Cathy Schoen

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Aiming High Towards a High Performance, High
Value U.S. Health SystemPerformance Reporting
to Inform and Stimulate Action

• Cathy Schoen
• Senior Vice President, The Commonwealth Fund
• AHRQ Annual Meeting Improving Health Care,
  Improving Lives
• National Performance Measurement Reporting
  Session
• Bethesda, MD
• September 28, 2007
• www.commonwealthfund.org

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Performance Reporting to Inform and Stimulate
Action

• Importance of AHRQ Quality and Disparities
  reports and efforts to develop performance
  indicators supporting efforts to improve
• Need for focus on whole system and how dimensions
  interact Access, Quality, Efficiency and Equity
• Examples from Fund sponsored work that builds on
  AHRQ
• Composites and benchmarks
• Geographic and care system variations
• Efficiency (quality/cost) indicators
• Where performance reporting in going
• U.S. and international examples
• Future directions critical role of public
  performance information analysis to guide and
  drive change

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Commonwealth Fund CommissionGoals for A High
Performance Health System

• ACCESS EQUITY FOR ALL
• Universal participation
• Affordable
• Equitable

LONG, HEALTHY, AND PRODUCTIVE LIVES
EFFICIENCY
SYSTEM CAPACITY TO INNOVATE IMPROVE
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U.S. National Scorecard Why Not the
Best?Commonwealth Fund Commission National
Scorecard

• 37 Indicators
• U.S. compared to benchmarks

Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, September 2006.
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Aiming Higher Commonwealth Fund Commission
State Scorecard on Health System Performance

• State ranks
• 32 indicators

Source Commonwealth Fund State Scorecard on U.S.
Health System Performance, 2007
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Composites, Benchmarks and Geographic Variation

• AHRQ development of indicators of key concepts
  critical to inform efforts to improve performance
• Composites
• A limited number of key indicators enables view
  of overall patterns
• Can drill down to understand variation
• Benchmarks
• Top percentiles (hospitals nursing homes
  geographic areas systems) provide targets
• Goal Improve and narrow the distribution between
  leading/lagging
• Geographic variations and cross-cutting analyses

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Mortality Amenable to Health Care
Mortality from causes considered amenable to
health care is deaths before age 75 that are
potentially preventable with timely and
appropriate medical care
Deaths per 100,000 population
International variation, 1998
U.S. State variation,2002
Percentiles
Countries age-standardized death rates, ages
074 includes ischemic heart disease. See
Technical Appendix for list of conditions
considered amenable to health care in the
analysis. Data International estimatesWorld
Health Organization, WHO mortality database
(Nolte and McKee 2003) State estimatesK.
Hempstead, Rutgers University using Nolte and
McKee methodology.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Having an Accessible Primary Care Provider, by
Age Group, Family Income, and Insurance Status,
2002
Percent of adults with a usual source of care who
provides preventive care, care for new and
ongoing health problems, and referrals, and who
is easy to get to
Elderly adults
Nonelderly adults
Data B. Mahato, Columbia University analysis of
2002 Medical Expenditure Panel Survey.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Receipt of All Three Recommended Services for
Diabetics,by Race/Ethnicity, Income, Insurance,
and Residence, 2002
Percent of diabetics (ages 18) who received
HbA1c test, retinal exam, and foot exam in past
year


Insurance for people ages 1864. Urban
refers to metropolitan area gt1 million
inhabitants Rural refers to noncore area lt10,000
inhabitants. Data 2002 Medical Expenditure Panel
Survey (AHRQ 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Medicare Admissions for Ambulatory Care Sensitive
Conditions,Rates and Associated Costs, by
Hospital Referral Regions, 2003
Rate of ACS admissions per 10,000 beneficiaries
Costs of ACS admissions as percent of all
admission costs, average in region groups
Percentiles
Percentiles
Data G. Anderson and R. Herbert, Johns Hopkins
University analysis of 2003 Medicare Standard
Analytical Files (SAF) 5 Inpatient Data.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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State Variation Potentially Preventable Hospital
Admissions Indicators
Percent
DATA Medicare readmissions 2003 Medicare SAF
5 Inpatient Data Nursing home admission and
readmissions 2000 Medicare enrollment records
and MedPAR file Home health admissions 2004
Outcome and Assessment Information Set SOURCE
Commonwealth Fund State Scorecard on Health
System Performance, 2007
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Medicare Hospital 30-Day Readmission Rates and
Associated Costs, by Hospital Referral Regions,
2003
Rate of hospital readmission within 30 days
Readmission reimbursement as percent of total
reimbursement for all admissions
Quartile of regions ranked by readmission rates
Percentiles
Data G. Anderson and R. Herbert, Johns Hopkins
University analysis of 2003 Medicare Standard
Analytical Files (SAF) 5 Inpatient Data.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Where Performance Reporting Is Going U.S. and
International

• United States
• Multi-payer initiatives
• Quality and value cost and price reporting
• Physician level reporting
• Patient experiences H-CAHPS ambulatory
• Effort to define/assess/measure outcomes
• Development of episode of care quality/cost and
  better measures of care coordination
• International
• Expanded set of indicators and public reporting
• System and financial incentives to support/reward
  improvement

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MHQP Setting the Stage for Public Reporting
Commonwealth Fund/RWJ Project
Massachusetts first state to publicly report
hospital and medical group patient-centered care
survey data Massachusetts Health Quality
Partners
Source Melinda Karp, Reporting Patients
Experiences with Their Doctors Process, Politics
and Public Reports in Massachusetts,
Presentation March 31, 2006.
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Patient-Centered Hospital Care Staff Managed
Pain, Responded When Needed Help, and Explained
Medicines, by Hospitals, 2005
Percent of patients reporting always
Patients pain was well controlled and hospital
staff did everything to help with pain Patient
got help as soon as wanted after patient pressed
call button and in getting to the bathroom/using
bedpan Hospital staff told patient what
medicine was for and described possible side
effects Data CAHPS Hospital Survey for 254
hospitals submitting data in 2005. National
CAHPS Benchmarking Database SOURCE Commonwealth
Fund National Scorecard on U.S. Health System
Performance, 2006
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National Quality Benchmarking in Germany

• Size of the project
• 2,000 German Hospitals (gt 98)
• 5,000 medical departments
• 3 Million cases in 2005
• 20 of all hospital cases in Germany
• 300 Quality indicators in 26 areas of care
• 800 experts involved (national and regional)

• Ideas and goals
• ? define standards (evidence based, public)
• ? define levels of acceptance
• ? document processes, risks and results
• ? present variation
• ? start structured dialog
• ? improve and check

Source Christof Veit, The Structured Dialog
National Quality Benchmarking in Germany,
Presentation at AcademyHealth Annual Research
Meeting, June 2006.
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German Hospital Quality Improvement
Hamburg Antibiotic Prophylaxes in
Hip-Replacement.
2003 95,6
2004 98,5
2005 99,3

Hospitals
Source Christof Veit, The Structured Dialog
National Quality Benchmarking in Germany,
Presentation at AcademyHealth Annual Research
Meeting, June 2006.
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Improve Quality Transparency The Netherlands
Death-rate after stroke in bottom-20 hospitals

• Collect comparative data (quality indicators)
• Inspectorate examines care providers with
  different quality indicators
• Make quality differences visible through the
  internet

Source Hans Hoogervorst, Minister of Health,
Netherlands,, A Vision for Health Care in the
21st Century, Presentation to the Commonwealth
Fund International Symposium, November 2, 2006.
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The Impact of Public Reportingthe U.S. NCQA
Experience

• Ten years of measuring data measurement and
  public reporting leads to improvement
• U.S. children today nearly three times more
  likely to have had all immunizations as in 1997
• U.S. diabetics today twice as likely to have
  cholesterol controlled (lt130 mg/dL) as in 1998
• More than 96 of U.S. cardiac patients prescribed
  beta-blockers after a heart attack (up from 62
  in 1997) NCQA retired the beta-blocker/post
  hospital measure this year

BETA-BLOCKER TREATMENT AFTER A HEART ATTACK
Score 97 2005
Score 71 1996
Source National Committee for Quality Assurance
Thomas Lee, Eulogy for a Quality Measure, New
England Journal of Medicine, September 20, 2007.
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Aiming High Future Directions?

• Critical role of public information and analysis
  to guide and drive change
• AHRQ potential
• Public repository and public data
• Composites and benchmarks enable focus on
  variation, high/low performance areas and care
  systems
• Quality, access and cost analysis High Value
• Research and collaboration
• Linking quality-related research to performance
  indicators
• E-indicators potential with electronic health
  records
• Collaborative efforts to understand key drivers
  of high performance
• Whole system view primary and specialized care

Commonwealth Fund/RWJF project with Jinnet
Fowles, Park Nicollet and Jonathan Weiner, Johns
Hopkins.
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Related Commonwealth Fund Reports and Newsletters

• REPORTS
• Why Not the Best? Results from a National
  Scorecard on U.S. Health System Performance
  (Sept. 20, 2006). The Commonwealth Fund
  Commission on a High Performance Health System.
• Aiming Higher Results from a State Scorecard on
  Health System Performance (June 13, 2007). The
  Commonwealth Fund Commission on a High
  Performance Health System.
• NEWLETTERS
• Quality Matters
• States in Action
• Download at www.commonwealthfund.org/publications
  /

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Thank You! Acknowledgments
Karen Davis, President kd_at_cmwf.org
Stephen Schoenbaum, M.D., Executive Vice
President and Executive Director, Commission on
a High Performance Health System scs_at_cmwf.org
Tony Shih, M.D., Senior Program Officer for
Quality Improvement and Efficiency ts_at_cmwf.org
Sabrina How, Senior Research Associate skh_at_cmwf.o
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