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Transparency in Health Care Quality What you need to know about public reporting Elizabeth Mort, MD, MPH Vice President Quality & Safety, MGH Associate Chief Medical Officer, MGH Team Leader for Uniform High Quality, Partners HealthCare Inc. Transparency in health care

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Transparency in Health Care QualityWhat you need to know about public reporting Elizabeth Mort, MD, MPHVice President Quality & Safety, MGHAssociate Chief Medical Officer, MGHTeam Leader for Uniform High Quality,Partners HealthCare Inc.

transparency in health care
Transparency in health care
  • Transparency involves being open about what you do, how you do it, and the results that you get.
  • In health care, transparency encompasses
    • Clinical quality and safety
    • Service and access
    • Pricing and cost
  • Purpose:
    • Increase public accountability
    • Inform consumers’ decision-making
    • Rationalize resource use (costs) in health care
    • Inspire providers to improve
  • How did we get here?
  • What information is out there?
  • A short primer on quality measurement, ranking, tiering
  • Landmark litigation
  • Current initiatives in MA
  • Discussion
how did we get here
How did we get here?
  • Rising cost of health care
    • Longstanding problem, now in crisis
  • Gaps in quality
    • Striking variation in quality and service delivery
  • Consumerism
    • Consumer empowerment driving transparency and accountability
    • Consumer directed health plans as a new tactic to reduce costs
international comparison of spending on health 1980 2005



Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

International Comparison of Spending on Health, 1980-2005

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

* PPP=Purchasing Power Parity.

Data: OECD Health Data 2007, Version 10/2007.


mortality amenable to health care



Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Mortality Amenable to Health Care

Deaths per 100,000 population*

* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.

See report Appendix B for list of all conditions considered amenable to health care in the analysis.

Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

recommended screening preventive care for adults



Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Recommended Screening & Preventive Care for Adults

Percent of adults (ages 18+) who received all recommended screening and

preventive care within a specific time frame given their age and sex*

U.S. Average

U.S. Variation 2005

* Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram,fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot. See report Appendix B for complete description.

Data: B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey.

emerging models of payment reform new combinations of old ideas
Emerging models of payment reform: new combinations of old ideas
  • Incremental reforms such as nonpayment for never events
  • Primary care payment reform, medical home, tiered case-management fees, capitation
  • Episode-based payments, global case rates
  • Shared savings models, providers share in savings, quality monitored
  • Consumer directed plans

Rosenthal MB, NEJM 359;12 Sept 18, 2008

consumer directed health plans are emerging
Consumer-directed health plans are emerging
  • Rationale: patients with more out of pocket expenses will drive more rationale use of resources (hopefully data-driven)
  • Several varieties
    • Higher co-payments and deductibles
    • Health savings accounts
    • Tax credits
    • Tiering of physicians
  • Tiering has been the tactic of choice in MA used by the Group Insurance Commission
so what s at issue
So, what’s at issue?
  • “The appropriate way to measure physicians’ (quality and) efficiency is a matter of disagreement between those that pay for (use) health care and those who provide it.”

Arnold Milstein, MD Thomas Lee, MD

NEJM 357:26 December 27, 2007

providers worry about
Providers worry about…
  • Poorly designed performance reporting can lead to risk aversion
  • The risk of misclassifying a physician threatens their reputation and livelihood
  • There are more effective ways to address cost of care
  • There are more accurate ways of measuring quality
consumers and purchasers
Consumers and purchasers
  • Consumers want more information about the quality of care their doctor’s provide
  • Consumers want more information about the value they are purchasing
our challenge
Our challenge
  • Not measuring MD competency in some way is simply not an option
  • Not controlling costs in some way is simply not an option
  • Goal this afternoon:
    • Review the current measurement initiatives
    • Discuss what we can get behind in terms of assessing the quality of care of MDs
sources of md specific information
Sources of MD-specific information
  • Word of mouth
  • BORIM physician profiles
  • Health grade profiles
  • MHQP profiles
  • Health plan products tiers
  • Angie’s list
  • Consumers checkbook
  • Rate MD
  • Google
benefits manager
Benefits manager
  • Husband and wife have just moved to Boston and are employed by the state and covered through the GIC
  • They’re signing up for a health plan and need access to: Cardiology
a short primer on quality measurement

A short primer on quality measurement

Measures of quality and efficiency

Physician profiling

Tiering methodologies

defining quality is a challenge
Defining quality is a challenge
  • Donabedian: structure, process, outcome
  • IOM six aims: safe, effective, patient-centered, timely, efficient, equitable
  • FACCT domains: staying healthy, getting better, living with illness or disability, coping with end of life
  • Internal vs. External audience
what we need for a good system
What we need for a good system
  • Standardized performance measures representing all relevant domains
  • Access to pt level data
  • Data verification and auditing
  • Comparative analyses and reporting

Performance Measurement Accelerating Improvement

IOM 2007

health care settings are not equally covered
Health care settings are not equally covered
  • Hospitals - most mature
  • Groups - somewhat developed
  • Provider-level - very spotty
  • Systems – nascent
  • Health plans – NCQA led the way
  • States - spotty
  • Community - undervalued
service line coverage is spotty
Service line coverage is spotty

Confidential and Proprietary © March 2008 Sg2


Steps toward transparency: where are we on this steep climb?

Confidential and Proprietary © March 2008 Sg2

meanwhile on line tools are proliferating
Meanwhile….on-line tools are proliferating…

Source: The Advisory Board Company. Drivers of Consumer Choice Implications from the 2007 Consumer

loose talk about accuracy
Loose talk about accuracy
  • Accuracy of measurement
    • Reliability
    • Validity
  • Misclassification of physicians
    • Reliability and validity
    • Cut-off points
  • Reliability speaks to the consistency of a measure
    • Internal consistency, (Cronbach’s Alpha) usually measured between 0-1.0)
    • Test-retest
    • Inter-rater
  • Reliability is a prerequisite for validity!!!
  • Face validity (sounds good)
  • Content (are all dimensions of the construct measured, assumes this is possible)
  • Construct (considered with that which is being measured cannot be operationally defined)
  • Predictive (cholesterol and CAD risk)
  • Concurrent (high scores on safety culture and low rates of SREs)
risk of mis classification
Risk of mis-classification

Score Significantly below

Significantly above




50th percentile

Risk of misclassification is low <2.5 % with sample size of 45 and measurement reliability of 0.7

Dana Safran. et al; J Gen Intern Med 20-06; 21:13-21

= area of uncertainty

efficiency measures
Efficiency measures
  • Currently, the majority of efficiency measures rely on the MD as the unit of analysis
  • Data sources: encounter and claims data
  • Risk adjustment relies on same source
efficiency measures44
Efficiency measures
  • Episode of treatment groupers (ETGs)
    • Pooled claims data are used to derive the total cost for a particular episode
    • Care is then attributed to a physician
    • Physicians average cost is determined for each ETG
    • Cost per ETG is averaged across all ETGs that relate to that doc
    • Proprietary
commentary on etg validity
Commentary on ETG validity
  • We have reason to be concerned

Elizabeth McGlynn, PhD Associate Director, RAND Health;

Distinguished Chair in Health Quality

Measure cost efficiency via “ETG” methodology

Measure quality via HEDIS, etc.

Squeeze quality and cost scores from claims data

Incent patient and physician behavior via differentials in co-payments

Implemented in 2006


gic s rules for 2008 2011
GIC’s rules for 2008-2011
  • Must individually rate MD’s in six specialties

Cardiology Endocrinology

Orthopedics Gastroenterology

Rheumatology OB-GYN

  • Three tiers for all plans predetermined

Tier 1: 20%

Tier 2: 65%

Tier 3: 15%

  • Must use GIC’s data
  • Standardized reports to make the rankings interpretable for the physicians (developed collaboratively with MMS input)
ny principles for md tiering
NY Principles for MD Tiering
  • Core principles of the settlement
    • Accuracy
    • Transparency of information
    • Oversight of process
  • Ratings examiner: a 501 c 3 organization
    • National standard setting organization
    • Regular reporting to NY AG
what physicians are saying
What Physicians Are Saying
  • “I am apparently treating patients for epilepsy, according to the GIC. Somewhat unusual for an ophthalmologist.”
  • “Several patients listed couldn't possibly be mine, as I don't perform the designated type of surgery.”
  • “There are procedures on my list that I have never performed. I called GIC and there was only voice mail.”
  • “We received our data March 11 and were told that all feedback was due by March 14. I called the health plan to give feedback March 12. I left a message and my call was not returned.”
  • “This program is unfair, and I'm hopping mad. Please let me know what I can do.”

Courtesy MMS

the litigation
The Litigation
  • Asks courts to “correct the wrongs” of the CPI
  • Defendants: GIC, Tufts, Unicare
  • Allegations
    • Physicians falsely ranked and defamed
    • Patients misled and financially penalized
  • Petition: Stop tiering, orrequire that it been done right, e.g.:
    • Transparency and 60 days prior notice
    • Feedback and correction process
    • Meaningful physician input
    • Accuracy, validity and reliability

Courtesy MMS

mms principles for md tiering
MMS Principles for MD Tiering
  • Aim to strengthen patient-physician relationships
  • Involve physician in the design and implementation of all programs
  • Use clinically important and sound performance measures
  • Ensure sample sizes are adequate to support meaningful data analysis
  • Rely on meaningful data and analytic techniques
  • Share and review data with physician or practices prior to public release
  • Ensure transparency of all quality and cost-effectiveness measure and methods
  • Identify and consider practice characteristics that may require special attention in quality and cost-effectiveness monitoring
  • Use uniform reporting formats
  • Minimize unintended harmful consequences of quality and cost-effectiveness monitoring and public reporting
  • Be pre-tested before implementation.
current initiatives discussion

Current initiatives & discussion

BORIM & MMS developing credentialing guidelines

TJC requires us to conduct periodic assessments of provider

CMS has developed PQRI to advance MD quality

MHQP advancing provider measurement

PCHI has been evolving its approach to MD measures