Panel on Measuring Quality and Value Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality IOM Committee Meeting on Geographic Variation.

Panel on MeasuringPanel on MeasuringQuality and ValueQuality and Value

Carolyn M. Clancy, MDCarolyn M. Clancy, MDDirectorDirector

Agency for Healthcare Research and QualityAgency for Healthcare Research and Quality

IOM Committee Meeting on Geographic Variation inIOM Committee Meeting on Geographic Variation inHealthcare Spending and Promotion of High Value CareHealthcare Spending and Promotion of High Value Care

Washington, DC – November 10, 2010Washington, DC – November 10, 2010

Not Just for Policy WonksNot Just for Policy Wonks

Up to 30 percent of health Up to 30 percent of health care spending goes care spending goes toward useless treatments toward useless treatments that we don’t needthat we don’t need

Overtreatment costs the Overtreatment costs the U.S. system $700 billion a U.S. system $700 billion a yearyear

““Unnecessary treatment Unnecessary treatment and tests aren’t just and tests aren’t just expensive; they also can expensive; they also can harm patients.”harm patients.”

What the Measures Tell Us What the Measures Tell Us TodayToday

Variation:Variation:– In care deliveryIn care delivery

– In spendingIn spending

– Across populationsAcross populations

– Across geographic regionsAcross geographic regions

Need to Document, RigorouslyNeed to Document, Rigorously

Recent LegislationRecent Legislation

Measuring Quality and ValueMeasuring Quality and Value

Improving Value:Improving Value:Three Necessary IngredientsThree Necessary Ingredients

Good measures and dataGood measures and data Evidence-based payment and incentivesEvidence-based payment and incentives Evidence-based strategies for improvementEvidence-based strategies for improvement

Leading to three paths:Leading to three paths: Transparency and public Transparency and public

reportingreporting Pay-for-performance and Pay-for-performance and

payment reformpayment reform Provider-based redesign and Provider-based redesign and

quality improvementquality improvement

Good Measures, Good Data Good Measures, Good Data Will Bridge the GapWill Bridge the Gap

Healthcare Cost and Utilization Healthcare Cost and Utilization Project (HCUP)Project (HCUP)

Quality IndicatorsQuality Indicators

Medical Expenditure Panel Medical Expenditure Panel Survey (MEPS)Survey (MEPS)

CAHPSCAHPS

National Healthcare Quality & National Healthcare Quality & Disparities ReportsDisparities Reports

AHRQ’s Role: Supplying the DataAHRQ’s Role: Supplying the Data

AHRQ Prevention Quality Indicators (PQIs): Potentially Avoidable

Hospitalizations

National hospital costs for National hospital costs for potentially avoidable potentially avoidable hospitalizations (adjusted for hospitalizations (adjusted for inflation)inflation)

decreased from $31.9 billion in decreased from $31.9 billion in 2003 to $30.1 billion in 2006 2003 to $30.1 billion in 2006 Changes are largely Changes are largely attributable to avoidable attributable to avoidable hospitalizations involving hospitalizations involving chronic conditionschronic conditions

These hospitalizations can be These hospitalizations can be the result of inadequate self-the result of inadequate self-management as well as management as well as inefficiency in the health care inefficiency in the health care systemsystem

AHRQ 2009 National Healthcare Quality ReportAHRQ 2009 National Healthcare Quality Report

Geographic VariationGeographic Variation

While there is wide variation While there is wide variation in care quality across states:in care quality across states:– Those in the upper Midwest Those in the upper Midwest

and New England tend to and New England tend to achieve the highest overall achieve the highest overall qualityquality

– States in the southwest and States in the southwest and south central tend to have the south central tend to have the lowest care qualitylowest care quality

Disparities Report: Key FindingsDisparities Report: Key Findings

Disparities are commonDisparities are common Lack of insurance is an Lack of insurance is an

important contributorimportant contributor Many disparities are Many disparities are

not decreasingnot decreasing

These variations These variations indicate that a basic indicate that a basic IOM tenet of quality IOM tenet of quality care—that care should care—that care should be equitable—is not be equitable—is not being metbeing met

How Do They Do That?How Do They Do That?

Lowest region in state (actual-expected)Lowest region in state (actual-expected) La Crosse, WILa Crosse, WI Portland, ME (one of only two HRRs in Maine)Portland, ME (one of only two HRRs in Maine) Asheville, NCAsheville, NC

Actual cost < expectedActual cost < expected Temple, TX (second lowest after Lubbock)Temple, TX (second lowest after Lubbock) Everett, WA (second lowest after Spokane)Everett, WA (second lowest after Spokane)

Four are problematicFour are problematic Richmond, VA (highest actual-expected in state)Richmond, VA (highest actual-expected in state) Sacramento, CA (actual > expected)Sacramento, CA (actual > expected) Cedar Rapids, IA (actual > expected, but in a low-cost state)Cedar Rapids, IA (actual > expected, but in a low-cost state) Tallahassee, FL (actual > expected)Tallahassee, FL (actual > expected)

Source: Source: Calculations from HCUP data using Dartmouth Atlas regions Calculations from HCUP data using Dartmouth Atlas regions http://www.ihi.org/IHI/Programs/StrategicInitiatives/HowDoTheyDoThat.htm?TabId=0http://www.ihi.org/IHI/Programs/StrategicInitiatives/HowDoTheyDoThat.htm?TabId=0

Multi-stakeholder effort examining high-performing regionsMulti-stakeholder effort examining high-performing regions

Important ProvisionsImportant Provisions

National Strategy to Improve Health Care National Strategy to Improve Health Care Quality Quality

Interagency Working Group on Health Care Interagency Working Group on Health Care QualityQuality

Quality Measure DevelopmentQuality Measure Development Data, Collection, Analysis and Public Data, Collection, Analysis and Public

ReportingReporting Health Care Quality Improvement (CQuIPS)Health Care Quality Improvement (CQuIPS) Patient-Centered Outcomes Research Patient-Centered Outcomes Research

InstituteInstitute

Payment Based on Quality, Payment Based on Quality, Safety and Value Safety and Value

National Pilot Program on Payment BundlingNational Pilot Program on Payment Bundling– HHS to work with AHRQ and a contract entity to develop HHS to work with AHRQ and a contract entity to develop

episode of care and post-acute quality measuresepisode of care and post-acute quality measures

Health Care Quality ImprovementHealth Care Quality Improvement– AHRQ’s Center for Quality Improvement and Patient AHRQ’s Center for Quality Improvement and Patient

Safety (CQuIPS) will identify, evaluate, disseminate, and Safety (CQuIPS) will identify, evaluate, disseminate, and provide training on best practices on quality, safety and provide training on best practices on quality, safety and valuevalue

– CQuIPS will award grants or contacts to provide CQuIPS will award grants or contacts to provide technical support or implements models and practices technical support or implements models and practices identified in researchidentified in research

– Technical grants also provided for organizations without Technical grants also provided for organizations without infrastructure or resourcesinfrastructure or resources

What’s Next? National Health What’s Next? National Health Care Quality StrategyCare Quality Strategy

Part of Affordable Care Act Part of Affordable Care Act

Builds on work of federal, Builds on work of federal, state, local and private state, local and private initiatives; identifies what initiatives; identifies what works and what needs works and what needs improvementimprovement

Move from provider-level Move from provider-level transparency to a patient-transparency to a patient-focused approachfocused approach

Evidence Still Weak on Evidence Still Weak on Critical Design Components Critical Design Components

What to reward?What to reward?– structure, process, or outcomesstructure, process, or outcomes– Improvement or achievement Improvement or achievement

How structure reward?How structure reward? Market factors affecting rewardsMarket factors affecting rewards

– How much market share do you need?How much market share do you need?

How much of what kind of a payment How much of what kind of a payment scheme is needed to correct perverse scheme is needed to correct perverse incentives?incentives?

Coming Soon: Coming Soon: The Evidence We Need?The Evidence We Need?

Payment Reform: Evidence on How Payment Can Payment Reform: Evidence on How Payment Can Improve Quality and Value (December)Improve Quality and Value (December)

AHRQ-sponsored AHRQ-sponsored Health Services ResearchHealth Services Research issue issue on payment reform: follow-on to 2009 special issue, on payment reform: follow-on to 2009 special issue, “Improving Efficiency and Value in Health Care”:“Improving Efficiency and Value in Health Care”:– Analyses assessing impact of efforts to improve care by Analyses assessing impact of efforts to improve care by

changing the way it’s paid forchanging the way it’s paid for

– Value-Based Insurance DesignValue-Based Insurance Design

– Models/simulations related to payment models for the futureModels/simulations related to payment models for the future

Thank YouThank You

AHRQ Mission AHRQ Mission

To improve the quality, safety, To improve the quality, safety, efficiency, and effectiveness of efficiency, and effectiveness of health care for all Americanshealth care for all Americans

AHRQ VisionAHRQ Vision

As a result of AHRQ's efforts, As a result of AHRQ's efforts, American health care will American health care will provide services of the highest provide services of the highest quality, with the best possible quality, with the best possible outcomes, at the lowest costoutcomes, at the lowest cost

www.ahrq.govwww.ahrq.gov