IMPROVING QUALITY – Class 5

Performance transparency may influence patient outcomes and care costs:

  • Staffing hours;
  • Surgical complications; and
  • Doctor communications ratings.

“In the age of data, performance transparency is the new norm”, an article by Christine K. Cassel, M.D.,  “performance transparency matters: from staffing hours to surgical complications to doctor communications ratings, these measures may very well influence patient outcomes as well as care costs.”

Dr. Cassel a visiting professor at University of California, San Francisco, and an advisory board member of OnlyBoth Inc. was part of the group that wrote “To Err is Human” in 1999 and “Crossing the Quality Chasm” in 2001 that brought attention to patient safety in the United States. Dr. Cassel also served on the presidential commission that created the National Quality Forum (NQF) a few years later, and then serve as CEO and President of NQF in 2013. 

The Affordable Care Act

The Affordable Care Act has many references to “quality” and “prevention of chronic disease and improving public health” and “outcomes“.  For example the following are some provisions included under the Affordable Care Act:

  • The law begins with Title I, “Quality, Affordable Health Care for All Americans” followed by Subtitle A, “Immediate Improvements in Health Care Coverage for All Americans.
  • Title III, “Improving the Quality and Efficiency of Health Care”, followed by Subtitle A, “Transforming the Health Care Delivery System”, followed by Part I, “linking Payment to Quality Outcomes under the Medicare Program”; and then Part II, “National Strategy to Improve Health Care Quality” with Sec. 3024, “Quality measurement”. Followed by Part III, Subtitle F, “”Health Care Quality Improvements”.
  • Title IV, “Prevention of Chronic Disease and Improving Public Health”.
  • Title VI, “Transparency and Program Integrity”, :Subtitle D, “Patient-Centered Outcomes Research”.
  • Title X, “Strengthening Quality, Affordable Health Care for All Americans”.

Also, the Affordable Care Act has many references to “access” such as the following provisions:

  • Title V, “Health Care Workforce”, Subtitle G, “Improving Access to Health Care Services”.
  • Title VII, “Improving Access to Innovative Medical Therapies”.

The National Strategy to Improve Health Care Quality

The National Strategy to Improve Health Care Quality under the Affordable Care Act states the following:

NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE.

(a) ESTABLISHMENT OF NATIONAL STRATEGY AND PRIORITIES.—

(1) NATIONAL STRATEGY.—The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.

(2) IDENTIFICATION OF PRIORITIES.—

(A) IN GENERAL.—The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1).

(B) REQUIREMENTS.—The Secretary shall ensure that priorities identified under subparagraph (A) will—

(i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations;

(ii) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care;

(iii) address gaps in quality, efficiency, comparative effectiveness information, and health outcomes measures and data aggregation techniques;

(iv) improve Federal payment policy to emphasize quality and efficiency;

(v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes;

(vi) address the health care provided to patients with high-cost chronic diseases;

(vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections;

(viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and

(ix) address other areas as determined appropriate by the Secretary.

The national strategy included a requirement for a comprehensive strategic plan to achieve the priorities described above.  The strategic plan was required to include provisions for addressing, at a minimum, the following:

(A) Coordination among agencies within the Department, which shall include steps to minimize duplication of efforts and utilization of common quality measures, where available. Such common quality measures shall be measures identified by the Secretary under section 1139A or 1139B of the Social Security Act or endorsed under section 1890 of such Act.

(B) Agency-specific strategic plans to achieve national priorities.

(C) Establishment of annual benchmarks for each relevant agency to achieve national priorities.

(D) A process for regular reporting by the agencies to the Secretary on the implementation of the strategic plan.

(E) Strategies to align public and private payers with regard to quality and patient safety efforts.

(F) Incorporating quality improvement and measurement in the strategic plan for health information technology required by the American Recovery and Reinvestment Act of 2009 (Public Law 111–5).

Accordingly, Payment reforms that better align payment with cost and provide incentives for efficiency such as shared savings and bundled payment programs hold potential to improve to care quality and reduce medical spending.  The United States faces the challenge of moving its health care system toward high-quality, high-value, and equitable person-centered care.

Tools for improvement

Tools for improvement and to improve efficiency and outcome of care involves information sharing, education, feedback, and control. This entails the following:

  1. Identify what you are going to improve.
  2. Look at data.
  3. Build utilization profiles – where individual physicians could compare their performance to their peers.
  4. Share information and use group input to improve efficiencies of care.

It is important to note that quality of care is considered the number one priority

Key to getting physicians to use care management processes is for health plans and large purchasers of health care – corporate employers and federal and state governments to provide external incentives to improve quality

  • 7 out of 10 physician groups surveyed do not keep a list of patients who have serious chronic diseases like diabetes. Half of groups reported having no clinical information technology such as electronic data systems to track patients’ illnesses, medication and laboratory results.

Examples of care management: nurse case managers, programs to help patients care for their illness, disease registries, reminder systems, feedback to physicians on their quality of care.

  • Asthma, congestive heart failure, depression, diabetes together account for 140,000 deaths and $173 billion in costs each year in the United States.

Quality assurance deals with comparing what physicians are actually doing against what is designated by the particular MCO as common medical practice standards. This goes with protocols, policies, and medical guidelines. HMO’s use various techniques to ensure that the quality of care they provide is as good, if not better, than that of the more traditional forms of health care.

The Institute of Medicine (IOM) has made a number of recommendations about ways to improve and maintain quality of care including that the Agency of Healthcare Research and Quality identify not fewer than 15 priority conditions, taking into account frequency of occurrence, health burden and resource use. IOM used the Medical Expenditure Panel Survey (MEDPS) to identify the 15 most expensive medical condition, defined according to total expenses incurred in providing care that is directly related to a particular condition

  • The most expensive condition overall in 1997 was heart disease with $58 billion in expenditures followed by cancer ($46 billion) and trauma ($44 billion). Heart disease accounted for about 10% of total expenditures in 1997, cancer and trauma were associated with about 8% each.

According to the Joint Commission on Accreditation of Healthcare Organizations, (JCAHO), the not-for-profit safety and quality evaluator of nearly 5,000 hospitals, new patient safety standards will go into effect on July 1,2001.  These standards will require hospitals to initiate specific efforts to prevent medical errors and to tell patients when they have been harmed during their treatment. 

A 1999 Institute of Medicine report estimates that medical errors kill between 44,000 and 98,000 hospital patients annually.  “Health care executive, physician, and nursing leaders must radically change their thinking about medical mistakes,” says Dennis O’Leary, M.D., president, JCAHO. “We need to create a culture of safety in hospitals and other health care organizations, in which errors are openly discussed and studied so that solutions can be found and put in place. These new standards are intended to do just that.”

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