The 2The 2ndnd P in P4P: Towards a Hybrid P in P4P: Towards a Hybrid Data StrategyData Strategy

Irene Fraser, Ph.D.. DirectorIrene Fraser, Ph.D.. DirectorCenter for Delivery, Organization and MarketsCenter for Delivery, Organization and Markets

Presentation toPresentation toMini-summit on HIE and P4PMini-summit on HIE and P4P

National Pay-for-Performance SummitNational Pay-for-Performance SummitMarch 10, 2009March 10, 2009

System Reform and Redesignfor Quality

& Value

Accurate Measures and Data Accurate Measures and Data Are Fundamental for P4PAre Fundamental for P4P

Documented Results

• Quality • Patient Safety• Efficiency• Access• ROI• For ALL

Americans

Incented by payment and other incentives

Facilitatedby improved

HIT

Informedby evidence andmodels of successful design strategies

Achieving Good Measures and Achieving Good Measures and Data Requires Multiple BridgesData Requires Multiple Bridges

Between…Between…HIT WorldHIT WorldEMR WorldEMR WorldClinical dataClinical dataHealth Info. ExchangesHealth Info. ExchangesMeasure developersMeasure developersMedicare and Medicaid Medicare and Medicaid

datadata

And…And…Quality worldQuality worldClaims data worldClaims data worldClaims dataClaims dataState data orgs.State data orgs.Data developersData developersPrivate payer dataPrivate payer data

AHRQ Work to Strengthen AHRQ Work to Strengthen EMR Measures and DataEMR Measures and Data

Work w/ NQF to add Work w/ NQF to add measures to EMRmeasures to EMR

Supporting HIEsSupporting HIEs Grants to improve Grants to improve

ambulatory care ambulatory care measures measures

Facilitating use of e-Facilitating use of e-prescribingprescribing

Jonathan.White@ahrq.hhs.govJonathan.White@ahrq.hhs.gov

Working from the Other Side: Working from the Other Side: AHRQ Work to Strengthen AHRQ Work to Strengthen

Claims DataClaims Data

Healthcare Cost and Healthcare Cost and Utilization ProjectUtilization Project

Quality IndicatorsQuality Indicators Efficiency MeasuresEfficiency Measures Public Reporting Public Reporting

TemplateTemplate Portals with Portals with

software for local software for local useuse

AZAZ

CACAUTUT

CTCT

FLFL

GAGA

IAIA

ILIL

KSKS

MAMA

MDMD

MOMONJNJ

NYNYOROR

PAPA

SCSCTNTN

COCO

WAWA

WIWI

VAVA

MEME

MIMI

TXTX

WVWVKYKY

NCNC

VTVT

RIRI

NENE

MNMN

ALAL

DCDC

MTMT

IDID

MSMS

HIHI

NVNV

NDND

SDSD

NMNM

OHOHININ

LALA

ARAROKOK

NHNH

The HCUP Partnership:The HCUP Partnership:A Voluntary Federal-State-Private Sector A Voluntary Federal-State-Private Sector

CollaborationCollaboration

AKAK

WYWY

HCUP PartnerHCUP Partner

Does Not Collect Does Not Collect StatewideStatewide

Inpatient DataInpatient Data

LegendLegend

DEDE

Potential PartnerPotential Partner

Not a PartnerNot a Partner

40 states in partnership40 states in partnership

90% of all discharges90% of all discharges

HCUP DatabasesHCUP Databases

State State Ambulatory Ambulatory

Surgery Surgery Databases Databases

(SASD)(SASD)

State State Inpatient Inpatient

Databases Databases (SID)(SID)

State State Emergency Emergency Department Department Databases Databases

(SEDD)(SEDD)

Nationwide Nationwide Inpatient Sample Inpatient Sample

(NIS)(NIS)

Kids Kids Inpatient Database Inpatient Database

(KID)(KID)

Nationwide Emergency Nationwide Emergency Department Sample Department Sample

(NEDS)(NEDS)

What is HCUP? What is HCUP? And what is it And what is it notnot? ?

HCUP is...HCUP is... HCUP is HCUP is notnot......

Discharge database for health care Discharge database for health care encountersencounters

A surveyA survey

All payer, including the uninsuredAll payer, including the uninsured Specific to a single payer, Specific to a single payer, e.g. Medicaree.g. Medicare

Hospital, ambulatory surgery, Hospital, ambulatory surgery, emergency department dataemergency department data

Outpatient visits, Outpatient visits, pharmacy, laboratorypharmacy, laboratory

All hospital dischargesAll hospital discharges A sampleA sample

Accessible multiple ways: raw data, Accessible multiple ways: raw data, regular reports, on-line (HCUPnet)regular reports, on-line (HCUPnet)

Just another databaseJust another database

AHRQ Quality Indicators (QIs)AHRQ Quality Indicators (QIs) Developed at behest of state partnersDeveloped at behest of state partners

Use existing hospital discharge dataUse existing hospital discharge data

Incorporate severity adjustmentIncorporate severity adjustment

Current modules: Inpatient, Patient Safety, Pediatric and NeonatalCurrent modules: Inpatient, Patient Safety, Pediatric and Neonatal, , PreventionPrevention

Include compositesInclude composites

Growing use for reporting and P4PGrowing use for reporting and P4P

NQF endorsement for 40+ so farNQF endorsement for 40+ so far

CMS using 9 under new Inpatient Payment ruleCMS using 9 under new Inpatient Payment rule

Evidence-based public reporting template availableEvidence-based public reporting template available

14 states use AHRQ QIs for public reporting14 states use AHRQ QIs for public reporting

14 States Use AHRQ QIs for 14 States Use AHRQ QIs for Public Hospital ReportingPublic Hospital Reporting

TexasTexas

NewYorkNewYorkWisconsin(parts of state)Wisconsin(parts of state)

ColoradoColorado

OregonOregon

MassachusettsMassachusetts

UtahUtah

FloridaFlorida

VermontVermont

New JerseyNew Jersey

KentuckyKentuckyCaliforniaCalifornia

IowaIowa

OhioOhio

Next Frontier: Measuring Next Frontier: Measuring Cost and EfficiencyCost and Efficiency

Evidence Review on Efficiency MeasurementEvidence Review on Efficiency Measurement Workshops on hospital efficiency measurement and Workshops on hospital efficiency measurement and

physician-level public reportingphysician-level public reporting HSR issue on “Improving Efficiency and Value in HSR issue on “Improving Efficiency and Value in

Health Care”Health Care” New efficiency chapter in Nat’l Healthcare Quality and New efficiency chapter in Nat’l Healthcare Quality and

Disparities Reports Disparities Reports

– National admissions and costs for aggregate PQIs

– Relative hospital cost efficiency index

Study Shows Cost-effective Study Shows Cost-effective Enhancements to Admin. Data*Enhancements to Admin. Data*

Assessed impact of incrementally adding more Assessed impact of incrementally adding more complex clinical informationcomplex clinical information

Administrative data can be improved at relatively low Administrative data can be improved at relatively low cost by:cost by:

– Adding present on admission (POA) modifiersAdding present on admission (POA) modifiers

– Adding numerical lab data on admissionAdding numerical lab data on admission

– Improved codingImproved coding AHRQ Awarded pilots in VA, FLA, MN, planning AHRQ Awarded pilots in VA, FLA, MN, planning

contract in WA to show proof of conceptcontract in WA to show proof of concept* Pine M, Jordan HS, Elixhauser A, et al. Enhancement of claims data to improve risk * Pine M, Jordan HS, Elixhauser A, et al. Enhancement of claims data to improve risk adjustment of hospital mortality. JAMA 2007, 267 (1): 71-76. adjustment of hospital mortality. JAMA 2007, 267 (1): 71-76.

Jordan HS, Pine M, Elixhauser A, et al., Cost-effective enhancement of claims data to Jordan HS, Pine M, Elixhauser A, et al., Cost-effective enhancement of claims data to improve comparisons of patient safety. Journal of Patient Safety 2007, 3(2): 82-90.improve comparisons of patient safety. Journal of Patient Safety 2007, 3(2): 82-90.

Fry DE, Pine M, Jordan HS, et al. Combining administrative and clinical data to Fry DE, Pine M, Jordan HS, et al. Combining administrative and clinical data to stratify surgical risk. Annals of Surgery 2007 (forthcoming).stratify surgical risk. Annals of Surgery 2007 (forthcoming).

Administrative/Hybrid Data: Administrative/Hybrid Data: The FutureThe Future

Improve Improve timelinesstimeliness

Provide on-line all-payer Provide on-line all-payer market-level datamarket-level data on cost, quality, on cost, quality, efficiency, price.efficiency, price.

Add Add clinical detail, data links forclinical detail, data links for accuracy, credibility accuracy, credibility

Expand Expand outpatientoutpatient reach (e.g. physician, episode) reach (e.g. physician, episode)

Pilot Pilot cross-sitecross-site data, new data data, new data linkslinks

New New toolstools for expanded data for expanded data

Additional Additional statesstates, as feasible, as feasible

Develop, validate, maintain, deployDevelop, validate, maintain, deploy measures in priority areas measures in priority areas

Expand data elements Expand data elements to align with levers of changeto align with levers of change

Tools for changeTools for change

Hospital DataHospital Data

ED DataED Data

A. Surg. DataA. Surg. Data

Cross-siteCross-siteDataData

Frontier in All-Payer Claims Data: Data ACROSS Sites:Data ACROSS Sites:

QI Reporting Template(s)QI Reporting Template(s)

Challenge: Presentation Matters!!Challenge: Presentation Matters!! Approach: Two Model Templates Approach: Two Model Templates

– Composite scorecardComposite scorecard– Health topic/diseaseHealth topic/disease

Report Sponsors Choose:Report Sponsors Choose:– Overall approach Overall approach – Topics, composites, & measures to reportTopics, composites, & measures to report– How scores will be calculatedHow scores will be calculated– The medium to be usedThe medium to be used

Model reports are based on:Model reports are based on:– Literature review and analysisLiterature review and analysis– Interviews with expertsInterviews with experts– Focus groups with different populationsFocus groups with different populations– Cognitive interviewsCognitive interviews 15

Preventable Hospitalization Costs: Preventable Hospitalization Costs: A County-level Mapping Tool A County-level Mapping Tool 

Potentially Preventable Potentially Preventable Hospitalizations cost over Hospitalizations cost over $30B$30B a year. a year.

Maps show the admission Maps show the admission rates for health problems rates for health problems by county. by county.

Calculates cost savings if Calculates cost savings if admissions are reduced. admissions are reduced.

Can add information Can add information about local populations about local populations show number of persons show number of persons at greatest risk for health at greatest risk for health problems in each county. problems in each county.

NEW! Portal for States, NEW! Portal for States, Communities, Others to Display, Communities, Others to Display,

Analyze DataAnalyze Data

Query paths currently in HCUPnetQuery paths currently in HCUPnet

Results based on AHRQ QIsResults based on AHRQ QIs

Preventable Hospitalization Costs Preventable Hospitalization Costs mapping toolmapping tool

New ways of presenting New ways of presenting informationinformation– Beyond tablesBeyond tables– QI Reporting TemplateQI Reporting Template

Other AHRQ tools? Other Other AHRQ tools? Other information?information?

Strategies for ImprovementStrategies for Improvement

Sites for Implementing Measures Sites for Implementing Measures and Data: Chartered Value and Data: Chartered Value

ExchangesExchanges

Coming Up Next: Starting Coming Up Next: Starting some Bridge-Buildingsome Bridge-Building

Janet Marchibroda – Janet Marchibroda – National View on National View on Improving HIEImproving HIE

J. Marc Overhage – J. Marc Overhage – HIE and Pay for HIE and Pay for PerformancePerformance

Linda Davis – Direct Linda Davis – Direct Submission of Submission of Clinical DataClinical Data

DiscussionDiscussion