The Quality Imperative: Creating a New Health Care System

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The Quality ImperativeCreating a New Health
Care System

• Janet M. Corrigan, PhD
• President and CEO
• National Quality Forum

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Creating a New Health Care System

• Background on NQF
• Quality - A Growing Sense of Urgency
• National Strategy for Fundamental Change
• Strengthening the National Quality Measurement
  and Reporting Capacity

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National Quality Forum

• Presidents Advisory Commission 1998
• NQF became operational 2000
• Merger with National Committee for Quality Health
  Care - 2006

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NQF -- Purpose

• To improve the quality of health care
• Transparency
• Endorse national standards for performance
  measurement and public reporting
• Education and Information Dissemination
• Policy-to-practice bridgehe mission of the NQF is
  to improve American healthcare through
  endorsement of consensus-based national standards
  for measurement and reporting of healthcare
  performance data that provide meaningful
  information to the public and healthcare
  providers about whether care is safe, timely,
  patient-centered, beneficial, equitable and
  efficient.
• The mission of the NQF is to improve American
  healthcare through endorsement of consensus-based
  national standards for measurement and reporting
  of healthcare performance data that provide
  meaningful information to the public and
  healthcare providers about whether care is safe,
  timely, patient-centered, beneficial, equitable
  and effici

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National Quality Forum Key Characteristics

• Open membership organization (330)
• Multi-stakeholder
• Public and private sector partnership
• Voluntary consensus standard setting body

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National Technology and Transfer Advancement Act
of 1995

• Defines 5 attributes of voluntary consensus
  standards body (i.e., openness, balance of
  interest, due process, consensus, and appeals
  process)
• Obligates federal government to adopt voluntary
  consensus standards (when adopting standards)
• Encourages federal government to participate in
  setting voluntary consensus standards

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NQF-Endorsed Measures

• Over 200 measures, events, practices
• Standardized specifications to facilitate
  comparisons
• Science-based, field-tested
• Best in class
• Publicly availableopen source
• Maintenance structure
• Measures of choice by federal government and
  others

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Growing Sense of UrgencyJust the Facts

• 55 overall adherence to recommended care
• Health care costs rising 1.5 to 2 times the rate
  of inflation
• Uninsured now total 45.5 M
• Up to 2-fold variation in per capita spending
  across communities
• U.S. spends more than all other industrialized
  countries by sizable margins

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Current National Strategy forClosing the Quality
Gap

• Create a marketplace rich in information on
  quality and cost (public reporting)
• Reward providers for providing safe and effective
  care and doing it efficiently (P4P)
• Encourage patients to seek high value providers
  by having skin in the game (high deductible
  plans, HSAs)

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Pay-for-Performance

• About 200 P4P projects
• Half target physicians and one-third hospitals
• Rely on process measures
• Incentive payments- 2 to 6

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CMS DEMOS AND VOLUNTARY REPORTING

• Demos, Demos, Demos
• Premier Hospital Quality
• Physician Group Practice
• Medicare Care Management
• Medicare Health Care Quality
• Medicare Health Support
• Dx Mgmt for Severely, Chronically Ill
• Dx Mgmt for Dual Eligible
• ESRD Dx Mgmt
• Care Mgmt for High Cost Beneficiaries
• Nursing Home P4P

• Voluntary Reporting
• Hospitals (P4R)
• Physicians

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Providers Engaged in Selecting Developing
Measures

• Broad-based Collaborative Efforts
• Hospital Quality Alliance
• Ambulatory Care Quality Alliance
• Pharmacy Quality Alliance
• Cancer Quality Alliance
• Specialty Specific Efforts
• 30 specialty/subspecialty societies
• 100 measures?

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Starter Sets
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Impact of P4P and Public Reporting?

• Financial incentives motivate change.
• Public reporting is strong incentive too.
• Engaging/educating physicians is critical.
• Information integrity is important.
• P4P is not THE solution part of a broader
  effort.

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National Quality Measurement Reporting
Infrastructure Areas for Improvement

• Lack a Coherent Strategy for Focusing and
  Evolving Measure Sets
• Variability in Measures
• Lack a Single Pipeline for Pooling Reporting
  Data
• Lack of a Model of Accountability

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NQF Strategic Framework BoardNational Quality
Measurement and Reporting System
Goals
Measure Development
NQF Endorsement
Measure Selection For Public Reporting
Data Collection, Aggregation, Verification
Public Reporting
Accountability
QI
Were the 6 Aims and Goals Achieved?
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National Goal-Setting Capacity is Needed

• NQF Will Engage Leaders in Setting Community-wide
  Transformational Goals
• Population health behaviors environmental
  safety threats
• Leading chronic conditionscomposite measures and
  longitudinal efficiency
• Cross cutting process issuescare coordination
  team communication medication management
• Patients and family caregivers health literacy,
  engagement in decision-making self-management
• End of life care

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Performance Measurement and Reporting Current
Status

• Starter Sets
• Provider is unit of analysis (e.g., hospital)
• Low hanging fruit available from claims data
  
• Primarily narrow process measures
• Some patient perceptions

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Evolution of Measure Sets

• Current measure sets have
• Limited scope of measurement
• Narrow time window
• Provider-centric focus
• Narrow definition of accountability

• Future measure sets will be
• Comprehensive
• Longitudinal
• Patient and population focused
• Shared accountability
• Adapted from IOM, 2005

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Longitudinal Measures

• Patient episode of illness- unit of analysis
• Process and outcomes
• Underuse and overuse
• Composite measures --Did the patient receive all
  the services from which they would likely have
  benefited?
• Longitudinal efficiency Did the patient receive
  only the services from which they would likely
  have benefited?

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Diabetes Composite Measure

• Numerator -- diabetic patients that received all
  5
• evidence-based services
• 
  
  
• Denominator Type 1 and Type 2 diabetics age
  18-75
• HbA1clt 8 percent mg/dl LDL cholesterol lt 130
  mg/dl blood pressure lt 130/85 mmHg aspirin for
  gt 40 years documentation of non-use of tobacco.
• 
  

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Variability in Performance Measures

• Sizable number of measure developers with varying
  levels of capability and experience
• Need standardized format for measure
  specifications
• More coordination with EHR standard setting and
  vendor community will be critical

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Lack of Single Pipeline for Pooling Reporting
Data

• Unnecessary Burden Providers comply with
  numerous payer-specific reporting requirements.
• Less Reliable Conclusions Complete view of
  providers practice is lacking.
• Public Confusion Many public reporting
  programs-different measures, different subset of
  patients, different formats.

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Data Collection, Aggregation and Verification

• AQA
• 6 regional pilots for pooling data
• HQA
• Booz, Allen and Hamilton assessment of hospital
  measurement and reporting issues includes
  alternative options for creating a single pipeline

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Public Reporting

• Medicare Compare
• Most significant effort
• Public and private sector data for some providers
  
• To date, institutional providers only

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AQA National Health Data Steward

• Data Analysis
• Data Validation
• Use of Data
• Data Access

• Data Aggregation
• Data Collection
• Data Attribution
• Methodologies

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Lack of an Accountability Model

• Rationalize Payment
• Greater focus on populations (capitation) and
  patients (per episode) to achieve greater
  emphasis on
• Access
• Prevention and early detection
• Align payments with appropriate level of
  accountability
• Capital investment in systems and organizational
  supports
• Flexibility

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Lack of an Accountability Model

• Develop Systems of Care and Hold Accountable
  for Longitudinal Performance
• Quality health care is a team sport
• Patients needs cross settings and professionals
• Organizational supports are critical
• Greater system integration needed
• Standardization of care processes
• Shared accountability shared rewards

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• National Quality Forum
• www.qualityforum.org