CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 1

1999 CAS Seminar onHealth and Managed Care

Hilton Head Island, SCOctober 18-19, 1999

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 2

Intro - Shevlin

Benchmarking Measures and Quality Control

Hilton Head Island, SCOctober 18-19, 1999

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 3

Overview on Healthcare Benchmarks

• What?

• Why?

• Examples

• Sources

• Classifications

• Planning

• Limitations

• Analysis

• Application

• Discussion

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 4

Healthcare Benchmarks - What are they? -- What are they? -

• “Gold standards”; target results

• Easily and reproducibly measured

• Pertaining to Financial or Clinical Outcomes

• Typically involve ratios

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 5

• Used for Comparison and Quality Improvement

• “If you cannot measure, you cannot improve”

• To provide objective measures that will drive performance to a new level of excellence

Healthcare Benchmarks - Why Do We Need Them? -- Why Do We Need Them? -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 6

History of Efforts in Healthcare QualityHistory of Efforts in Healthcare Quality• Early years - physician esteem/ethics/peers

• 1980s - Utilization Management (UM)

• 1990s - Case/Care Management

• Now - Disease/Health Management

Healthcare Benchmarks - Why Do We Need Them Today? -- Why Do We Need Them Today? -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 7

• Apply evidence-based medicine

• Establish “Best Practice”

• Monitoring results: “Report Cards”

• Target “Intervention Strategies”

• Establish Value

Healthcare Benchmarks - Why Do We Need Them? -- Why Do We Need Them? -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 8

Improving healthcare:

• Services

• Process

• Outcomes

• Resources

Healthcare Benchmarks - Why Do We Need Them? -- Why Do We Need Them? -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 9

Healthcare Benchmarks - Clinical Examples -- Clinical Examples -

Mortality - Unequivocal? - Clinical v.s. cost implication- Certain diseases and surgeries- Must be severity risk adjusted

Morbidity - Tests (lab)- Vitals signs- Physical findings (disease classes)- Trends- Manual records extraction is expensive

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 10

Healthcare Benchmarks - Clinical Examples -- Clinical Examples -

Prevention• Primary

- Screenings/Immunizations• Secondary

- Drugs/ServicesClinical Guidelines

- Diagnostics/Therapeutics- Inappropriate

Complications - Medical/Surgical

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 11

Healthcare Benchmarks - Other Examples -- Other Examples -

Financials - Dollars - Resources

Perception / Satisfaction / Patient Self-Assessment - Functional status- Access to care- Waiting times, time to return calls- Quality of life- In areas of concern to the patient

Proxy Measures - Length of stay - Number of visits/services/readmissions

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 12

Intro - Shevlin

Asthma

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 13

• Medical & pharmacy claims data• Laboratory data• Electronic medical records• Hospital information systems• Utilization review & incident reports• Surveys & direct observation• Proxy Measures: LOS, visits (billing)

Healthcare Benchmarks - Sources: for Data -- Sources: for Data -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 14

0

20

40

60

80

100

0% 25% 50% 75% 100%

Healthcare Benchmarks - Sources: Market Characteristics -- Sources: Market Characteristics -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 15

Drivers Drivers – Purchasers

– Comparatives among suppliers

– Financial and quality objectives

– Lacking knowledge and/or resource for measures and outcomes

Healthcare Benchmarks - Sources: Accreditation/Measurements -- Sources: Accreditation/Measurements -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 16

Healthcare Benchmarks - Sources: The Accreditation Industry -- Sources: The Accreditation Industry -

OrganizationsOrganizations•The “Joint Commission” on Accreditation of Healthcare Organizations (JCAHO)•National Committee for Quality Assurance (NCQA)•Accreditation Association for Ambulatory Health Care (AAAHC)•Utilization Review Accreditation Commission (URAC)

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 17

OrganizationsOrganizations• Foundation for Accountability (FACCT)• University of Wisconsin• University of California• Association for Healthcare and Policy

Research (AHCPR)

Healthcare Benchmarks - Sources: The Measurement Industry -- Sources: The Measurement Industry -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 18

Review Review

– Customers care about “value”

– Suppliers care about customers

– Third parties make it happen

Healthcare Benchmarks - Sources -- Sources -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 19

• CodesCodes – ICD

– CPT

– DRG

Healthcare Benchmarks - Classifications -- Classifications -

• GroupersGroupers – MDCs

– ACGs

– DCGs

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 20

• Relevant Outcomes (desirable or not)

• Measurable (reproducibly)

• Impact Sensitive

• Achievable

• Return on Investment

Healthcare Benchmarks - Planning: Choosing the Right Ones -- Planning: Choosing the Right Ones -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 21

• Time Requirements

• Volume Requirements

• Scope Management

• Buy-In

• Realistic, Incremental Goals

Healthcare Benchmarks - Planning: Achievability -- Planning: Achievability -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 22

• General – Case matched

– Temporal issues

• Internal– Most similar

– Randomized

Healthcare Benchmarks - Planning: Controls -- Planning: Controls -

• External– Availability/Quality

– Industry ‘Best Practice’

– Improvement priorities

– Historical perspective

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 23

Intro - Shevlin

Don’t Forget to Plan

Don’t Forget to Update

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 24

• Regularly (annually)

• New measurement or coding procedures

• New technology or diagnostics

• New therapeutic modalities or interventions

Healthcare Benchmarks - Planning: Reevaluation -- Planning: Reevaluation -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 25

• Population drift/differences

• Environmental issues

• Collection process/irregularity

• Storage process/irregularity

• Integrity indicators

Healthcare Benchmarks - Data Limitations -- Data Limitations -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 26

• Data limitations

• Barriers

• Be suspicious– Skewed or broken axes

– Missing data

– Sub-populations

– Undisclosed methods

Healthcare Benchmarks - Analysis -- Analysis -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 27

• Physicians do not need more medical school

• Practice Guidelines and Outcomes Data

• Benchmarks and Peer Profiling

• Physicians do not like to be outliers

• Physicians are uncomfortable with change

Healthcare Benchmarks - Application: How to make it work -- Application: How to make it work -

CAS Seminar on Health and Managed CareBenchmarking Measures and Quality Control

October 18-19, 1999page 28

Intro - Shevlin

“If You Can Not Measure, You Can Not Improve”