towards a value driven system

September 2009

Towards a Value Driven SystemMeasurement as a first step

2WisconsinSeptember 2009

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Overview

• Goals of health care• Definitions –quality, cost,

efficiency, value • What can we measure now? • What COULD we measure in full

EHR environment in organized systems (?with right incentives)

• Moving forward incrementally


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If you can’t determine (measure) where you are, where you have

been, and where you want to go- it is difficult to get there


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What should a “value based” Health Care Do?

What should a “value based” Health Care Do?

A value-based health care system

20% of peoplegenerate

80% of costs

A: Keep or move population to healthy

or low

Healthy/Low Risk

At-Risk

HighRisk

Severe Disease

Current Health Care Spending

Active Disease

Source: HealthPartners

Ideal Spending


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The Critical Aims of Health Care IOM

• Safe• Timely• Effective• Efficient• Equitable• Patient Centered


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Definitions-towards the practical

• Value in health care: – A SUBJECTIVE assessment of the net

benefits (benefits-risks) of health care in relationships to the costs relative to other goods and services •Depends on who is doing the “valuing”

(patient, consumer, purchaser, “society”)•Based on variable amount of objective

information

• Value= (benefits-risks)/costs– Difficult to measure benefits, risks and

costs directly (at least right now)


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Definitions-towards the practical

• Efficiency: – The physical relation between

resources used and health outcome…when the maximum set of possible improvements is obtained from a set of resource inputs (resources-cost). Palmer & Torgerson, BMJ 1999

• Measureable Efficiency: – An objective assessment of quality

relative to the costs (resources used and/or price paid)


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Definitions

• Quality: – The degree to which health services for

individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

• Measureable quality: – reliable and valid assessment of the

structures, processes and outcomes related to provision of health care related to the aims of care that is safe, timely, effective, efficient, equitable and patient centered


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Current to Ideal Quality & Cost Measurement

Useful Interventions

NOT Done

Under use

Useful Interventions

Done

Interventions of zero or negative

utility

Overuse

Ineffective

Interventions

Misuse

Cost of Misuse

Excess relative cost for useful care

Cost of Overuse

Cost of Avoidable

Consequences

COSTCOST

“Waste”

Total Use-Costs

QUALITYQUALITY

Episode based or Total Relative Resource Use or Costs for given patient (by disease, condition, episode or time) )

Measureable Outcomes- Clinical, Patient Experience Other

Structure

Process

Outcomes

Clinical-Pt

From high benefit to risk to low or no benefit to risk

Un Certain Utility


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So where are we now?

• Quality measures– Underuse- ample number of measures– Overuse-misuse- a few useful measures

mostly for medications– Outcomes- best related to patient experience

(CAHPS), few clinical intermediate outcomes• Appropriateness (relative benefit-risk)

– virtually no measures• Cost-resources use

– Commercial (complex defined episode based-specific costs)

– NCQA RRU measures (time episode based total costs)

NO measures standardized For EMR use


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So what to do now to “define” value?

• Use (where possible) NQF endorsed measures-preferably those used in PQRI and/or Hospital incentive program – Quality

• HEDIS-MD specified• Physician consortium for Performance

Improvement PCPI (selected)

– Cost-Resource use (NQF review late 2009)• HEDIS RRU (used at plan level 2007-09)• Episode of care –commercial, ABMS (2010)


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Complex episode of care measures• Positives

– Widely used by health plans– Focused on specific procedure or claims

defined episode of care allows drill down • Negatives

– Nearly all products use some sophisticated (and non transparent) set of conventions to sort costs into discrete episodes and to risk adjust

– Need for large numbers to get valid results (400 plus episodes)

– Questionable use for public reporting given variation and difficulty in summarizing

– The more episodes created the lower the apparent cost

– Is not sensitive to the appropriateness of what was done


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Population Resource Use Approach

• Positives– Publically available specifications with

public domain risk adjustment– Measures resource use of care for

groups of patients with index condition over time –sensitive to effects of in appropriate care

• Negatives– Does not look at disease or procedure

specific costs– Only limited drill down potential (best if

coupled with internal episode measures)


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The Good NewsIt CAN be done

Quality and

Resource Use

HEDIS- 2007-08-09


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NCQA Population RRU MeasuresNCQA Population RRU Measures• Total yearly relative

resource use over for people with– COPD (08)– Cardiac Conditions (08)– Hypertension,

uncomplicated (08)– Diabetes (07 & 08)– Asthma (07 & 08)

• Condition, episode delimited resource use for people with– Acute low back pain (07

& 08)

• Cost Service Categories– Inpatient Facility– Surgery & Procedure – Evaluation &

Management– Pharmacy, ambulatory

• Utilization Service Categories– Inpatient Discharges– ED Discharges– MRI (low back pain only)


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Features of NCQA RRU MeasurementFeatures of NCQA RRU Measurement• Transparent-anyone can “look inside”• Uses same population as HEDIS Quality Measures in

same disease-so can be reported together• Simple risk adjustment

– Age & Gender– Disease severity (Type 1 v Type 2 diabetes)– Presence of co-morbidities (yes-no)– Exclusions of other dominant conditions

• Active cancer, HIV/AIDS, ESRD, etc.– Member cost capped if exceeds specified amount – Adjusted for enrollment and pharmacy benefit status

(medical and pharmacy member months)• Standardized Fee Schedule—weighted resource use

– Cost differentiates between a more intense and less intense service—e.g., amputation & office visit


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Resource Use and Quality ResultsResource Use and Quality Results

Plan

Diabetes Quality

Composite

Diabetes Medical Components Resource Use

Pharmacy

Resource Use

Combined Medical

Inpatient

Facility Eval & Mngmt

Surgery & Procedure

s

Plan A 1.06 1.14 1.32 1.00 0.89 1.14

Plan B 1.10 0.85 0.96 0.74 0.73 1.12

Plan C 1.10 0.80 0.84 0.79 0.71 1.16

Plan D 1.14 0.74 0.77 0.85 0.56 1.13

Plan E 0.97 0.73 0.79 0.76 0.54 1.19

Sample Diabetes Relative Resource Use in a Single State – HEDIS 2008:

Note: Same as1.00= average, Less than 1.00 = below average Greater than 1.00 = above average


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Resource Use and Quality Results


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Resource Use and Quality ResultsResource Use and Quality Results

Note: Plan results are based on national relative indices for quality and RRU.

AB

CD

E

High Quality, Low Use High Quality, High Use

Low Quality, Low Use Low Quality, High Use0.70

0.80

0.90

1.00

1.10

1.20

1.30

Qua

lity

0.50 0.60 0.70 0.80 0.90 1.00 1.10 1.20 1.30 1.40 1.50Relative Resource Use

Source: HEDIS 2008, with national RRU.Exclusions: 1. Eligible population in plan < 400. 2. Outliers for Total Medical RRU components.

Commerical HMOs in One StateHEDIS 2008 Quality & RRU -- Diabetes


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And now the bad newsResource Use Measures

• Even though transparent-resource use measures are complex

• Due to inherent wide variation of costs in patient groups, need very large sample sizes (>400) at least for public reporting

• Data incompleteness and lack of standardization is rampant– Bundling of services– Missing data (losing data in reporting

cost-resource use makes you look better)


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More bad newsComparison with Quality

• No consistent relationship between resource use-cost and quality– Weak correlations

• Higher quality with higher pharmacy and outpt E&M• Lower quality with higher in-patient and surgery-

procedures

• Too few or too weak quality measures to link in most diseases (diabetes, CV, asthma, hypertension exceptions)

• Most KEY quality measures still require manual chart review (paper AND some EMR’s)-so nearly impossible to measure at individual MD level


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But a bright futureSome promising developments

• Creation of standardization of measures in EMR and EHR environments– Limitations of EMR measurement

(physician versus patient focus)

• Measures building on EHR capabilities• Measurement of Appropriateness-

overuse (relative risk- benefit) measures-towards a real VALUE measurement


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Standardization of measures in EHRs

• Stampede of activity related to ARRA and 35 plus Billion– Multiple standard setting organizations

racing to create protocols for specifying and embedding measures, extracting data and reporting in EMR-EHRs

– Definition of “meaningful use” for 2011, 2013, and 2015

– Likely to have profound effects on EMR’s, EHRs and measures (project to create standard specifications for EMR measures launched)


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New Measures for EHRs


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Advances using E-data

• Measures linked to guidelines and clinical decision support (concurrent measurement)– Adherence to guidelines-exceptions and rapid

cycle learning– Overall CV risk reduction (verses single

measures)– Appropriateness- relative risk benefit (more to

come)

• Measures of outcomes of clinical care– Reduction of CV risk (Archimedes)-real time and

in follow-up– Functional status over time– Intensification of treatment and exceptions

• Coordination of care


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Advances in other realms

• Patient experience of care– More sophisticated surveys (medical

home related)– More sophisticated data collection

•Email-webased-time of encounter

– Incorporation into quality improvement- payment driven


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Major GAPAbility to Measure Relative Benefit and Risk Directly

AHRQ-NQF-NCQA-PCPI Conference


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Relative Benefit Risk (?and cost) • There are virtually NO measures of

quality related to many of the big ticket items driving cost

• Areas identified by NPP as critical– Surgical procedures (by pass surgery)– Other procedures (endoscopy)– Diagnostic imaging (PET, MRI, CT scans)– Screening (excess pap smears,

mammograms etc)


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Why this gap?

• For these interventions, it is difficult to judge quality without dealing with the relative benefit and risks of applying procedure to a given set of patients – Example of problem

•Excellent “quality” score -but patients had a low probability of getting any benefit from the procedure

•Fair quality score – but all patients really had high probability of benefiting from the procedure


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Barriers

•Technical-scientific– Weakness of evidence and analysis of

evidence (including efficacy and effectiveness)

– Paucity of consensus, evidenced based guidelines

– Need for clinically rich data to determine appropriateness

– Range in expert consensus based on specialty and weighting of evidence


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Barriers

• Political-cultural – Lack of funding for development (evidence,

analysis or application)– Overuse encouraged by fee for service

reimbursement (one persons overuse is another’s income)

– Belief that doing something is better than nothing

– Public belief in technical solutions to health problems

– Legal concerns (populations versus individual outcomes)

– Strong push within organized medicine to use predicted clinical effectiveness ONLY for decision support or feedback


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Essential

Relative Risk Benefit 10 8 6 4 2 0

SmallBenefit To Risk

Desirable Optional Harmful

Characterizing Relative Benefit and Risk

Net harm

Highbenef

it to risk

Appropriate Uncertain In appropriate

Overuse


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Low Hanging Fruit

• Overuse: Application of an otherwise effective intervention to patients for whom the benefits are small or negative relative to the risks AND/OR costs

• “Currently definable overuse”: overuse in groups of patients that can be defined using currently available data (claims, age, gender etc)


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Priorities for Overuse• Interventions with high variation and high

cost (NPP defined areas) – Imaging, Procedures Screening

• Look where existing criteria or guidelines have been developed indicating lack of benefit– US Preventive Services Task Force-”D”

recommendations– American College of Cardiology-American College of

Radiology

• Look for specific areas where “overuse” could be defined by existing claims or demographic data (duplication of services, hospital readmissions, ambulatory sensitive readmissions)


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Currently definable overuse projects(initial focus of PCPI and NCQA work) • Imaging

– Cardiac– Sinusitis

• Procedures – GI (endoscopy) – Angioplasty, Angiography, By-Pass Surgery– Induction of labor– Low back pain (surgery, injection)

• Screening (over screening)• Other related measures under development

(possibly waste-overuse)– Readmissions – Ambulatory sensitive or avoidable admissions


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BUT- reducing overuse using existing data

is only a first step

Next: Begin research and collaboration

with others to create framework to address full range of benefit risk

measurement


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Uses of relative benefit- risk “scores”

• Use in Clinical Decision Support– Real time “academic detailing” to reduce low

benefit use (MGH)– Peer review of clinicians who do a high risk,

low benefit procedure – Comparison to actual outcomes (learning)

• Use as Performance Measures– Overall performance based feedback to

individual clinicians (7.5 versus 4.5) – Review by group leaders or by Boards (MOC) – Substitute for utilization review– Linked to payment


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Work to date on Relative Risk Benefit

• RAND studies (Appropriateness)• American College of Cardiology

– Have developed Criteria for CV PET scanning, Percutaneous Coronary Interventions, others

• American College of Radiology– “Relative Clinical Utility” criteria for >30

imaging procedures– Mass General has developed computer based

ordering decision support (Radiology Order Entry)

• Very little beyond these –and above were done either for research or within the professional organizations for QI only purposes


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Conclusion: Critical area to pursue

BUTDifficult and expensive to create

measures

Requires full electronic health record system

Likely to be controversial


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Path Beyond • Need for further technical –

methodological work– How best to create criteria and measures of

relative risk benefit ? – How to build interface with

• Effectiveness research • Computer modeling of effectiveness• Clinical decision support (patient and provider)

• Focus would be from start on development of benefit-risk measures for use in EHRs since detailed clinical data in electronic formats needed to – To identify eligible populations – To calculate benefit/risk scores– To link to concurrent clinical decision support


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Sooo- in Conclusion• We are making progress-but a lot

slower than we would like to do in creating evidence for VALUE determinations

• Limited at present by data, data collection, payment system and a lot more

• Some help is on the way-but uncertain how much or when

• So-ON WISCONSIN (except when playing Penn State)

towards a value driven system

Health & Medicine

value based health care

provision of health

episode of care commercial

defined episode of care

aims of care

valuebased health care

measures costresources

costs relative