Performance Transparency and Improvement: The Uniquely American Journey

1
Performance Transparency and Improvement The
Uniquely American Journey
Lewis G. Sandy MD American Health Quality
Association Annual Meeting February 25, 2009
2
UnitedHealth Group Mission

• Our mission is to help people live healthier
  lives.
• We seek to enhance the performance of the health
  system and improve the overall health and
  well-being of the people we serve and their
  communities.
• We work with health care professionals and other
  key partners to expand access to high quality
  health care so people get the care they need at
  an affordable price.
• We support the physician/patient relationship and
  empower people with the information, guidance and
  tools they need to make personal health choices
  and decisions.

3
How Old is the Performance Measurement and
Improvement Movement in the US?
"Every hospital should follow every patient it
treats long enough to determine whether the
treatment has been successful, and then to
inquire if not, why not with a view to
preventing similar failures in the future."
Ernest Codman, 1914
4
So Are We Done Yet?...

• Adults receive about half
• of recommended care
• 54.9 Overall care
• 54.9 Preventive care
• 53.5 Acute care
• 56.1 Chronic care

Not Getting the Right Care at the Right Time
Source McGlynn EA, et al., The Quality of
Health Care Delivered to Adults in the United
States, New England Journal of Medicine, Vol.
348, No. 26, June 26, 2003, pp. 2635-2645
5
And We Have A Healthcare Affordability Crisis

• Results
• 47M uninsured
• Rising underinsured

Its a Crisis
Sources KFF/HRET 2007 Employer Health Benefits
Survey, BLS Consumer Price Index
6
Rx An Integrated Approach to Quality and
Affordability
Personal Health Support
Incentives
Consumers
Information
Choice
Clinical Data
Employers
Physicians Facilities
Clinical Improvement
Affordability
7
Measuring Physician Quality and Cost
EfficiencyEpisodes of Care
Radiologist
Reference Lab
Primary Care, MD
Specialist

Episode Example ETG 29 Type 2 Diabetes, with
comorbidity (other illnesses)
ANALYSIS
Hospital B for Rehab
UnitedHealthcare
Emergency Room
Now we can see all services for which we have
claims across all providers.
Hospital A for Surgery
Ambulance
Pharmacy I
Pharmacy II
8
UnitedHealth Premium Designation
Episodes/ procedures analyzed for efficiency of
care benchmarking market specialty averages and
case mix/severity adjusted
24 months of data is collected and analyzed on
all physicians in the specialties eligible for
designation
Physicians who meet/exceed the quality criteria
are designated by a quality star and proceed to
the efficiency of care analysis
The quality screens are applied based on
specialty and, where applicable, condition
Physicians who meet or exceed market cost
criteria are designated
Quality and Efficiency of Care Designation
Quality Only Designation
9
Designation Display on myuhc.com
Individual

• Designation status identified online
• Quality and efficiency ??
• Quality only ?
• Specialty not evaluated
• Insufficient UnitedHealthcare data
• Not displayed upon physicians request

10
Medical Professional Practice Improvement Online
Physician Level and Detail Reports

• Actionable information comparing physician
  performance to national quality standards and
  market cost efficiency standards
• A view of the entire episode of care
• Patient level detail reports provide physicians
  with specific patient data attributed to their
  designation
• Online detail reports available through the
  physician Web site, www.UnitedHealthcareOnline.com

11
Where Is This Field Today?

• Growing Sophistication and Understanding of
• Performance Assessment Tools and Techniques
• Clinical Improvement Methods and Tools
• Emergence of Standards
• National Quality Forum-re-energized and focused
• AMA PCPI-evolving beyond PQRI
• NYAG/NCQA-measuring the measurers
• Consumer-Purchaser Disclosure Project-its about
  us!
• Evalu8 RFI-incenting plans
• Promising Data Aggregation initiatives
• Certifying Boards Mandating Improvement for MOC
• An Important Element of Health Reform?

12
UnitedHealthcare Awarded NCQA Physician and
Hospital Quality Plus Distinction

• Four key principles served as the foundation for
  development of NCQA's
• Physician and Hospital Quality standards
• Standardization NCQA supports standardized
  measures where it is not possible, it encourages
  the drive towards standardization. Quality and
  resource use measures must be evidence-based,
  reliable and valid.
• Transparency These standards require that
  measurement specifications be available to the
  organizations being measured and the public.
• Collaboration These standards encourage
  collaboration between plans by streamlining the
  review process for organizations participating in
  collaborative initiatives. The standards also
  support collaboration between plans and
  providersa key to successful measurement
  activities.
• Action The objective of measurement is quality
  improvement and affordability. Plans should take
  specific actions to improve performance such as
  reporting and engaging in quality improvement
  activities or using payment and product design
  strategies.

24 UnitedHealthcare plans hold NCQA Quality Plus
distinctions
13
UnitedHealthcare Supports Consumer Disclosure
Projects Patient Charter

• Standard set of principles for performance
  measurement and reporting assessed by an
  independent review organization.
• Supported by Physicians, Consumers, Labor,
  Purchasers, and Payors including
• American College of Physicians, American Academy
  of Family Physicians, American Medical
  Association, American College of Cardiology,
  American College of Surgeons
• Following the charter will mean that
• Consumers can make more informed decisions based
  on both quality and cost, with adequate guidance
  about how to use the information and any
  limitations in the data.
• Measurement is based on sound national standards
  and methodology.
• Both consumers and physicians have input into the
  measurement process and how results are reported.
  
• Measurement is a transparent process so that both
  consumers and physicians can understand the basis
  upon which performance is being measured and
  reported.
• Physicians have adequate notice and opportunity
  to correct any errors.
• Physicians will have information that helps them
  improve the quality of care they provide.

14
QASC A Promising Data Aggregation Initiative

• The Quality Alliance Steering Committee (QASC) is
  a collaborative effort among government agencies,
  physicians, nurses, pharmacists, hospitals,
  health insurers, consumers, accrediting agencies,
  foundations and others
• QASC co-chairs
• Carolyn Clancy, MD, Director, Agency for Health
  Care Research and Quality
• Mark McClellan, MD, PhD, Director, Engelberg
  Center for Health Care Reform at the Brookings
  Institution.
• Vision to advance a high-quality, affordable,
  patient-centered health care system through the
  coordination of various groups that are working
  to provide public information on health care
  providers performance.
• The QASC will actively support the implementation
  and use of standard health care performance
  information for
• Performance improvement directly by providers
• Public reporting and more informed consumer
  decision-making
• Effective public policies, payment policies, and
  consumer incentives that reward or foster better
  provider performance

15
Many critical partners needed to optimize the
system
NQF National Priorities Partners
AHRQ
Foundations Other
NCQA The Joint
Commission AMA PCPI
Medical Societies Medical Specialty
Boards CMS
AHRQ Others
Set national priorities and goals to drive
improvement and affordability
Continuously evaluate health and
health care
QIOs
Regional Collaboratives

Providers
Oversight Organizations
Employers
Health Plans
Improve quality and reduce waste
Consumer Outcomes High Quality Equitable
Affordable Patient-Centered
Develop and test evidence-based measures
Establish effective public policies, payment
policies, and consumer incentives to reward or
foster better performance
NQF
Fed/State Govt Health Plans Employers
Consumers Providers
Endorse and maintain measures and incorporate
specifications into EHRs
Develop coordinated and streamlined
implementation strategies prioritization,
timelines, and process solutions
Generate public reports on quality and cost
Aggregate data and pilot test and validate
standard performance information
QASC Quality Alliances
Joint Commission NCQA
Medical Specialty Boards
Regional Collaboratives Fed/State Govt.
Health Plans
Others
QASC Regional Collaboratives
RHIOs/HIEs CMS
States Health
Data Stewards
June 6, 2008
15
15
List of all involved partners available.
Nursing, Academic
Communities, etc.
16
Practice-based Feedback Regional-National
Innovation

• National Coordination
• Performance Measure Standard
• Methodological Standards
• Technical Standards
• Data Aggregation Standards
• Implementation Strategies
• Promotion of Best Practices

Regional Experience
Regional Experience
Consistency
17
Performance Transparency and Improvement A
Field With Some Evolving Coherence?

• Movement towards convergence on standard measures
  (NQF, PCPI)
• Emerging standards for measuring the measurers
  (NYAG RX/NCQA/CPDP Pt. Charter)
• Societies and Certifying Boards beginning to
  align
• Guideline development
• Registry and performance improvement programs
• MOC
• On the other hand.
• There are a plethora of regional and local
  initiatives
• Many of which are naïve, are reinventing the
  wheel, and/or have no sustainable business
  model.

Ongoing Communication and Collaboration are the
key to continuing progress!
18
Will We Get It Right?
You can always trust the Americans. in the end
they will do the right thing, after they have
eliminated all the other possibilities