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Perfect Care. When is performance good enough? For you; for your family Near-perfection is attainable even in health care The question we all should be asking: How soon can we achieve perfect care? Within our organization Across the entire health care system.

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Perfect care

Perfect Care

  • When is performance good enough?

    • For you; for your family

  • Near-perfection is attainable even in health care

  • The question we all should be asking:

    • How soon can we achieve perfect care?

      • Within our organization

      • Across the entire health care system


An organized delivery system that emphasizes primary and preventive care and is patient centered

An Organized Delivery System that Emphasizes Primary and Preventive Care and Is Patient-Centered

3. Emphasize Primary, Preventive, and Patient-Centered Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements


Expand primary care and preventive services

Expand Primary Care and Preventive Services

  • Primary care is the provision of first contact, person-focused ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.

    • Barbara Starfield, MD


Expand primary care and preventive services1

Expand Primary Care and Preventive Services

  • Health is better in areas where there are more primary care physicians or more primary care services

  • People who receive care from a primary care physician are healthier

  • Costs of care are lower in areas where there are more primary care physicians or more primary care services

  • More primary care is associated with more equitable care

Source: Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” Milbank Quarterly 83(3):457-502.


Shared decision making an important aspect of patient centered care

Shared Decision-Making:An Important Aspect of Patient-Centered Care


Why is shared decision making important

Why Is Shared Decision Making Important

  • Combines evidence-based practice with patient preferences

  • Many clinical decisions involve value judgments

  • Interventions have different benefits/ risks that patients value differently

  • There is no single right answer for everyone

  • Ethical principle of patient autonomy and legal requirement of informed consent

  • Health care providers cannot automatically infer what patients value, nor can they assume what care decisions are in patients' best interest.

  • Uncertain nature of clinical information


Center for shared decision making dartmouth hitchcock medical center

Center for Shared Decision-Making Dartmouth-Hitchcock Medical Center

  • Provides evidence-based tools to help patients understand trade-offs of medical vs. surgical treatment given their preferences

  • Assists with health care decisions (e.g., videotapes, booklets, websites)

  • Provides follow-up counseling with skilled staff

  • Generally results in lower rates of invasive procedures once the patient understands the trade-offs

Kate Clay, BA, MSN, Program Director


Being there for the patient

Being There For The Patient

  • The importance of continuity

  • “After-hours” care


Perfect care

Practice Has Arrangement for After-Hours Care to See Nurse/Doctor

Percent

2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians


Increase transparency and reporting on quality and costs

Increase Transparency and Reporting on Quality and Costs

3. Emphasize Primary, Preventive, and Patient-Centered Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements

4. Increase Transparency and Reporting on Quality and Costs


Ncqa hedis experience

NCQA/HEDIS Experience

  • Ten years of measuring data has shown that measurement and public reporting leads to improvement:

    • Children today nearly three times more likely to have had all immunizations as in 1997

    • Diabetics today twice as likely to have cholesterol controlled (<130 mg/dL) as in 1998

    • More than 96% of cardiac patients prescribed bet-blockers after a heart attack (up from 62% in 1997)

Source: NCQA, “The State of Health Care Quality 2006,” 2006.


Improvements in use of beta blockers after a heart attack

Improvements in Use of Beta BlockersAfter a Heart Attack

Source: National Committee for Quality Assurance, TheState of Health Care Quality: 2006, Washington, D.C.: NCQA, 2006.


Expand the use of interoperable information technology

Expand the Use of Interoperable Information Technology

3. Emphasize Primary, Preventive, and Patient-Centered Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements

5. Expand the Use of Interoperable Information

Technology

4. Increase Transparency and Reporting on Quality and Costs


Electronic medical records and information systems

Electronic Medical Records and Information Systems

  • Reduce duplicate tests

  • Reduce hospital admissions by having information accessible to emergency room physicians

  • Improve patient care

  • Provide decision support for physicians and patients

  • Facilitate “referrals,” secure transfer of responsibility

  • Reduce medical errors

  • Promote better management of chronic conditions and care coordination

    • Registries

    • Performance information

    • Facilitated by interoperability


Over 80 medication errors prevented with computerized order entry system

Over 80% Medication Errors Prevented with Computerized Order Entry System

Source: Adapted with permission from D.W. Bates et . al. 1999. “The Impact of Computerized Physician Order Entry on Medication Error Prevention.” Journal of the American Medical Informatics Association 6(4):313-21.


U s adoption of health information technology

U.S. Adoption of Health Information Technology

Source: Presentation by Ashish Jha. “Health IT Adoption: a cross-national comparison.” June 26, 2006.


Perfect care

Primary Care Practices with Advanced Information Capacity

Percent reporting 7 or more out of 14 functions*

*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care.

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians


Perfect care

Network

Prescriptions

1289023 = 87%

GP´s

with

EDI : 2150 = 98 %

Specialists

with

EDI: 639 = 80 %

Hospitals

with

EDI : 63 = 100%

Pharmacies with

EDI: 331 = 100 %

Doctors on

Call

: 15 = 100 %

Health Insurance

: 17 = 100 %

79

messages

/min

Referrals

Referrals

Referrals

Referrals

115597 = 60 %

Reimbursement

21049 = 92 %

THE COMMONWEALTH

FUND

MedCom – The Danish Health Data Network

Prescriptions

1039105 = 73%

Disch

Disch

. Letters

. Letters

682923 = 85 %

1054314 = 88 %

Lab.

Lab.

reports

reports

844528 = 98 %

543040 = 82 %

Lab Requests

44385 = 15 %

Source: I. Johansen, “What Makes a High Performance Health Care System and How Do We Get There? Denmark,” Presentation to the Commonwealth Fund International Symposium, November 3, 2006.


Reward performance for quality and efficiency

Reward Performance for Quality and Efficiency

3. Emphasize Primary, Preventive, and Patient-Centered Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements

5. Expand the Use of Interoperable Information

Technology

4. Increase Transparency and Reporting on Quality and Costs

6. Reward Performance for Quality and Efficiency


Medicare premier hospital quality p4p demonstration

Medicare/Premier Hospital Quality P4P Demonstration

  • First year results showed significant improvement; composite score increased –

    • AMI: 87% to 91%

    • Heart Failure: 65% to 74%

    • Pneumonia: 69% to 79%

    • CABG: 85% to 90%

    • Hip/knee replacement: 85% to 90%

  • Patients receiving better care showed lower mortality (AMI, CHF)

  • Cost savings for hospitals (AMI, Pneumonia, CABG, Hip/Knee) and Medicare


Perfect care

Primary Care Doctors’ Reports of Any Financial Incentives Targeted on Quality of Care

Percent reporting any financial incentive*

*Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians


Encourage public private collaboration to achieve simplification more effective change

Encourage Public-Private Collaboration to Achieve Simplification, More Effective Change

3. Emphasize Primary, Preventive, and Patient-Centered Care

1. Guarantee Affordable Health Insurance Coverage

2. Implement Major Quality and Safety Improvements

7. Encourage Public-Private Collaboration to

Achieve

Simplification, More

Effective

Change

5. Expand the Use of Interoperable Information

Technology

4. Increase Transparency and Reporting on Quality and Costs

6. Reward Performance for Quality and Efficiency


There has to be leadership

There Has To Be Leadership

  • Federal laggership

  • Collaborating public-private groups can lead

    • IHA (California)

    • MHQP (Massachusetts)

    • HQA, AQA

    • IHI’s new 5 million lives campaign


Iha integrated healthcare association california

IHA (Integrated Healthcare Association) - California

  • Collaboration of multiple stakeholders with a neutral convener

    • Purchasers – Pacific Business Group on Health

    • California Association of Physician Groups (225)

    • California health plans (7)

    • Consumer Groups

    • State of California Department of Managed Health Care & Office of the Patient Advocate

    • California HealthCare Foundation – Rewarding Results grant

    • NCQA (National Committee on Quality Assurance)


Iha california

IHA - California

Agreement on measures (technical quality, patient experience, use of health information technology)

  • Competitive stakeholders can collaborate on aligning incentives

    Agreement to tie P4P to the common measures; but no attempt to agree on payment formulae

    Results

  • Year over year improvement

  • Scatter in performance

    • This isn’t sufficient to achieve perfection


Massachusetts health quality partners mhqp

Massachusetts Health Quality Partners (MHQP)

  • MHQP

    • A broad-based coalition of physicians, hospitals, health plans, purchasers, and government agencies

    • Seeks to improve health care through collaboration among all stakeholders

    • Common quality agenda, including shared guidelines and tools, as well as becoming a source for comparative health quality information

  • Public Reporting

    • In 2006, started Medical Group level reporting of 15 quality measures and patient satisfaction measures

    • Moving forward, will incorporate Medicare/Medicaid data (designated as one of the 6 Ambulatory Quality Alliance pilots)

    • Beginning to explore new efficiency measures and their role in public reporting


Achieving a high performance health system what you can do

Achieving a High Performance Health System: What You Can Do


Perfect care

  • What You Must Do

    • Take An Active Role In Improving Your Own Care

    • Take An Active Role In Improving Care In Your Health System

    • See The Positive Side To Change

  • What We All Must Stop Doing

    • Protect Our Turf (there is still a lot of turf to go around)


Achieving a high performance health system what you can do1

Achieving a High Performance Health System: What You Can Do

  • Advocate for affordable health insurance for all

  • Establish and publicize policy on discounted care for uninsured and low-income

  • Invest in chronic care improvement, transitional care

  • Share and help spread best practices; join collaboratives to implement proven quality and patient safety measures

  • Improve patient-centered care; survey and respond to patient concerns

  • Support transparency; public reporting of clinical quality, patient-centered care, and efficiency

  • Accelerate adoption of IT; ensure patient access to an integrated personal health record

  • Participate in demonstrations that reward high quality and efficient care; be actively involved in design of incentivized payment systems

  • Consider options for better coordination and integration of care delivery; shared accountability for patient care through physician-hospital organizations; accountable medical homes


Thank you

Thank You!

Karen Davis, President, The Commonwealth Fund

Anne Gauthier, Senior Policy Director, Commission on a High Performance Health System, The Commonwealth Fund

Tony Shih, MD, Senior Program Officer, Quality Improvement and Efficiency, The Commonwealth Fund

Elizabeth Sturla, Executive Assistant, The Commonwealth Fund


Visit the fund www cmwf org

Visit the Fundwww.cmwf.org


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