies:CMS
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Weightings for VBP have shifted towards outcomes and cost
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Outcomes Process Pt Experience Efficiency
2013
2014
2015
2016
None
25%
30%
40%
70%
45%
20%
10%
30%
30%
20%
25%
None
None
30%
25%
Value Based Quality Metrics%
ThroughVBP,mosthospitalsintheUnitedStateshaveaportionoftheirreimbursementcontingentoncostandoutcomes
CaseStudies:CMS
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CMS calculates a Total Performance Score that adjust payments
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Clinical Domain Weight
Efficiency
Patient Experience
Outcomes
Clinical – weighted Score
Domain Weight
Domain Weight
Domain Weight
X
X
X
X
=
=
=
=
Patient Experience –Weighted Score
Outcomes – Weighted Score
Efficiency – Weighted Score
+
+
+
Total Performance ScoreNewdomainswillbecalculatedforFY17
CaseStudies:CMS
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HospitalCompare.gov gives patients quality comparisons of hospitals
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PatientExperience
Clinicalprocess
Readmissionandcomplications
PaymentandValueofcare
HospitalCompare.govisfocusedonMedicaredataonly,Thiswebsitedoesnotofferany physicianspecificdata
CaseStudies:CMS
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Measure: Examples to study
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- CMS: Hospital Value based purchasing
- Commercial Payer: adequate clinical care.
- Health System: Patient Satisfaction
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Private Payer: Evaluate appropriate disease screening
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Select chlamydia screening: an important evidence based screening guideline.
From NCQA:“The percentage of women 15 – 24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.“
How does a payer define “sexually active” via its data?
CaseStudy:CommercialPayer
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Private payers often use billing and claims data for quality measurement
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NCQA language on chlamydia screening - “Two methods identify sexually active women: pharmacy data and claim/encounter data. The organization must use both methods to identify the eligible population; however, a member only needs to be identified in one method to be eligible for the measure.”
What are the implications of this in clinical practice?
CaseStudy:CommercialPayer
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Measure: Examples to study
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- CMS: Hospital Value based purchasing
- Commercial Payer: adequate clinical care.
- Health System: Patient Satisfaction
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In 2009, University of Utah began publishing patient satisfaction scores on all providers
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CaseStudy:PatientSatisfaction
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Univ of Utah also releases patient comments on providers
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- Pre2009:4%ofprovidersUniv ofUtahintop10%ofPressGaineysurvey.By2013thenumberhadincreasedto46%
- Powerfultoolfortransparencyandpatientmarketing- Incentiveforproviderbehaviorchange
CaseStudy:PatientSatisfaction
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Duke Health began providing similar ratings in 2016
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Numeroushealthsystemsnowfollowingthispathincluding:- Duke- Clevland Clinic- Univ ofPittsburgh- Stanford- Manyothers
AtDuke,variousmeasuresofpatientsatisfactionarelinkedtohealthsystemqualitydashboards
CaseStudy:PatientSatisfaction
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Define
Measure
Improve: The Duke Primary Care Experience
OverviewofQuality
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Translating science into clinical practice is challenging
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Basic science
Clinical Research
Regulatory approval
Medical community consensus
Scientific knowledgeVariable uptake of new research and practice guidelines
Limited infrastructure for implementation science varied across the country
Implementation Challenge
How to fix this?
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An overview of Duke Primary Care
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Demographics- 34 clinics including continuity and urgent care- 200+ providers including FP, IM, Peds- 700K visits in the last fiscal year
Provider Compensation: - Base Salary- Productivity Bonus- Quality Bonus based upon
- 3 quality metrics (varies by provider type)- Patient Satisfaction
Improve
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Duke Primary Care has developed a quality improvement infrastructure
Improvement teamDirector of Performance ExcellencePhysician and nurse champions at clinicsPractice level coaching and mentoring
Leadership trainingAdministrationClinic leadership
Value based financial incentivesQualityPatient satisfaction
Data transparencyVisibility boards in clinicsMonthly dashboard and quality reporting
Improve
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What does Lean healthcare look like?Afocusonunderstandingcurrentstate:dataandprocess
Afocusontargetstate
Goseewheretheworkisdone
Involvethepeoplewhodothework
Leadershipmodelthatsupportsimprovementwork
PDSAandRapidimprovementevents- Involveallstakeholdersinproblemsolving- Pilotworkflowandcaredeliveryinoneortwoclinics- Refinebestpracticesarethenspread
Improve
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Numerous health care organizations are leveraging quality improvement science
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Virginia Mason Medical Center- Virginia Mason Institute: Lean Healthcare solutions
ThedaCare- ThedaCare Center for Health Care Value
Intermountain Health- Intermountain Institute for Health Care Leadership.
Duke University Health System- Redesigning inpatient care into codified care bundles - Improving care for patients who are “Familiar faces” by redesigning
the outpatient care team- Transforming Primary Care Collaborative
Improve
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A Duke Primary Care Example: Improving Care for Diabetic Patients
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Defining the problem
Measure current performance
Improve care- Engage and incentivize providers- Engage front line staff
Improve
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Duke Primary Care defined a composite diabetes quality metric
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Diabetescomposite– A1c– BP– Statintherapy– Antiplatelettherapy– Smokingstatus
Engagedprovidersondefiningwhatisoptimalcarefordiabetics,andwhatthetargetsshouldbe
Relevanttopatienthealthandoutcomes
Alignedwithpayersponsoredqualitymetrics
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Defining all of the elements for this quality metric is challenging
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- Howdoesonedefineadiabetic?- Whatpatientsdooneincludeorexclude?- Howmanymonths/yearsbackshouldthisgo?
- WhatistheA1cgoal?- WhatBPgoals?Shouldtheyvarybyage?- Shouldalldiabeticsbeonaspirinand/orstatin?- Shouldprovidersgetcreditformedicationallergies- Shouldaproviderreceivecreditfortobaccocessationcounseling- Whatdoesitmeanto“meet”themetric?
Manyothers!!!!
Improve
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% of a provider’s patients 18-75 who are in the Diabetes registry AND who have the DPC provider listed in the Maestro PCP field AND who have a visit anywhere in the Duke system within the reporting period who meet all 5 of the following criteria:
- A1c <8.0- BP < 140/90 (<150/90 for age >60)- On a statin OR have a documented allergy in the allergy list to statin OR are
<40 y/o- On anti-platelet therapy OR have a documented allergy in the allergy list to
aspirin OR <40 y/o OR 10 yr ASCVD <10% OR On Anticoagulation- Non-smoking status
Target: 25%
Final definition for the diabetes metric
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RIE demonstrated substantial gaps in use of ancillary services
Analyzed how several clinics take care of patients with diabetes.
Physicians were significantly involved in care but...
Improve
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What the rapid improvement event accomplished• Data: Progress bulletin boards in clinics• Rooming staff:
– CMAs performing diabetic foot exams– Standardize intake documentation around diabetic meds and
diet– Automatic referral to DM education for uncontrolled diabetics
• Nurses– New population health nurse– Outreach calls to diabetics
• Provider Resources– CME– Embedded diabetic education at some select practices– E Consults to endocrinology– Smoking cessation clinics
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Over the last year, providers have made improvement
70.0%
80.3%
72.1%
88.1%
62.2%
26.5%
73.1%
79.7%77.0%
89.1%
82.9%
36.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
A1C%Met BP%Met Statin%Met Smoke%Met AP%Met All5%Met
DPCTotalFY2016 DPCTotalFY2017
Improve
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Conclusions
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- Define, Measure, Improve…
- Quality and value can be approached systematically
- Quality metrics are pervasive in numerous clinical and insurance models
- Paying for quality can be an important component of a broader quality strategy
- Quality improvement methodologies can markedly improve the delivery of health care services
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Interesting thought questions
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- Are we measuring the right thing?
- Is “Value” or “Quality” creating dangerous incentives?
- What type of people and skills are needed to manage this?
- What is the next generation of value and quality?
