Northeast Ohios Consumer Guide to Hospital Quality A Case Study

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Northeast Ohios Consumer Guide to Hospital
QualityA Case Study
The Community Healthcare Coalition, Inc.

• July 13, 2004

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Agenda

• Background Overview
• Review of Methodology
• Sample Reports
• Strategy for Public Release
• Vision for Next Iteration of Consumer Guide
  (Version 2.0)
• Questions

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Background Overview
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Background and OverviewThe Community Healthcare
Coalition, Inc.
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Background and OverviewCHC / EHPCO

• Founded in 1983 by 9 Canton employers to contain
  healthcare costs.
• More than 130 member companies domiciled in Ohio,
  West Virginia, Illinois, California, Iowa, New
  Hampshire and Pennsylvania.

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Background and OverviewCHC / EHPCO

• Monitor and lobby state and federal healthcare
  legislation
• Engaged in group purchasing for healthcare
  benefits
• Manage PBM contract for over 130 companies,
  school districts and munici-palities, covering
  nearly 400,000 lives.
• Community Initiatives

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Background and OverviewTimeline

• High Level Process of Hospital Guide Development
  

Initial data set received (CY2001)
Refresh data set received (CY2002)
Identified Healthshare as data partner
Developed Consumer Version
Project Kick-off
8/03
10/03
12/03
2/04
4/04
Today
Roll-Out Hospital Quality Guide
Developed Employer Version
Identified target conditions and measures
Reviewed initial data set and analyzed results

• Developing the Consumer Guide to Hospital Quality
  has been a collaborative effort between CHC,
  Mercer Human Resource Consulting, and HealthShare
  Technology

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Background and OverviewExperienced Group

• Key Players
• Mercer Human Resource Consulting
• Global consulting firm with employees in over 140
  cities and 40 countries with local knowledge and
  worldwide presence to develop and implement
  market leading solutions.
• Extensive experience in developing solutions that
  focus on improving health care programs for large
  purchasers, providers and government agencies.
• Leading in the development of national quality
  initiatives such as the Leapfrog Group, High
  Performance Networks, Emerging models of Consumer
  Driven Health Care (CDHC) and the Care Focused
  Purchasing Initiative.
• HealthShare Technology, Inc.
• HealthShares information and/or approach is the
  basis for 6 other regional and national health
  plan efforts regarding tiered networks, hospital
  value indexes or hospital pay-for-performance
  plans.
• Tufts Health Plan developed hospital tiers based
  on cost and quality for Massachusetts state
  employees, with varying employee co-payments
  dependent on the tier.
• Health plans representing over 80 million members
  currently offer HealthShares hospital comparison
  tool online at their web sites for consumer
  decisions pertaining to over 160
  procedures/diagnoses.

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Review of Methodology
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Review of MethodologyWhy MEDPAR Data?

• Data used to rank hospitals was provided by
  HealthShare Technology
• Medicare cost report data, MEDPAR, from 2002
  (the most recent year for which data is
  available) was the basis for the rankings
• At present, there is no publicly-available data
  pertaining to the commercially insured population
  in Ohio
• Correlation between hospital performance using
  Medicare data versus using all payer data
  (inclusive of Medicare) is consistently strong,
  both for quality and resource use metrics. (See
  discussion on next page)
• MEDPAR data is accepted in the marketplace as a
  basis for objective ratings among healthcare
  providers U.S. News and World Report also relies
  on MedPar data for its annual Americas Best
  Hospitals edition.

NOTE 2002 denotes the federal fiscal year (i.e.
fourth quarter 2001 and the first three quarters
of 2002).
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Review of MethodologyShortage of Public Data in
Ohio

• The National Association of Health Data
  Organizations (NAHDO) monitors the reporting
  requirements for healthcare data, both mandatory
  and voluntary, within the U.S. (Sample below)
• Overall, 38 states have mandatory collection
  through a state agency.

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Review of MethodologyMEDPAR Data is a Valid
Predictor

• In order to evaluate how representative Medicare
  data is as a predictor of a hospitals relative
  performance across all patients, HealthShare
  conducted a study in two states, New York and
  Massachusetts.
• HealthShare compared Medicare discharges with all
  payer discharges using 2002 publicly available
  data across all hospitals in NY and MA.
• After adjusting for severity of illness using
  RDRGs, Spearman Rank Correlation statistics were
  calculated. (See table below)

Note Results using the Pearson Product-Moment
Correlation statistic were very similar.
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Review of MethodologyWhat Hospitals are Measured?

• Fifty-eight Ohio hospitals that were deemed
  relevant to the membership of the Community
  Healthcare Coalition (based on county) were
  ranked for a group of clinical conditions/procedur
  es for which each had experience in 2002.
• It is important to note that comparisons were
  drawn among hospitals using ALL of the Ohio
  hospitals for which HealthShare has data, not
  merely those hospitals in the CHC dataset.
• Data pertaining to those Ohio hospitals that were
  not included in the CHC dataset will not be made
  available.

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Review of MethodologyWhat Hospitals are Measured?
Hospitals in the following counties were measured
and ranked Ashland, Ashtabula, Columbiana,
Cuyahoga, Erie, Geauga, Holmes, Huron, Lake,
Lorain, Mahoning, Medina, Portage, Richland,
Stark, Summit, Trumbull, Tuscarawas, Wayne. (star
locations may not accurately reflect true
geography)
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Review of MethodologyWhat Conditions and
Treatments are Measured?
Hospitals were measured and ranked for these ten
commonly measured conditions and/or procedures.

• General Surgery
• Colon Surgery
• Orthopedic Surgery
• Hip Replacement
• Knee Replacement
• Pulmonary Disease
• Pneumonia
• Chronic Obstructive Pulmonary Disease (COPD)

• Cardiac Care
• Abdominal Aortic Aneurysm Repair (AAA)
• Heart Attack/Angioplasty
• Coronary Artery Bypass Graft (CABG)
• Carotid Artery Surgery
• Cardiac Catheterization

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Review of MethodologyHow is the Data
Risk-Adjusted?

• Before meaningful comparisons can be drawn
  between hospitals, the data must be risk adjusted
  to account for the fact that some hospitals tend
  to handle sicker patients than do others.
• With the exception of procedure volume, ALL of
  the aforementioned quality and resource use
  metrics have been risk adjusted.
• Risk adjustment was accomplished through Refined
  Diagnosis Related Groups (RDRGs) which relate
  common patient characteristics such as diagnosis,
  procedures, age and gender to an expected
  consumption of hospital resources and length of
  stay.
• 1,178 RDRGs (510 Medical, 616 Surgical, 26 Early
  Death, 26 Other)
• The principal diagnosis or procedure combined
  with the secondary diagnosis place each patient
  into an RDRG which reflects their severity
  (minor, moderate, major, catastrophic).

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Review of MethodologyWhat are the Key Metrics?

• For each clinical condition and/or procedure,
  hospitals were evaluated on the basis of multiple
  metrics.
• Some of the metrics address the quality of care
  while others capture the efficiency of resource
  utilization (Resource Use).
• The metrics chosen for these rankings are a
  sampling of those prevalent in the marketplace
  which Mercer and HealthShare advocate. There are
  other metrics by which hospitals could be
  measured and compared that are not incorporated
  in these rankings.

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Review of MethodologyWhat are the Key Metrics?

• QUALITY METRICS
• (1) Procedure Volume the total number of
  patients treated in 2002 (federal fiscal year)
• (2) Mortality percentage of patients with a
  discharge disposition of expired (in-hospital
  mortality)
• (3) Major Complications percentage of patients
  that have experienced one/more of the following
  quality indicators
• Pulmonary Compromise Urinary tract infection
• Acute Myocardial Infarction after
  surgery Pneumonia after surgery
• GI Hemorrhage Wound infection
• Venus Thrombosis/Pulmonary Embolism Adverse
  effects
• Mechanical complications (malfunction of
  device/graft/implant)
• (4) Failure to Rescue percentage of patients
  that die following the development of a
  complication. (Underlying assumption is that
  good hospitals may not be able to prevent
  complications, but they identify these
  complications quickly and treat them aggressively
  to prevent adverse outcomes such as death).

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Review of MethodologyWhat are the Key Metrics?

• RESOURCE USE METRICS
• (Informational use only, not reported in Consumer
  Guide Version 1.0)
• (1) Length of Stay (LOS) number of days patient
  stays in healthcare facility calculated as admit
  date minus the discharge date
• (2) Short LOS outliers atypically short stays in
  the hospital, where atypical is the bottom 5 of
  all peer group hospitalizations
• (3) Long LOS outliers atypically long stays in
  the hospital, where atypical is the top 5 of all
  peer group hospitalizations
• (4) Total Charges average total charges of
  patients discharged within a specified service
  line.
• (5) Total Cost average total costs of patients
  discharged within a specified service line.
  (Detail on next page)
• Note that total charges/costs have no direct
  relation to the actual reimbursement received by
  the hospital from Medicare

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Review of MethodologyWhat are the Key Metrics?

• RESOURCE USE METRICS (cont) Charges and Costs
• Approach is basic ratio of costs to charges (RCC)
• RCCs calculated for each hospital department
  using 2 data points from the specific hospitals
  Medicare Cost Report (1) Charge, (2)
  Total Cost after indirect allocation
• Department specific RCCs applied against
  department charges for each patient to derive
  total and direct cost for each patient by dept.
• Total costs include capital and exclude Direct
  Medical Education (DME).

RCC Department Costs / Department Charges
Patient Cost for Dept RCC Patient Charges for
Dept
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Review of MethodologyHow are the Hospitals
Ranked?

• Every hospital was awarded a single quality
  ranking and a single resource use ranking for
  each of the ten conditions and/or procedures.
• In order to arrive at these single ratings, each
  metric (4 for quality and 5 for resource use) was
  scored as a 1,2,3 or 4 where 1 signifies the best
  performance and 4 signifies the worst. The score
  for each metric translated into a specified
  number of points depending on the desired weight
  of that metric.
• All of the metrics that support the resource use
  ranking were weighted equally (20).
• For the quality ranking, however, the four
  metrics carry different weights
• Procedure Volume 40 Mortality 20
• Major Complications 30 Failure to Rescue 10

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Review of MethodologyHow are the Hospitals
Ranked?

• Procedure Volume was weighted more heavily than
  the other metrics because it has long been
  associated with better quality outcomes. While
  there are many reputable journal articles on this
  subject, the following had the greatest impact on
  the decision to weight this most heavily
• Birkmeyer M.D., John D. Hospital Volume and
  Surgical Mortality in the United States. The
  New England Journal of Medicine (April 11, 2002)
  1128-1137.
• Kizer M.D., M.P.H., Kenneth W. The
  Volume-Outcome Conundrum. The New England
  Journal of Medicine (November 27, 2003)
  2159-2161.
• Failure to Rescue carried less weight than the
  other quality metrics, not because its validity
  as an indicator of quality is questionable, but
  rather because it is a novel way of describing
  quality.

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Review of Methodology How are the Hospitals
Ranked?

• The points were summed across all of the metrics
  that impact resource use and SEPARATELY across
  all of the metrics that impact quality of care.
• The resource use and quality rankings are
  mutually exclusive.
• Finally, the hospitals were ranked (within each
  condition) based on these point totals with
  possible scores ranging from 1 to 10, where 1
  signifies the best overall performance and 10
  signifies the worst.
• An example follows...

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Review of Methodology How are the Hospitals
Ranked?

• The following table shows how we arrived at the
  QUALITY rank for Cardiac Catheterization
  performed at Hospital X
• Hospital X earned 43 out of 100 possible points
  placing it in tier 8 of 10 compared to all other
  hospitals that performed the procedure.

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Review of Methodology How are the Hospitals
Ranked?

• The following table shows how we arrived at the
  RESOURCE USE rank for Cardiac Catheterization
  performed at Hospital X
• Hospital X earned 64 out of 100 possible points
  placing it in tier 5 of 10 compared to all other
  hospitals that performed the procedure.

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How to Understand the Employer and Consumer Guide

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Sample ReportsWhy Two Versions of the Same
Report?

• Ultimate goal was to provide a useful consumer
  tool comparing cost AND quality
• Due to managed care network discounts and the
  artificial nature of charge data, CHC decided to
  leave resource use out of the Consumer Version to
  avoid confusion and frustration
• However, CHC felt it important to provide
  resource use data to employers and hospital
  executives in the spirit of transparency and
  disclosure
• Corporate version is much more detailed, showing
  each hospitals score for every indicator. The
  consumer version rolls each score up to an
  overall rating that is easier for consumers to
  digest.
• Receipt of Corporate Version is predicated upon
  participation in a one-hour training session to
  ensure understanding and responsible use

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Strategy for Public Release of the Consumer Guide
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Strategy for Public ReleaseUndisclosed to Ranked
Hospitals

• Experience of failed voluntary reporting systems
  in other Ohio markets indicated that CHCs report
  should remain undisclosed to ranked hospitals
  until completed
• Also, CHC had a desire to avoid endless
  discussion and consensus building without
  eventual public release of the data
• Finally, CHC wanted to demonstrate to the
  provider community that the employer community is
  serious about and committed to transparency and
  disclosure in the healthcare industry
• Relied on expertise of Mercer and HealthShare as
  well as academic literature to validate data and
  methodology

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Strategy for Public ReleaseManaging Public
Relations

• Hired Strategy One, a local public relations
  firm, to lend strategic and practical advice and
  guidance
• PR firm developed release strategy
• Sent two non-descript press releases in advance
  of the public release announcing an upcoming
  press conference
• Provided confidential copies of the report to
  trusted sources for advance story preparation
• Allowed press access to both Corporate and
  Consumer Versions of the Report in the spirit of
  transparency
• Focused on print and radio outlets rather than
  visual media outlets due to the academic nature
  of the story

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Strategy for Public ReleaseManaging Public
Relations

• Invitations to the Friday morning meeting were
  the first notice that hospital
• executives received of the report. Letters
  were sent certified, directly to the
• CEO, to ensure delivery and receipt.

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Strategy for Public ReleaseAn Assessment of the
Strategy

• Despite objections of the hospitals, CHCs
  strategy was successful
• Positive coverage of the guide in 5 major
  newspapers
• Akron Beacon Journal
• Canton Repository
• Youngtown Business Journal
• Lorain Daily News
• Warren Tribune
• Story on Cleveland NPR affiliate
• Articles presented in an informative light, with
  limited negative quotes from hospital executives

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Strategy for Public ReleasePost-Release Activity

• Conducting one-on-one meetings with hospitals
• Conducting additional employer training meetings
  as requested
• Hosting a training session for practicing
  physicians and/or office staff in late July
• Founding a Quality Council for Northeast Ohio
• Partnership of the Akron Regional Hospital
  Association
• Support of the Ohio Hospital Association
• Quality Council will serve as advisory and
  editorial board of all future versions of the
  Consumer Guide to Hospital Quality

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Strategy for Public ReleaseAnticipated Use by
Employers

• To date, CHC has distributed 19,463 copies of the
  Consumer Guide to employers for distribution to
  associates. Many employers also plan to release
  a PDF version via intranet or email
• Two common strategies by employers
• Immediate release of the Guides with an
  accompanying memo from the benefits manager
• Delay distribution of Guides until Fall to
  supplement open enrollment materials
• CHC provided members with a template FAQ document
  to address potential questions from associates
  such as
• Why do the results in this report differ from
  others that I have seen?
• What if my in-network hospitals do not rank well?

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Strategy for Public ReleaseCommon Hospital
Objections

• Frustration with the simultaneous release of the
  report to the hospitals and the media. Hospitals
  expressed a desire for an opportunity to peer
  review or at least have time to prepare a
  statement for the media
• Strong objections to volume weighted at 40
• Concerns from small rural and community hospitals
• Suggestion to set a volume threshold rather than
  reward mass-production of procedures and
  treatments
• Concerns about potential misuse by patients
• Emergency situations
• Generalizing about care overall based on total
  number of 5 star rankings
• Worry that consumers are becoming overwhelmed by
  multiple sources of hospital quality comparison
  and the potential for confusion about conflicting
  results

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Vision for Next Iteration of Reports (Version
2.0)
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Vision Version 2.0
The vision for the next iteration of the Consumer
Guide to Hospital Quality would include the
following enhancements

• Incorporate commercial payer data into the
  rankings. As a result, include more clinical
  conditions and/or procedures, especially OB/GYN
  and pediatric related services
• Distribution in an interactive, online format as
  opposed to pamphlets
• Measure and rank all hospitals statewide
• Incorporate efficiency measures into the consumer
  version
• Measure physician quality/efficiency

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Questions