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THE WHITE HOUSE
Domestic Policy Council
DATE:
FACSIMILE FOR: Pamela Johnson
PHONE: ( ) -
FAX: ( ) -
FACSIMILE FROM: Sarah Bianchi
632 0390
PHONE: ( ) -
FAX: ( ) -
NUMBER OF PAGES (INCLUDING COVER):
[
]
FOR YOUR REVIEW
[ ]
PER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU
[ ]
PER YOUR REQUEST
dight
COMMENTS: Few more changes on memo
Thank - SB
WILLIAMM.
MERCER
May 8, 1998
Mr. Christopher C. Jennings
Special Assistant to the President for Health Policy Development
Domestic Policy Council
Old Executive Office Building, Room 212
17th St. & Pennsylvania Avenue, NW
Washington, DC 20502
Dear Mr. Jennings;
I would like to be considered as a purchasers' clinical representative for the Vice-President's
Blue Ribbon Panel on Quality of Care and for the subsequent Forum. I would bring following
qualifications:
1. Described in May 1998 New England Journal of Medicine article on employer managed
health care as "a pioneer" in employer advocacy of quality of care.
2. Medical Director of the largest American employer health purchasers coalition.
(Pacific Business Group on Health - with over 3 million covered lives) and architect of its
nationally distinguished quality advancement program.
3. Head of clinical consulting of largest employee benefits consulting firm in U.S.
(William M. Mercer, Incorporated).
4. Sole consulting industry representative selected for national quality of care measures
development committees of both NCQA and FACCT.
5. Invited to speak on behalf of U.S. purchasers at the Institute of Medicine's 1998 Rosenthal
lecture series on the state-of-the-art in health care performance measurement.
6. Selected to testify on exemplary private sector health quality initiatives at March 3, 1998
hearing of Bipartisan Congressional Task Force on Health Care Quality.
7. Selected to review 1998 Institute of Medicine Roundtable Statements on Quality of Care.
8. Board certified physician (in Utilization Management/Quality Assurance and Psychiatry)
9. Associate Clinical Professor at University of California, San Francisco with more than 30
published articles and book chapters on performance measurement and management in
health care.
10. Selected as one of 20 people "who have made a difference over the last 20 years" in
employee benefits management by Business Insurance Magazine.
I have attached my CV and my recent Congressional testimony.
Please contact me if I can be of further help. I would be honored to serve.
Yours truly,
Arme Milster
Arnold Milstein MD, MPH
CC: Ms. Sarah Bianchi
William M. Mercer, Incorporated
Phone 415 743 8700
California Insurance License 0510400
3 Embarcadero Center, Suite 1500
Fax 415 743 8950
Box 7440/94120
San Francisco, CA 94111-4015
A Marsh & McLennan Company
MOBILIZING EMPLOYER PURCHASING POWER
TO ADVANCE QUALITY OF CARE IN CALIFORNIA
TESTIMONY BY ARNOLD MILSTEIN MD, MPH TO
THE BI-PARTISAN CONGRESSIONAL TASK FORCE ON HEALTH CARE QUALITY
MARCH 3, 1998
Introduction
I am the Medical Director of the Pacific Business Group on Health (PBGH), the
country's largest employer health purchasers coalition. I am also a physician
consultant at William M. Mercer, specializing in reengineering clinical services and
quality of care management. The former role is a window on employers' quality
of care objectives; the latter role is a window on physician uptake of opportunities
to improve health care quality and affordability.
Today I will focus on PBGH and its quality advancement efforts.
PBGH is a nine-year-old coalition comprising 34 large private and public California
employers and employer groups who collectively purchase on behalf of roughly
three million Americans and spend in excess of $3 billion on health care. PBGH
includes Fortune 500 employers such as Bank of America and General Electric; we
also encompass small employers which are part of CalPERS and the HIPC,
California's small employer purchasing pool.
Overarching Value Focus
Our coalition's central focus is on obtaining more quality and customer service per
dollar. While PBGH is perhaps best known for its early success in negotiating
lower HMO premiums, the lion's share of its budget and effort has been dedicated
to advancing quality of care and customer service.
Primary PBGH Quality-Advancement Activities
1. Counting Quality and Making it Count
PBGH's quality of care advocacy has focused on two activities: counting
quality of care and making quality count in the market.
Counting quality of care means taking the best-groomed quality measures from
NCQA and nationally distinguished health service research centers; and then
using our purchasing power to ask California's health plans, hospitals and
physician groups to apply these measures and report them publicly. We have
made significant progress on all three levels.
In measuring the quality of health plans, we manage a multi-lateral California
partnership, the California Cooperative Healthcare Reporting Initiative (CCHRI).
CCHRI applies and publicly reports the HEDIS 3.0 quality and enrollee
satisfaction measures annually (see Attachment A) and is expanding into other
N:MMAS\MILSTEIN\CLIENTSIAPBGH\PBGH1.DOC
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05/08/98
quality advancement activities. In measuring the quality of hospitals, we co-
lead with the State of California a program to measure and publicly report risk-
adjusted hospital mortality from coronary artery bypass graft surgery and will
seek to expand this to other measures of hospital quality. In measuring the
quality of physician groups, we co-lead with The Medical Quality Commission,
a program to measure and publicly report patient satisfaction and quality of
care for more than 58 physician groups in California, as well as Oregon and
Washington (see Attachment B).
It is important to note that, while in 20 years our measures will be judged to be
crude and non-comprehensive, they already constitute a solid starting point.
They encompass technical quality (such as providing retinal exams to
diabetics), as well as customer service (such as waiting times for a physician
appointment); processes of care (such as whether children are getting
immunized) as well as outcomes (such as whether high blood pressure is
being successfully reduced); preventive care as well as illness care; and
narrow performance measures as well as broad performance measures. With
respect to broad measures of outcome, within 24 months, California's
purchasers and consumers will be able to access publicly reported, risk-
adjusted performance measures for health plans and physician groups in
maintaining the longitudinal health status of seniors and of working age
populations, respectively.
Making quality count means using market incentives to reward reporting,
improvement or superiority in quality. PBGH is pursuing this by two types of
incentives: incentives to reward quality by greater patient volume and by
greater unit prices. We create patient volume incentives by explicitly tying
purchaser choice of health plans to comparative quality ratings and by
sharing with consumers comparative quality ratings to support quality-based
consumer choice of health plans, hospitals and physician groups. Consumer
choice is supported via posting of comparative quality scores at a public
internet site (www.healthscope.org) and by 1-800 number access to a printed
version available in English or Spanish (see Attachment C). In addition, many
PBGH employers provide comparative quality scores with open enrollment
material, and then pro-actively track and manage continuous improvement in
its use by their employees. Finally, PBGH annually selects and publicly
acknowledges the California HMO achieving the most favorable combination of
quality, affordability, information systems advance, and customer partnership.
Thus far, unit price incentives to reward quality have been applied to health
plans which are required to rebate up to 2% of premium to PBGH's HMO
Negotiating Alliance, if pre-negotiated annual improvements in quality of care
and customer service scores are not achieved. While there have been failures
to reach improvement targets, in the majority the targets have been met and
quality as well as customer service are steadily advancing. PBGH is now in the
process of collaborating with its health plans and providers to extend unit price
rewards for quality to physician groups and hospitals. In broad brush, via
multiple methods, we are aiming to create a quality-sensitive demand curve
for health care in California.
N:AMAS\MILSTEINVCLIENTSLAPBGH\PBGH1.DOC
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05/08/98
2. Advancing Electronic Health Information Systems
Another critical element in our quality of care advocacy is our program to
advance health information systems (IS). Our efforts are rooted in recognition
that improved quality accountability and quality management depend on IS
advance. In pursuing this initiative, we have acknowledged that advances are
required of employers in their enrollment and disability systems in addition to
advances by plans, hospitals, other providers and, most critically, of physician
offices. The road will be challenging. We are moving in partnership with our
plans, our providers and the California Health Care Foundation. Our initiative
is managed by a doctorate level, full-time PBGH health informatics specialist,
propelled by purchaser demand, and aligned with NCQA's excellent Roadmap
for Health Information Systems.
3. Partner Relations
In advancing quality, we start with the core assumption that our target is
quality improvement, not our suppliers. Accordingly, all that we have
accomplished has been by collaboration with our plans, our providers, CCHRI,
health industry organizations, accreditors, the State of California and visionary
foundations.
Focusing on the Forest not the Trees
Underlying PBGH's quality advancement efforts has been the central awareness
that America's biggest quality problem is not the debatable gap between managed
care and unmanaged care. Our biggest quality problem is the gap between best
American quality and average American quality. As documented by multiple
American researchers, the latter gap is wide, comprising a silent ongoing national
calamity.
Dr. Lucien Leape has shown that deviation from best clinical practice results in
avoidable death or disability in 3 of every 100 American hospitalizations.
Dr. Robert Brook has shown that deviation from best clinical practice avoidably
impairs 11 of every 100 Americans with common chronic diseases. In contrast,
Drs. Robert Miller and Harold Luft's analysis of available scientific evidence found
no clear differences in quality between managed and unmanaged care. Average
American care, managed or unmanaged, is today unsafe at any price.
Clinicians, like other humans, do not embrace change. However, scientific review
of evidence on clinician behavior change by Drs. Peter Greco and John Eisenberg
concludes that economic incentives can be effective. PBGH quality advancement
activities are using this principle to build for PBGH suppliers a business case for
quality, both directly as purchasers as well as by supporting quality-informed
consumerism. My reengineering work with delivery systems continuously
validates the conclusion that a strong business case will be a prerequisite for the
health industry's integration of industrial-strength quality management into the
mainstream of its daily operations.
N:AMASAMILSTEIN\CLIENTSLAPBGH\PBGHL.DOC
3
05/08/98
In using market incentives to advance quality, PBGH is at the front edge of an
innovation adoption curve. But PBGH and other innovative, quality-focused
purchasers cannot close America's big quality of care gap alone. The pace of
quality advancement will depend on the level of help from regulators, accreditors,
the health industry, the media, and the weight of many more purchasers. There is
much that each of these stakeholders can do.
The key is focusing on the forest, which is the gap between best and average
American care, and on the highest leverage points for closing this gap. These high
leverage points do not include what may be popular, narrow mandates with
equivocal evidence bases, such as minimum lengths of maternity stay. They do
not include shotgun attacks on the managed care industry as a whole. They do
include stretching our managed care industry to be as effective in improving
quality as it has been in improving affordability.
Thank you for the opportunity to speak with you.
N:AMAS\MILSTEINACLIENTSLAPBGH\PBGH1.DOC
4
05/08/98
ARNOLD MILSTEIN MD, MPH
BIOGRAPHICAL SUMMARY
Arnie directs the national clinical consulting practice at William M. Mercer Inc.
and is the Medical Director of the Pacific Business Group on Health. His work
focuses on improving managed care programs for providers, large purchasers,
insurers and government.
His 30 book chapters and published articles have centered on managed care
program design. Dow Jones' and McGraw-Hill's reference texts on managed
care contain his chapter on utilization management. His articles, which have
encompassed quality measurement, behavioral health and workers
compensation performance evaluations, have been published in Barron's, HMO
Magazine and the New England Journal of Medicine.
A member of NCQA's national committee to develop HEDIS 3.0 and the FACCT
Measures Council, he also served on the National Academy of Science's
Committees on Utilization Management and Children's Health Insurance.
Business Insurance magazine selected him as "one of the 20 people who has
made a difference in employee benefits management in the past 20 years."
Arnie was educated at Harvard (BA-Economics), Tufts (MD) and UC-Berkeley
(MPH-Health Services Planning). He is an associate clinical professor at the
University of California-San Francisco Medical Center and a Worldwide Partner
at Mercer.
Three Embarcadero Center, Suite 1250
San Francisco, California 94111
(415) 393-5657
CURRICULUM VITAE
Arnold Milstein, MD, MPH
January 1998
General Information
Address:
Three Embarcadero Center, Suite 1500
San Francisco, California 94111
Telephone:
(415) 743-8803
E-mail:
[email protected]
Date of Birth:
January 4, 1946
Marital Status:
Married
Education
B.A. (cum laude)
Harvard University
Economics
1967
M.D.
Tufts University
General Medicine
1971
Internship
UCSF Mount Zion Hospital
Medicine and Psychiatry
1972
Residency
UCSF Mount Zion Hospital
Psychiatry
1974
M.P.H.
Univ. of California, Berkeley
Health Administration and Planning
1975
Professional Certification
Licensed Physician
California Board of
Medicine
1974
Medical Quality Assurance
Board Certification
American Board of
Psychiatry
1981
Psychiatry and Neurology
Board Certification
American Board of
UR and Quality Assurance
1986
(with honors)
Utilization Review and
Quality Assurance
C\HERNDONMILS\PERS\CV.DOC
Curriculum Vitae
Arnold Milstein, MD, MPH
Page 2
Employment
Managing Director and Worldwide Partner, William M. Mercer, Inc., a Marsh & McLennan
Company, August 1986 to present.
President, National Medical Audit, a Mercer consulting group specializing in the design and
evaluation of innovations in managed health care, December 1984 to present.
Chief Medical Advisor, Health Care Financing Administration, Region IX, January 1982 to
December 1984.
Director, Division of Professional Standards Review, Health Care Financing Administration,
Region IX, January 1977 to December 1981.
Regional Program Consultant for HSA Development, U.S. Public Health Service, Region IX,
February 1976 to December 1976.
Private medical practice in hospital, intermediate psychiatric facility, and outpatient settings, 1974
to 1988.
Research Assistant, Department of Economics, Harvard University, Cambridge, Massachusetts,
June 1965 to July 1967.
Honors and Awards
Rosenthal Lecturer, Institute of Medicine, National Academy of Sciences
1998
"Using Purchasing Power to Advance Health Care Quality"
Selected by Business Insurance as
1987
" one of the 20 people who made a difference over the last 20 years
in employee benefit management in America =
U.S. Public Health Service Commendation Medal for
1981
"
leadership, initiative and creativity, leading to extraordinary benefits
to the federal government =
U.S. Public Health Service Plaque for
1980
= an exceptional record in providing intelligent and perceptive leadership "
Mount Zion Hospital Mark Berke Prize for
1974
"The House Officer Best Exemplifying the Qualities of the Compleat Physician."
National Institute of Mental Health Career Development Fellowship
1972
Honorary Harvard College Scholarship
1964
K:\users\bios\cv
Curriculum Vitae
Arnold Milstein, MD, MPH
Page 3
Consultation and Professional Activities
Member, Institute of Medicine Committee on Children's Health Insurance, National Academy of
Science, 1997 to present.
Advisory Committee, UCSF Center for Health Professions, 1997 to present.
Member, University of California Commission on the Future of Medical Education, 1996 to
present.
Board Member, The Medical Quality Commission, 1996 to present.
Member, National Measures Council, Foundation for Accountability (FACCT), 1996 to present.
Member, NCQA HEDIS 3.0 Committee on Performance Measurement, 1995 to present.
Trustee, University of California-Mount Zion Campus, 1994 to present.
Trustee, San Francisco University High School, 1994 to present.
Advisor, White House Health Care Reform Task Force, 1993.
Editorial Board, Medical Outcomes and Guidelines, Faulkner & Gray, 1993 to present.
Member, Institute of Medicine Committee on Utilization Management, National Academy of
Sciences, 1988 to 1990.
Medical Director, Pacific Business Group on Health, 1988 to present.
Medical Director, Department of Defense CHAMPUS prepaid psychiatric quality monitoring
project, May 1987 to 1993.
Associate Clinical Professor, University of California at San Francisco, July 1986 to present.
Editor, "Review Decisions," a bi-monthly UR case analysis published in Medical Utilization Review,
McGraw-Hill Publications, April 1986 to 1990.
Medical Director, National SuperPRO project, July 1985 to 1992.
Member, California Chamber of Commerce Task Force on Preferred Provider Organizations and
Utilization Review Programs, 1983.
Assistant Clinical Professor, University of California at San Francisco, December 1980 to 1986.
Chairman, Skilled Nursing Facility Subcommittee, California State Psychiatric Association,
September 1976 to 1979.
K:\users\bios\cv
Curriculum Vitae
Arnold Milstein, MD, MPH
Page 4
Consultant, Planning Task Force, California Conference of Local Mental Health Directors,
September 1975 to December 1976.
Consultant in clinical program evaluation, Rand Corporation, July 1974 to 1977.
Publications and Papers
1. "Hospitalists and Pursuit of Value," Annuls of Internal Medicine, (in review) Spring, 1998.
2. "Bringing Outcome-Based Quality Differentiation to the Physician Group Market," Medical
Outcomes Trust Monitor, January, 1998.
3. "Better Managing Utilization Management" Health Affairs, Spring 1997.
4. "Health Education and Patient Satisfaction," with H. Schauffler and T. Rodiguez, The Journal
of Family Practice, January 1996.
5. "Industry in Transition: Central Engines, Blooming Flowers, Batting Averages and Re-
Invention," Viewpoint, Fall 1994.
6. "Evaluating Psychiatric and Substance Abuse Case Management Organizations," with M.
Henderson, J. Berlant and D. Anderson, Managed Behavioral Health Care, S. Shueman, W.
Troy and S. Mayhugh, eds., Charles C. Thomas Publisher, 1994.
7. "UR Liability: A Continuing Question," HMO Magazine, January/February, 1993.
8. "Increased Costs and Rates of Use in the California Workers' Compensation System As a
Result of Self-Referral by Physicians," with A. Swedlow, G. Johnson and N. Smithline, The
New England Journal of Medicine, November 19, 1992.
9. "Utilization Management Lessons," HMO Magazine, March/April, 1992.
10. "Ambulatory Care Utilization Review," with T. Mayer, Ambulatory Care Management and
Practice, A. Barnett, ed., Aspen Publishers, 1992.
11. "Evaluating Indemnity Plan Managed Care," Managing Employee Health Costs: Assuring
Quality and Value, J. Harris, H. Belk and L. Wood, eds., OEM Press, 1992.
K:\users\bios\cv
Curriculum Vitae
Arnold Milstein, MD, MPH
Page 5
12. "Excellence in Programs to Manage Workers' Compensation Costs," Viewpoint, Summer
1991.
13. "Mirror, Mirror on the Wall, Is My UR Program Best of All?", Medical Interface, July, 1990.
14. "Managing the Medical Cost of Hospital Workers' Compensation Claims," Handbook of Health
Care Human Resources Management, Norman Metzger, ed., Aspen Publishers, Inc., 1990.
15. "In Pursuit of Value; Fifteen Years of American Utilization Management," Making Managed
Health Care Work, P. Boland, ed., McGraw Hill, 1990.
16. "Controlling Workers' Compensation Medical Costs--California Style," Risk Management,
September, 1988.
17. "Second Generation Perspectives on Employer Medical Cost Controls," Barron's,
June 27, 1988.
18. "Controlling Medical Costs in Workers' Compensation," Business and Health, March, 1988.
19. "Enhancing Utilization Review Program Results," with M. Martin, Health Cost Management,
March/April 1988.
20. "The Future of Utilization Review," Business Insurance, October, 1987 (invited paper for 20th
Anniversary Issue).
21. "Gauging the Performance of UR Programs via Medical Record Audit," Business and Health,
February, 1987.
22. "Auditing the Quality of Care--an Employer Based Approach," Business and Health,
July/August 1986.
23. "Controlling Utilization through Preferred Provider Arrangements," The New Health Care
Market, Peter Boland, ed., Dow-Jones Irwin, 1985.
24. An Employer's Guide to Utilization Review, with Jack Bush, published by the California
Chamber of Commerce, February, 1984.
25. An Employer's Guide to PPOs, with Dr. Joan Trauner, published by the California Chamber of
Commerce, February, 1984.
K:\users\bios\cv
Curriculum Vitae
Arnold Milstein, MD, MPH
Page 6
26. "Factors Associated With Successful Physician Peer Review," with Dr. Nancy E. Adler,
American Journal of Public Health, October, 1983.
27. "Psychological Dimensions of Health Planning," (with N.E. Adler), Health Psychology,
G. Stone, F. Cohen and N. Adler, eds., Jossey-Bass Publishers, June, 1979.
28. "Opportunities for Improving Mental Health Services at the Interface between PSROs and
HSAs," (invited paper), Special Session on Mental Planning, American Psychiatric Association
Annual Meeting, May, 1978.
29. "Effects of the National Health Planning Act on the Use of Data Processing Hardware in
Health Care Institutions," Journal of Clinical Computing, Spring, 1977.
30. "Public Law 93-641 and Its Implications for the Diffusion of Ultrasonic Medical
Instrumentation," Proceedings of the First Meeting of the World Federation of Ultrasound in
Medicine and Biology, August, 1976.
31. "Anticipating the Impact of Public Law 93-641 on Mental Health Services," American Journal
of Psychiatry, June, 1976.
K:\users\bios\cv
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P04
File Saralis
Minority
Summit Health Coalition
tobacco
1424 K Street, N.W., Suite 500
Washington, D.C. 20005
(202) 371-0277
Fax (202) 508-3826
note San
Board of Directors
American Concer Society
Association of Block Cardiologista, Inc.
TESTIMONY OF
Block Caucus of Health Workers
City of Ope-lodes, Rorido
Congressional Block Covers Foundation, Inc.
Medical Care Monagement Company
Mehorry Medical College
SUMMIT HEALTH COALITION
Morehouse School of Medicine
National Alliance of Community Based Care
National Association for the Advancement
of Colored People
National Association of Block County Officials
National Amointion of Block Social Workers, Inc.
VIEWS FROM THE PUBLIC
National Association of Health Services Executives
National Block Coucus of State Legislators
National Black Leadership Commission on AIDS
National Block Nurses Association
National Coucus and Center on
ON
Block Aged, Inc.
National Conference of Black Mayors, Inc.
National Dental Association
National Education Association
National Medical Association
COMPREHENSIVE TOBACCO CONTROL LEGISLATION
National Pharmaceutical Association
National Urban League, Inc.
Presbyterian Church (USA),
Washington Office
Tennessee Monaged Care Network
The Congress of National Block Churches, Inc.
United Church Board for Homeland Ministries
Vermont Avenue Boptist Church
Executive Committee
President
Richard O. Butcher, M.D.
Vice President
BEFORE THE
Ramona McCarthy Howkins
Secretary
Hazel J. Harper, D.D.S.
UNITED STATES HOUSE OF REPRESENTATIVES
Treasurer
Samuel J. Simmons
Board Members at Large
Rev. Bemodine Grant McRipley
Charyl A. Townsel
HOUSE COMMERCE COMMITTEE
Executive Director
Ruth T. Perol
SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT
Coalition Partners
African American Healthlink
Health Management Resources, Inc.
Healthy Solutions, Inc.
Hines Family Core Center, Inc.
WASHINGTON, DC 20515
Howard University Hospital
llhnois Chapter, Summit
Health Coolition
Lamox Health Systems, Inc.
Medical Billing Incorporated
National Coolition of 100
Block Women, Manhattan Chapter
Prairie State Medical Society
Soint John Baptist Church
Student National Dental Association
The Greater Maryland Coolition for
March 19, 1998
Health Assurance, Inc.
Tennessee Block Health Core Commission
Total Core Home Health System, Inc.
Tristole Center of the National Podictric
Medical Association
octor, NY State Project
"Networking to ensure meaningful health care reform"
neilo L Thome
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P05
Testimony of
Summit Health Coalition
Before the
United States House of Representatives
House Commerce Committee
Subcommittee on Health and the Environment
March 19, 1998
Introduction
Summit Health Coalition, the nation's largest network of organizations focused
on health policies as they affect African Americans, welcomes this opportunity to
communicate with the Subcommittee on Health and the Environment of the
House Commerce Committee. We are aware of the critical role this
subcommittee will play in developing comprehensive, bipartisan legislation
addressing the issue of tobacco control. We are appreciative of your leadership.
Summit Health Coalition is a national public health advocate for minorities and
underserved populations. It encompasses the key minority health professional
organizations in the United States, including the National Medical Association,
the Association of Black Cardiologists, the National Dental Association, the
National Black Nurses Association, the National Pharmaceutical Association, the
National Association of Health Services Executives and the Black Caucus of
Health Workers.
Historically black colleges and universities are also members of Summit, along
with major civil rights and consumer organizations, associations representing
elected officials, religious groups and health care businesses. At present, fifty
national, otatc and community based institutions and organizations comprise
Summit Health Coalition.
Summit also works cooperatively with coalitions and organizations that
represent other communities of color and public health groups with respect to
tobacco control and other health policy issues. Regarding tobacco, we are
committed to three priority goals: 1) preventing the use of tobacco products by
minority and other youth and adults; 2) helping minorities stop smoking; and 3)
improving the health of minorities and other vulnerable, underserved
populations.
2
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P06
With this testimony we seek to convey three messages.
1.
By passing comprehensive tobacco control legislation, the Congress can make a
major contribution to eliminating disparities in health status among racial and
ethnic groups in the United States - disparities that limit the productivity and
potential of far too many Americans.
2.
By passing comprehensive tobacco control legislation, the Congress can reverse
the negative health effects of decades of targeting by the tobacco industry.
3.
By passing comprehensive tobacco control legislation, the Congress can
strengthen the capacity of individuals and organizations throughout the nation
to assume responsibility as partners with health providers for promoting health
and preventing tobacco-related diseases.
The Impact of the Tobacco Industry's Targeting of African Americans
It is very appropriate that the Subcommittee on Health and the Environment is hearing
testimony today from representatives of both youth and minority organizations. The
tobacco industry by its own admission has targeted both of these groups - with
devastating effects. For example, at a time when African Americans comprised
approximately ten percent of the population, almost twenty percent of the advertising
budget for Kool cigarettes was dedicated to marketing to African Americans. The result
- African Americans made up not twenty, but thirty percent of the Kool market.1/
What has been the impact of this deliberate targeting? Consider these statistics.
Overall cancer mortality rates among African Americans are higher than those
among other racial or ethnic populations in the United States. Mortality rates for
African American men are about 50% higher than those for white men. Rates for
African American women are about 20% higher than those for white women.2/
African Americans have higher overall cancer incidence rates than any other
racial or ethnic group in the United States.3/
Lung cancer is the cause of 32% of all deaths attributed to cancer among African
American men and is the leading cause of cancer deaths among black men and
women.4/
Between 1950 and 1985, the occurrence of lung cancer increased 86% among
white men while increasing 220% among African American men.5/
Cancer incidence rates for African American women increased 21% from 1973 to
1992, a period coinciding with intensified targeted marketing. These increases
have been attributed to increasing rates of lung and breast cancer.6/
It is estimated that smoking causes 87% of all cases of lung cancer.7/
African Americans have the second highest smoking rate (27.2%) of all racial and
ethnic groups, following American Indians (42.2%).8/
3
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P07
Smoking among African American high school boys nearly doubled between
1991 and 1995, from 14.1% to 24.8%, Frequent smoking among this group
nearly doubled as well.9/
Estimates are that 76% of all African American smokers smoke menthol
cigarettes as compared to 23% of all white smokers.]
African Americans tend to start smoking at a later age, are more likely to attempt
to quit smoking, are less likely to succeed that their white counterparts.11/
An estimated 47,000 African Americans die each year from smoking-related
diseases.
These statistics clearly suggest that a substantial reduction in smoking rates among
African Americans and other minorities would lead to a significant decrease in their
mortality and morbidity rates. Such an outcome would lead to the accomplishment of
the principal goal of Healthy People 2010 and other government initiatives to eliminate
health disparities among racial and ethnic groups.
Appropriate Responses to Minority Targeting
1. Countertargeting is Necessary.
In formulating its essential positions on national tobacco control policy, Summit
Health Coalition has proceeded from the premise that the tobacco industry has had
a disproportionate impact on minorities. This impact is evidenced by these groups'
disproportionate rates of tobacco use, addition, morbidity and mortality. Resources
required to counter the effects and undo the damage of the industry's targeting
should be made available, at minimum in proportion to the incidence of minorities
in the smoking population.
2. Significant Reductions in Tobacco Use Require Well-Financed, Community- Wide
Participation
For most of this century, the tobacco industry has spent billions to promote its
message. Undoing the damage from this propaganda barrage requires the
engagement of all levels of government, the private sector, non-profits, colleges and
universities, essential community and other health providers, schools, faith and
community-based organizations. National tobacco control policy, backed by
adequate resources, must serve to strengthen and equip these partners to do
battle. A strong federal role is a prerequisite for success if national goals are to be
met.
3. Diversity Is Essential to Effective Tobacco Control Policy.
There are significant differences among racial and ethnic groups with respect to
mortality and morbidity rates, smoking use and patterns. The tobacco industry's
marketing strategies illustrate that a "one size fits all" approach is ineffective.
Counter-advertising, research, prevention and cessation programs must be
culturally sensitive and appropriate. They should be implemented by minority
institutions and organizations with a history of service to and involvement with the
racial and ethnic groups to be served.
4
From 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P08
4. Public Health Must Be A Funding Priority
A substantial portion of tobacco control resources will be raised from smokers,
many of whom have low incomes and are members of minority groups. Fairness
dictates that most of the funds received from smokers or the tobacco industry be
reinvested, in the communities in which these smokers reside, for the support of
regulation, prevention, cessation and related programs.
Summit Health Coalition's Essential Positions
on National Tobacco Control Policy
1.
Summit Health Coalition urges Congress and the President to ensure that
tobacco control legislation will prohibit targeted marketing of tobacco products to
children and youth, African Americans, women and other at-risk populations. At
the same time, such legislation must require that targeted anti-tobacco
marketing be aimed at these vulnerable groups with adequate funding.
2.
Funds must be allocated for demographic, physiological and behavioral research
to foster better understanding of such phenomena as differing tobacco
consumption and use patterns, incidence, morbidity and mortality rates among
African Americans and other vulnerable populations. This research should
involve historically black colleges and universities (HCBUs) and other minority
health professions schools, as well as other African American institutions
involved in health care delivery and research, professional associations, non-
profit organizations and individual African American researchers.
3.
Funds derived from penalties on the tobacco industry, increased excise taxes
and other sources must be allocated in relation to tobacco-related mortality and
morbidity rates among various population groups, as well as past targeted
marketing practices by the tobacco industry. These funds should be used for
culturally relevant and appropriate programs to support prevention, cessation,
treatment and rehabilitation efforts aimed at reducing and eliminating tobacco
addiction among African Americans and other vulnerable, at-risk groups.
4.
In recognition of the impact that anti-tobacco legislation and regulations will
have on certain communities and geographic areas, legislation should be enacted
to protect these communities by means of economic development services and
targeted resources. These services may include job retraining, small business
loans, support for community redevelopment planning and program
implementation, expansion or creation of empowerment zones.
5.
The Food and Drug Administration (FDA) must have full jurisdiction over all
tobacco products (i.e., cigarettes, cigars and smokeless tobacco) and nicotine
delivery devices immediately upon enactment of legislation. Congress must
affirm through legislation the FDA's authority to regulate the tobacco industry's
marketing practices to prevent targeting of children, youth, women, African
Americans and other people of color, and must provide the requisite funding for
FDA's strengthening and expansion so as to fulfill these responsibilities.
6.
We urge the passage of legislation that will require all health insurers, health
benefit plans, managed care organizations and other entities providing health
services to emphasize prevention and health promotion and provide information
to enrollees, beneficiaries and patients to help them prevent and decrease
smoking and improve their quality of life.
5
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P09
7.
The federal government should support international tobacco control initiatives
through legislation, regulation, Executive Orders, funding and other means, as
well as through the dissemination of information on effective models and
strategies for tobacco use prevention and control.
8.
National tobacco control legislation must provide for a substantial and immediate
increase in the price of tobacco products to support public health initiatives and
to discourage tobacco consumption. An increase in the federal excise tax of at
least $2.00 per cigarette pack is recommended.
Summit Legislative Proposals
Summit offers the following proposals, which serve to operationalize the foregoing
principles and positions, for incorporation in comprehensive tobacco control legislation.
The list is not exhaustive, and we would welcome an opportunity to meet with members
of the subcommittee and staff to offer other proposals and relevant information.
1.
Funding of public health research, education, cessation and counter-advertising
programs should be distributed to the Department of Health and Human
Services and its constituent agencies with the understanding that an appropriate
percentage of those funds should be targeted to address the needs of
underserved and vulnerable racial and ethnic groups. Said percentage to be
determined on the basis of such factors as: the prevalence of racial and ethnic
groups within the youth and adult smoking population; or the proportion of
racial and ethnic groups within the general population (nationally or by state).
2.
In addition, the Office of Minority Health (OMH) should be charged with the
responsibilities of oversight, coordination, monitoring and reporting with respect
to Department-wide tobacco control activities on behalf of minorities. It should
have expanded grant-making authority and should be funded at a level
commensurate with its expanded responsibilities, including oversight,
coordination, monitoring and reporting with respect to state offices of minority
health. An Advisory Committee should be created and appointed by the
Secretary to provide guidance to the Department on the development of goals
and program activities undertaken by OMH, as well as on minority-focused
activities undertaken by other HHS agencies.
3.
There should be full participation of historically black colleges and universities
and other minority institutions and organizations with a history of service to or
involvement with the group to be served in the implementation of public health
research, prevention, cessation and counter-advertising programs at federal and
state levels, in proportion to minority smoking prevalence rates (or in
accordance with other appropriate standards).
4.
Comprehensive legislation should provide for the conduct of surveys on adult
and youth tobacco use, with data to be collected by race, ethnicity, gender and
age.
5.
"Look-back" targets for youth should be established by gender, race and
ethnicity.
6
From : 301 567-2409 FT WASH MD USA
Apr. 22. 1998 02:03 PM
P10
Conclusion
Tobacco claims the lives of 420,000 people in the United States each year. There is no
time to spare. We pledge our full support to any effort that will put an end to the
needless ill health, death and addiction for which tobacco is responsible.
We urge you therefore to seize this unprecedented opportunity and enact
comprehensive legislation that will attain that goal. We would welcome an opportunity
to work with you in the days and weeks ahead.
7
National Committee
Margaret E. O'Kane
President
for Quality Assurance
NCQA
2000 L Street, N.W.
Suite 500
Washington, D.C. 20036
202/955-3500 FAX 202/955-3599
www.ncqa.org
Direct Dial 202/955-5100
email: [email protected]
National Committee
Stephen N. Lamb
for Quality Assurance
Assistant Vice President for
Public Policy
NCQA
2000 L Street, N.W.
Suite 500
Washington, D.C. 20036
202/955-3500 FAX 202/955-3599
www.ncqa.org
Direct Dial 202/955-5102
email: [email protected]
FOR IMMEDIATE RELEASE
FOR MORE INFORMATION:
File Quality
AMAP -- Robert Mills 312-464-5970 Form
JCAHO -- Cathy Barry-Ipema 630-792-5630
Janet McIntyre 630-792-5175
NCQA -- Barry Scholl 202-955-5197
Ntble
Brian Schilling 202-955-5104
NATION'S THREE LEADING HEALTH CARE QUALITY
OVERSIGHT BODIES TO COORDINATE
MEASUREMENT ACTIVITIES
Landmark collaboration among AMAP, JCAHO, and NCQA will help ensure
efficient collection of comprehensive performance information
across all levels of the health care system
WASHINGTON - The nation's preeminent health care accrediting organizations --
the American Medical Accreditation ProgramSM (AMAPSM), the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), and the National Committee for
Quality Assurance (NCQA) -- today announced a collaborative effort designed to
coordinate performance measurement activities across the entire health care system. The
agreement establishes the Performance Measurement Coordinating Council (PMCC), a
15-member group that will work to ensure that measurement driven assessment processes
are efficient, consistent and useful for the many parties that rely on them to help make
important decisions about health care.
"Independently, our organizations are working aggressively to develop rigorous
performance measurement programs for different levels of the health care system," said
NCQA President Margaret E. O'Kane. "Working together, we can make performance
measurement not only much less burdensome, but also more meaningful to consumers,
employers and health care professionals."
"The work of the PMCC will start a positive chain reaction," said Randolph D.
Smoak, Jr., M.D., Chair AMAP Governing Body, and Vice Chair of the American
Medical Association (AMA) Board of Trustees. "More efficient measurement will lead to
broader participation in accreditation programs, which will lead to quality improvement,
which will lead to better care and service. Ultimately, patients and the public are the real
winners."
Formation of the PMCC dovetails with the recent recommendation from President
Clinton's Advisory Commission on Consumer Protection and Quality in the Health Care
Industry urging greater coordination in health care performance measurement efforts. In a
related executive order, President Clinton has directed Vice President Gore to organize a
"Forum for Health Care Quality Measurement and Reporting" that will seek to incorporate
existing private sector efforts. The PMCC expects to work through the Forum to help
shape measurement priorities and approaches that serve the needs of the American public.
The PMCC's efforts will build on a consensus statement, "Principles for
Performance Measurement in Health Care,' developed by the group's sponsoring
organizations. The document briefly outlines:
the rationale behind performance measurement efforts;
appropriate uses of performance data;
specific areas on which measures should focus;
guidelines for using performance data for comparative purposes;
general requirements for cost effective measurement;
and specific opportunities for collaboration.
"This is an exciting opportunity to pool and collectively expand our quality
measurement expertise in service of the public interest," said Dennis S. O'Leary, M.D.,
2
President, JCAHO. "Good measures and good data will eventually provide good
information to drive improvement in health care services and to better inform consumer
decision making."
Currently, AMAP, JCAHO and NCQA each define performance measurement at
different levels of the health care system. AMAP focuses on standards of quality for the
individual physician. JCAHO accredits a range of health care facilities, including
organizations providing acute care, ambulatory care, behavioral health care, home care,
clinical laboratory services, long term care and managed care. In addition, JCAHO has
begun integrating performance measurement into the accreditation process.
The focus of NCQA Accreditation and performance measurement program
(HEDIS) is on systems of care for defined populations, such as HMOs and point-of-
service plans. More than 90 percent of the nation's managed health care plans already use
HEDIS to track and report their performance. NCQA recently announced a new
accreditation program that will base accreditation decisions in part on a health plan's
performance on key HEDIS measures such as member satisfaction, immunization rates,
and mammography screening.
Each organization is committed to developing and advancing rigorous, dynamic
measurement programs to improve care and help consumers and purchasers make
important health care coverage decisions. The accreditation programs developed by
JCAHO and NCQA already enjoy broad participation across the health care industry, and
have consistently drawn upon the input of various constituencies. The new AMAP
initiative, similarly, is gaining rapid acceptance from physicians, hospitals, health plans
and health care purchasers.
3
Performance measures currently vary from one level of the health care system to
the next, but there is overlap. For example, member satisfaction, immunization rates and
cervical cancer screening rates have been used to assess providers, facilities and plans
alike. Other broadly applied performance measures include cesarean section rates,
mammography screening rates, measures of the accessibility of care, cost measures,
utilization rates (e.g., coronary artery bypass graft surgeries per 1,000 members) and
average office wait times.
A common criticism of performance measurement activities -- even from those
who appreciate their importance to quality improvement -- is that costs for data collection
and reporting can be high. The PMCC's efforts will help to reduce those costs by:
coordinating identification and/or development of groups of 'universal'
measures (i.e., measures that could be used to assess performance of
physicians, facilities or health plans in the same ways)
standardizing data requirements for different measurement systems;
devising means of coordinating measurement activities among physicians,
organizational providers, facilities and health plans;
establishing more efficient verification and data quality assurance systems;
and developing guidelines for the appropriate use of performance data.
"This collaborative effort represents a significant step forward toward improving
the delivery of health care in this country," said David B. Pryor, M.D., Chair of JCAHO's
Advisory Council on Performance Measurement and System Vice President for
Information Services, Allina Health System.
4
The PMCC will also address other important issues such as standardization of risk
adjustment techniques (adjusting for differences in the health of covered populations or
patients) which is a key issue for measuring performance at the physician, facility and
health plan levels. Ultimately the group expects to articulate principles to deal with risk
adjustment that will help the science of performance measurement move forward.
The PMCC will begin work on these issues at its first meeting this summer. The
group will meet three to four times per year. Work groups addressing specific issues will
meet in person and via conference call more frequently.
#
#
#
The American Medical Association is the voice of the American medical
profession. The AMA is a partnership of physicians and their professional
associations dedicated to promoting the art and science of medicine and betterment
of public health. AMAP sponsored by the American Medical Association - is
designed to enhance the health of the public by setting standards and improving
the performance of individual physicians, while replacing the current duplicative
and fragmented patchwork of existing physician review and assessment programs.
Founded in 1951, the Joint Commission on Accreditation of Healthcare
Organizations' mission is to improve the quality of care provided to the public
through the provision of health care accreditation and related services that support
performance improvement in health care organizations. The Joint Commission
evaluates and accredits over 18,000 health care organizations and programs,
including hospitals, integrated delivery networks, and organizations that provide
home care, long term care, behavioral health care, laboratory and ambulatory care
services. The Joint Commission also accredits health plans, integrated delivery
networks, and other managed care entities. An independent, not-for-profit
organization, the Joint Commission is the nation's oldest and largest standards-
setting and accrediting body in health care.
A non-profit watchdog organization, the National Committee for Quality
Assurance (NCQA) is widely recognized as the leader in the effort to assess,
measure and report on the quality of care provided by the nation's managed care
organizations. More than three quarters of Americans enrolled in HMOs are in
plans that have been reviewed by NCQA.
5
National Committee
2000 L Street, N.W.
Main: 202/955-3500
for Quality Assurance
Suite 500
FAX: 202/955-3599
Washington, D.C. 20036
http://www.ncqa.org
NCQA
EMBARGOED UNTIL:
FOR MORE INFORMATION:
March 31, 1998
Barry Scholl or Brian Schilling
(202) 955-5197 or 955-5104
NCQA REDEFINES ACCREDITATION WITH HEALTH PLAN
STANDARDS THAT FOCUS ON RESULTS
Draft requirements will provide more complete information to guide choice;
program will require health plans to report independently audited results
WASHINGTON - The National Committee for Quality Assurance (NCQA) today
released for comment new accreditation standards for HMOs and other health plans
which expand the scope of the nation's leading health care accreditation program to
emphasize results across a range of important care and service dimensions. The standards
include selected performance measures from NCQA's Health Plan Employer Data and
Information Set (HEDIS), making Accreditation '99 the nation's first true performance-
based accreditation program. As a result, consumers and employers will soon receive
more complete, easier-to-use information about health plan quality than ever before.
"With Accreditation '99, results count," said NCQA President Margaret E.
O'Kane. "Accreditation '99 uses three approaches to evaluating health plan quality -
rigorous standards, objective measures, and customer satisfaction. That comprehensive
assessment gives consumers and employers more information with which to make
informed health care coverage decisions."
NCQA's HEDIS, the nation's premier performance measurement tool for health
plans, is a set of measures related to such issues as immunization rates, mammography
rates, member satisfaction, access, service and other areas of public concern. Many
health plans already use HEDIS to comply with accreditation requirements which require
them to demonstrate improvement over time.
"Accreditation '99 is the best health plan assessment program yet. Basing
accreditation decisions on actual performance - using standardized measures - is a
critical step towards moving the industry from prevailing practices to best practices," said
Robert Galvin, M.D., Director of Healthcare, GE. "That's what the quality movement is
all about. Accreditation '99 will help us work with our employees to reward those plans
that are doing thing right."
Other employers have expressed similar support for the program. "Working with
health plans that have achieved the highest level of NCQA Accreditation is good business
- it helps ensure that our employees and their families get top quality care and service,"
said Kathleen Angel, Vice President, World Wide Benefits and Work Life Solutions,
Digital Equipment Corp. "Accreditation '99 and its emphasis on consumer information
raises the bar on performance measurement and improves our ability to select the best
plans for our employees."
HEDIS results will initially count for 25 percent of a plan's accreditation score.
(See page 6 for the list of measures and survey results plans will report.) The remaining
75 percent will be based on a plan's degree of compliance with NCQA's standards. In the
future, NCQA anticipates increasing the proportion of the accreditation score based on a
health plan's performance. HEDIS results will initially be evaluated relative to national
and regional averages, and national benchmarks.
"Accreditation should provide easy-to-understand information about a plan's
strengths and weaknesses; it should speak to the consumer and help make the decision
about what plan to choose easier," said Andrew Webber, Senior Associate, Consumer
Coalition for Quality Health Care. "Accreditation '99 does that. This represents a big
step forward in the national effort to promote quality in managed care."
2
To make accreditation outcomes more intuitively understandable for consumers,
NCQA renamed and redefined the different accreditation designations. Under
Accreditation '99, plans will earn one of the following accreditation levels:
Excellent
Commendable
Acceptable
Denied.
"The distinction between the higher levels of accreditation will be based on
results," said Cary Sennett, M.D., Ph.D., NCQA Executive Vice President. "Only those
plans that demonstrate excellence both in terms of their quality improvement and
consumer protection systems, and on important measures of care and service, will achieve
the highest levels of accreditation."
To help consumers and others better understand each health plan's strengths and
weaknesses, reports based on Accreditation '99 surveys will indicate plan performance in
five new categories, each of which reflects performance on several measures and
standards. The new reporting categories are:
Access and Service
Qualified Providers
Staying Healthy
Getting Better
Living With Illness.
NCQA worked with the Foundation for Accountability (FACCT) and others to
develop and test these categories, to ensure that they address consumers' concerns.
NCQA will continue to work with FACCT and others to refine these categories in the
coming weeks.
"For a health plan that can demonstrate excellent care and service,
Accreditation '99 represents an opportunity to achieve greater distinction in the market,"
said Linda Winslow, Director of Purchaser Relations and Accreditation, Harvard Pilgrim
Health Care. "This program validates all the hard work we've put into improving our
results over the years."
3
To aid consumers, NCQA will include a separate entry on its Accreditation Status
List for each "product type" a health plan offers. Many health plans offer HMO, point-
of-service and other plan options, and also offer separate plans for commercial, Medicare
and Medicaid beneficiaries. NCQA's Accreditation Status List will distinguish between
these various product types to ensure that consumers know whether their plan has been
accredited.
Accreditation '99 also introduces new standards that help protect consumers by:
prohibiting health plans from using financial incentives to encourage case
managers to limit or deny care
requiring health plans to have a process for approving exceptions to restricted
drug formularies
evaluating whether health plans unduly limit access to emergency room care
requiring health plans to coordinate medical and behavioral health care.
To ensure that quality and performance are maintained between on-site surveys
(which occur at least every three years), plans will be required to submit independently
audited HEDIS results to NCQA annually. Should these results, or other factors such as
regulatory action, suggest a lapse in quality, NCQA may elect to resurvey the health plan
sooner. NCQA will also resurvey a plan sooner if its initial compliance with NCQA
standards is low.
Accreditation '99 also confronts head on the critical need to improve the state of
health plan information systems. At present, most health plan information systems fall
far short of the ideal and cannot easily or routinely provide important data to employers,
consumers or care managers. New "advisory" standards specify the capabilities health
plan information systems must have in the future. Acquiring these capabilities will mean
better care and service for health plan members and improved coordination between
providers.
Specifically, the new Information System standards will require managed care
organizations to be able to: ensure the security and confidentiality of members' data and
information; link data from different sources and databases; ensure the accuracy and
4
reliability of data; use data to help manage care and improve performance; and monitor
internal and external data needs on an ongoing basis.
The standards have been mailed to approximately 2,500 business coalitions,
employers, health plans, medical groups, associations, regulatory bodies, and other
groups to encourage broad comment. The full text of the standards is also available for
download from NCQA's Web site (www.ncqa.org/99draft.htm) The comment period
runs through May 15, 1998. NCQA will accept written comments via regular mail or e-
mail ([email protected]). The final standards will be released in August 1998. Health
plan reviews against NCQA's 1999 MCO Accreditation requirements will commence
July 1, 1999.
A non-profit watchdog organization, NCQA is widely recognized as the leader in the
effort to assess, measure and report on the quality of care provided by the nation's managed
care organizations. More than three quarters of Americans enrolled in HMOs are in plans that
have been reviewed by NCQA.
#
#
#
5
The Following HEDIS® and Consumer Survey
Measures
are Required Under Accreditation '99
Effectiveness of Care
Childhood Immunization Status*
Adolescent Immunization Status*
Breast Cancer Screening
Cervical Cancer Screening
Prenatal Care in the First Trimester*
Advising Smokers to Quit
Beta-Blocker Treatment After a Heart Attack
Eye Exams for People with Diabetes
Check-Ups After Delivery*
Follow-Up After Hospitalization for Mental Illness
Flu Shots for the Elderly**
*
Measures relevant to and required for commercial and Medicaid products,
but not Medicare products.
** Measure relevant to and required for Medicare products only.
Consumer Survey Results
Getting Care Quickly
Doctors Who Communicate
Courteous and Helpful Office Staff
Easy to Find a Personal Doctor or Nurse
Getting Needed Care
Claims Processing
Customer Service
Rating of Personal Doctor or Nurse
Rating of Specialist Seen Most Often
Rating of Health Care in the Past 12 Months
Rating of Experience With Health Plan
6
File Quality
Fown Ntbk.
Daniel N. Mendelson
05/21/98 05:01:23 PM
Record Type: Record
To:
Christopher C. Jennings/OPD/EOP, Sarah A. Bianchi/OPD/EOP
cc:
Subject: HHS Report on Targeting Efforts on Asthma
Here is another disease that can be targeted in a discussion of outcomes and effectiveness
research. AHCPR research creates algorithms to target potentially vulnerable kids (often minorities
in low income areas), treat them appropriately, and save money by keeping them out of the ER.
Forwarded by Daniel N. Mendelson/OMB/EOP on 05/21/98 04:59 PM
Richard J. Turman
05/21/98 03:39:37 PM
Record Type:
Record
To:
Daniel N. Mendelson/OMB/EOP@EOP
cc:
Barry T. Clendenin/OMB/EOP@EOP, Mark E. Miller/OMB/EOP@EOP
Subject: HHS Report on Targeting Efforts on Asthma
Forwarded by Richard J. Turman/OMB/EOP on 05/21/98 03:39 PM
Farooq Khan
05/21/98 03:31:36 PM
Record Type:
Record
To:
See the distribution list at the bottom of this message
cc:
Subject: HHS Report on Targeting Efforts on Asthma
bHHS Report on Targeting Efforts on Asthma
To: National Desk, Health Writer
Contact: U.S. Department of Health and Human Services
Press Office, 202-690-6343
WASHINGTON, May 21 /U.S. Newswire/ -- The following was released
today by the U.S. Department of Health and Human Services
HHS TARGETS EFFORTS ON ASTHMA
Overview: Asthma is a major public health problem in the United
States, with prevalence increasing rapidly in recent decades,
especially among children. More than 15 million Americans are
affected, some 5 million of whom are under the age of 18. Between
1980 and 1994, the percentage of Americans with asthma increased 75
percent, and the percentage of preschool-age children with asthma
increased 160 percent.
HHS efforts to combat asthma will exceed $100 million in
discretionary funding for the first time this year, up about 70
percent from 1993. HHS agencies support a wide range of activities
to better understand this disease and its increasing prevalence,
and to help patients and physicians better recognize and treat it:
-- Basic research into asthma's underlying causes and
mechanisms, the triggers that bring on asthma symptoms, and other
issues surrounding the disease.
-- Treatment studies to evaluate the effects of different
medications on various populations.
-- Epidemiology to more precisely identify populations at risk
for the disease and the factors that put them at risk in order to
better understand and control it.
-- Prevention efforts to prevent asthma onset and to reduce
asthma symptoms, hospitalizations and deaths.
-- Guidance and education for physicians, patients and their
families, and the general public to increase asthma awareness and
knowledge.
The Medicare and Medicaid programs pay for asthma treatment for
low-income, elderly and disabled Americans.
In addition to ongoing HHS efforts, Secretary Donna E. Shalala
and Environmental Protection Agency Administrator Carol Browner are
also making asthma a special focus of the Interagency Task Force on
Children's Environmental Health and Safety, created by President
Clinton in April 1997.
Today, Secretary Shalala announced that a new National Heart,
Lung, and Blood Institute initiative will be launched this summer
to better understand the role of respiratory infections in
childhood asthma. NHLBI will support $2.5 million per year for five
years of research projects to study asthma using new techniques in
cellular and molecular biology.
Background
Asthma is a chronic lung disease that is characterized by
intermittent, recurring episodes of wheezing, breathlessness,
tightness of the chest, and coughing. More Americans than ever
before say they are suffering from asthma, according to a report
released April 24 by the Centers for Disease Control and
Prevention. The report entitled, Surveillance for Asthma --
United States 1960-1995" also concluded that the increases in
cases, deaths, and visits to doctors occurred in persons of all
ages, spanned across all racial groups, and occurred in all regions
of the U.S.
People with asthma experience well over 100 million days of
restricted activity each year, and costs for asthma care exceed $6
billion annually. Children with asthma miss an average of twice as
many school days as other children. Asthma attacks can vary from
mild symptoms to serious, life-threatening episodes. More than
5,000 Americans died last year from asthma attacks.
The prevalence of asthma is greater for women (5.6 percent) than
men (5.1 percent) and greater for blacks (5.8 percent) than whites
(5.1 percent). Blacks also have significantly more emergency room
visits, hospitalizations, and deaths from asthma than whites. From
1993-1995, there were an average of 38.5 deaths per million from
asthma in blacks compared to 15.1 per million in whites. In 1995,
blacks were more than four times more likely than whites to visit
an emergency room because of asthma.
The cause of asthma is not well-understood, and scientists do
not know why so many more people today are suffering from asthma
and why symptoms appear more severe than they were 10 years ago. It
is most likely that a combination of environmental and genetic
factors is responsible. The best documented factor contributing to
the development of asthma is atopy, the genetic, inherited
susceptibility to become allergic. In susceptible persons with
asthma, exposure to allergens such as dust mites, cockroaches,
molds and dander from pets is associated with more severe symptoms.
Further, children of smokers are more prone to develop asthma
because exposure to environmental tobacco smoke can increase
sensitivity to allergens. Although outdoor air pollutants have not
been identified as causing asthma, several of them, particularly
ozone, have been identified as triggers of asthma attacks.
Respiratory infections in early childhood may influence the
development of asthma. Some infections may increase the likelihood
of developing asthma, while others might actually be protective.
Researchers are exploring how respiratory infections early in
childhood might stimulate an immune response that suppresses the
development of allergies.
Ongoing Asthma Activities at HHS
The National Institutes of Health (NIH)
NIH is supporting an extensive range of research programs
examining asthma management, genetics, epidemiology, demonstration
and education, and prevention. NIH estimates it spent $92 million
on asthma research in FY 1997, $99 million in FY 1998 with $107
million proposed for FY 1999.
-- Genetics of Asthma -- Researchers supported by the National
Heart, Lung, and Blood Institute (NHLBI) and the National Institute
of Allergy and Infectious Diseases (NIAID) are working together to
identify the major genes that may contribute to asthma and
asthma-associated phenotypes such as allergy and airway
hyper-responsiveness. Early findings confirm that multiple genes
may be involved in asthma and that they may vary between
ethnic/racial groups.
-- Pathogenesis and Mechanisms of Asthma -- The National
Institutes of Health supports studies about the role of
inflammation in the pathogenesis of asthma. The studies are
directed at the examination of the cellular and molecular events
that appear to initiate, direct, and perpetuate the development of
airway inflammation. Researchers supported by NHLBI and NIAID are
studying how respiratory infections in early life acting
individually and in combination with each other, regulate airway
inflammation, airway hyper-responsiveness, and airway remodeling,
thus leading to the onset of asthma. A new NHLBI research
initiative will examine the multiple risk factors for the onset of
asthma in early life and the mechanisms that cause them. This will
lead to the identification of novel interventions to prevent the
development of the disease.
-- Epidemiologic Research -- The National Institute of
Environmental Health Sciences (NIEHS) is sponsoring several studies
involving asthmatics who live in areas where they are exposed to
high levels of ambient air pollutants, factors that are associated
with the risk of asthma-related hospitalizations and death, and the
respiratory health status of minorities, children under age-5, and
the elderly. Other epidemiologic research supported by NHLBI,
NIAID, and NIEHS include long-term studies to identify the specific
risk factors associated with developing asthma and the risk factors
that lead to severe, life-threatening asthma attacks. This research
increases our understanding about what causes asthma, and helps
identify promising new targets for asthma treatments.
-- Clinical Studies -- NIH institutes are carrying out several
clinical studies that focus on prevention of asthma and
effectiveness of new treatments. Clinical studies sponsored by NIH
include:
o The Environmental Intervention in the Primary Prevention of
Asthma in Children Study (NIEHS)
o The Childhood Asthma Management Program (NHLBI)
o Asthma Clinical Research Network (NHLBI)
0 The Asthma and Pregnancy Trial (NHLBI and the National
Institute of Child Health and Human Development (NICHD))
o The National Cooperative Inner-City Asthma Study (NIAID).
-- Demonstration and Education Research -- NIH supports
demonstration and education (D&E) research which evaluate
educational and behavioral approaches and organization strategies
that may improve the management of asthma. A major thrust of recent
D&E research has been on identifying appropriate programs and
methods for extending the benefits of asthma management to
populations that have been traditionally harder to reach, and who
experience a disproportionate burden of asthma illness-for example,
minorities and economically disadvantaged children. Outreach
education programs using non-medical settings (e.g. the school and
community neighborhood centers) are testing the use of
community-based and culturally sensitive behavior change strategies
for asthma control.
-- Research Translation: Dissemination and Education -- An
ongoing and important part of the HHS/NIH asthma research program
is to translate and disseminate scientific findings to improve the
health and quality of life of people with asthma. The NHLBI
established the National Asthma Education and Prevention Program
(NAEPP) in 1989 to improve the diagnosis, treatment, and control of
asthma, to enhance the quality of life of the asthma patients, and
to decrease asthma morbidity and mortality. The NAEPP has a
three-pronged strategy to achieve these goals: develop
science-based clinical practice guidelines for the diagnosis and
management of asthma; use partnerships among federal agencies,
professional societies, and voluntary and private organizations to
disseminate recommendations and implement asthma programs; and
organize public communications.
Centers for Disease Control and Prevention (CDC)
As the nation's disease prevention agency, the Centers for
Disease Control and Prevention (CDC) is working with state and
local partners to implement core and comprehensive asthma
prevention programs as well as to evaluate programs' success. These
programs will include monitoring to identify local disease trends,
community asthma prevention interventions, intervention and
evaluation research, and state-wide education of practitioners,
patients, and health community organizations. CDC sponsors a number
of local programs, working with state and local health department
partners, to examine how a change in environmental influences can
reduce asthma. The goal is to translate research findings into
public health action. These include:
-- ZAP Asthma, Atlanta, Ga.: CDC is one of 17 partners in this
project that seeks to show that a comprehensive approach to
controlling asthma will reduce the number of asthma
hospitalizations for children.
-- The California Community-Based Asthma Intervention
Demonstrations Project: This project seeks to show that a reduction
in exposure to environmental tobacco smoke will result in a
reduction in asthma hospitalizations in children living in Fresno.
-- Identification and Prevention of Air Pollutants and Other
Environmental Determinants in Urban Minority Children: Los Angeles:
This project tracks the asthma status of 100 black children in
central Los Angeles County to evaluate the effect of air pollution
on asthma among urban, minority children.
-- Asthma Surveillance in Wisconsin: The purpose of this pilot
project was to identify the most effective methods to monitor the
trends in asthma through a consensus workshop, and pilot
surveillance projects based on the workshop recommendations.
-- Out-of Hospital Asthma Deaths: North Carolina: Since
out-of-hospital asthma deaths may be preventable, this project is
helping to determine what proportion of total asthma deaths they
comprise and what populations they affect.
-- Asthma Prevalence Study in the Catano Area of Puerto Rico: In
collaboration with the Puerto Rico Department of Health, CDC and
EPA investigated the possible relationship between air pollution
and asthma. The study described the prevalence and severity of
asthma among school-aged children in the Catano area, obtained
baseline measures for assessment of future trends in the prevalence
and severity of asthma, identified risk factors for the disease,
and established a framework for further research.
Food and Drug Administration (FDA)
The FDA is working in partnership with the pharmaceutical
industry to facilitate the timely development and approval of new
drugs for the treatment of asthma and related conditions such as
allergic rhinitis. This partnership has resulted in a significant
number of approvals by the Agency over the past few years for new
drugs to treat asthma as well as a significant increase in the
number of drugs specifically approved for use in children with
asthma and allergic rhinitis. For example, in the past two years
the FDA approved the first three members of an entirely new class
of asthma therapy that work by blocking leukotrienes which are
important mediators of asthma. Other examples of important new
products approved by the FDA for first multiple-strength
metered-dose inhalers (MDIs) and three new multi-dose dry powder
inhalers (DPIs). These new drugs and devices provide physicians and
patients with valuable new options that may help to improve the
management of asthma.
Health Care Financing Administration (HCFA)
As part of Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT), Medicaid covers all medically necessary services
for the diagnosis and treatment of asthma in children, including
X-rays, drugs, inpatient stays, outpatient and emergency room
visits.
Medicare provides Part B coverage for both physician visits and
durable medical equipment, such as nebulizers, and oxygen equipment
required by some asthmatic patients, HCFA also covers the
medication that is put into the nebulizers as a necessary supply
for the operation of the equipment.
-- HCFA recently supported the Aetna Medicare Care Counseling
Program in the Phoenix, Arizona, a pilot program for Part B
beneficiaries with diabetes and asthma. The Aetna Care Counseling
program was a voluntary, confidential, telephone support service
offered free of charge to qualifying beneficiaries with asthma or
diabetes. In providing care counseling by registered nurses, the
program's purpose was to enhance customer service and to improve
beneficiaries' health and quality of life by providing a better
understanding of asthma and the medications and equipment used to
treat the disease. HCFA is currently in the process of reviewing
and commenting on the findings.
Agency for Health Care Policy and Research (AHCPR)
AHCPR is sponsoring the Pediatric Asthma Patient Outcome
Research Team (PORT) II" a randomized clinical trial, co-funded by
NHLBI. The trial tests the cost-effectiveness of NHLBI's practice
guidelines designed to reduce asthma morbidity among children. The
agency is supporting several other studies measuring quality of
life, patient outcomes and other issues related to asthma care.
-0-
/U.S. Newswire 202-347-2770/
APNP-05-21-98 1450EDT
04/28/98 TUE 16:30 FAX
TOOD
SERVICES
(
ADVISORY COMMISSION ON
HEALTH
3
CONSUMER PROTECTION AND QUALITY
IN THE HEALTH CARE INDUSTRY
FAX TRANSMISSION
To: C hris Jennings
Date: 4/28/98
Fax #:
456-5557
Pages: 11 including this cover sheet.
From: Janet Corrigon
Subject:
COMMENTS:
HUBERT H. HUMPHREY BUILDING
200 INDEPENDENCE AVENUE, SW ROOM 118-F
WASHINGTON, DC 20201
PH: 202-205-3333
FAX: 202-205-3347
04/28/98 TUE 16:30 FAX
0 002
TO:
Ad Hoc Group on the Forum
FROM:
Janet Corrigan, PhD
RE:
May 1, 1998 Meeting
DATE:
April 24, 1998
Enclosed please find the agenda and meeting materials for the May 1st meeting. Please Note:
the meeting will begin at 9:30 am (EST) and adjourn at 1:30 pm. The location for the meeting is
Conference Room 640H of the H.H. Humphrey Building, 200 Independence Ave., SW,
Washington DC.
The objectives of this meeting are twofold: 1) to plan for the Forum kick-off meeting to be
convened by the Vice President in June 1998; and 2) to identify and discuss key issues related to
the 6 month planning process that will commence in June and culminate with the establishment
of the Forum in early 1999.
If you have any questions, please contact me at 202/205-3045 (or pager #202-490-0321). I look
forward to seeing you on May 1st.
Distribution
Lipschitz
Toby Donnenfeld, Office of the Vice President
John Eisenberg, AHCPR
Nancy Foster, AHCPR
Chris Jennings, Office of the President
Sheila Leatherman, United Health Care Corporation
Randy MacDonald, GTE
Meredith Miller, DOL
10 I was >for E & Brond nox
Paul Montrone, Fisher Scientific International
Christopher Queram, Employer Health Care Alliance Cooperative
Thomas Reardon, Adventist Medical Group
Gerald Shea, AFL-CIO
James Tallon, United Hospital Fund
Peter Thomas, Powers, Pyles, Sutter and Verville, P.C.
Gail Warden, Henry Ford Health System
04/28/98 TUE 16:30 FAX
U.S.) UUS
DRAFT AGENDA
AD Hoc GROUP ON THE FORUM
May 1, 1998 Meeting
9:30 am
Welcome and Introductory Comments
- Introduction of participants
- Purpose of the meeting
9:50
Discussion of Forum Planning Process (draft proposal attached)
- Facilitator and Institutional Base
(see attached biographical sketch for James Tallon)
- Foundation Support
- Discussion of Process
- Planning Committee
-- Composition
-- Nominees
11:45
Break for Lunch
12:15
Discussion of June Kick-off Event
- Background Information on Other Activities Underway
- Messages
- Participants
1:30
Adjournment
04/28/98 TUE 16:30 FAX
004
PROPOSAL TO FUND A PLANNING PROCESS
FOR A NATIONAL
FORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING
DRAFT - APRIL 24, 1998
This is a proposal to fund a process for planning the development of a Forum for Health Care
Quality Measurement and Reporting ("the Forum"), a private-sector entity to be established to
provide coordination and guidance to the multiple public- and private-sector parties involved in
evaluating health care quality. Creation of the Forum was one of the major recommendations of
the Advisory Commission on Consumer Protection and Quality in the Health Care Industry ("the
Quality Commission") in its final report to the President.
This proposal begins by describing the need to coordinate ongoing work in the area of health care
quality measurement and reporting, and by laying out the specific objectives, activities, and
organizational characteristics of an entity to be created to undertake that effort. It then describes
the objectives, time line, and budget of the proposed process for convening key stakeholders to
assist in operationalizing the entity.
BACKGROUND
Need for Standardized Information on Health Care Quality
Routinely generating comparable, standardized information on the quality of health care is
critical for both motivating and enabling improvement. Standardized measures of quality are
needed to track the health care industry's progress in achieving national quality improvement
aims and to guide public planning and policy making. Comparative information on quality also
is needed for individual consumers, employers, and others to use in selecting health care
providers and health plans. Furthermore, valid and stable quality measures are integral to health
care providers' efforts to improve their performance. When standardized, such measures provide
an opportunity for health care organizations to make comparisons and identify "best performers."
Despite a growing number of efforts to measure and report on health care quality, useful
information is neither uniformly nor widely available. Improving our ability to measure quality
has been the object of significant public and private-sector activity over the last decade,
reflecting the expectation that measurement can serve as both a catalyst and a tool for
improvement as well as to facilitate consumer choice. While considerable advancements have
been made in the quality measurement field in recent years, current efforts fall short of fully
meeting users' needs, do not provide measures for many of the most important health burdens
(e.g., chronic conditions), and often are duplicative and unduly burdensome on health care
providers, health plans, and others.
04/28/98 TUE 16:31 FAX
01 005
Draft 4/24/98
Forum for Quality Measurement and Reporting
Objectives. The Forum for Health Care Quality Measurement and Reporting is being established
to build the systemwide capacity to evaluate and report on the quality of care. The Forum would
develop and implement effective, efficient, and coordinated strategies for focusing incentives for
quality improvement on national priorities while assuring the public availability of information
needed to support the marketplace and the efforts of the various existing quality oversight
entities.
Activities. To achieve its objectives, the Forum will need to:
develop a comprehensive plan for implementing quality measurement, data collection,
and reporting standards to assure the widespread public availability of comparative
information on the quality of care furnished by all sectors of the health care industry;
establish measurement priorities that address national aims for improvement and that
meet the common information needs of consumers, purchasers, federal and state policy
makers, public health officials, and other stakeholders;
periodically endorse core sets of quality measures and standardized methods for
measurement and reporting;
foster an agenda for research and development needed to advance quality measurement
and reporting and to encourage collaborative funding for such activities;
develop and foster implementation of an effective public education, communication, and
dissemination plan to make quality measures and comparative information on quality
most useful to consumers and other interested parties; and
encourage the development of health information systems and technology to support
quality measurement, reporting, and improvement needs.
To evaluate the success of its efforts, the Forum will need to create and utilize feedback
mechanisms designed to assess the feasibility and acceptance of the measurement sets it
promulgates as well as the extent to which information is reported, available, and used by
interested parties. Armed with this information, the Forum will be able to initiate improvement
strategies as necessary.
Structure. The key organizational characteristics of the Forum that will enable it to accomplish
its objectives are its status as a private-sector organization and its representation of key
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Draft 4/24/98
stakeholders from both the public and private sectors.
Operating in the private sector will provide the Forum with two needed characteristics. First, it
will have greater flexibility and the means to act quickly to respond to changes in the health
system and advances in technology that have implications for measurement and reporting
strategies and capacity. Second, it will be well-positioned to harness and coordinate the market
forces needed to drive this initiative.
Because the Forum will operate in the private sector as a voluntary initiative, its success will
depend upon the commitment and influence of a critical mass of stakeholders in the health care
marketplace. The Forum will therefore need to be broadly representative of stakeholders. The
users and potential users of information on quality must be involved in the process of identifying
core quality measures for reporting if those processes are to succeed in addressing their common
information needs. The Forum also will need to include a core constituency of influential
stakeholders that can assure the implementation of the measures once they are promulgated.
Compliance with reporting requirements will be attained by purchasers and oversight bodies (i.e.,
accreditation, certification and licensure entities) by the mechanisms available to them (e.g.,
purchasing contracts and oversight processes). A decision to participate in the Forum would be
viewed as constituting an endorsement of its work and an agreement to leverage compliance with
the results to the full extent of the participant's ability.
Also critical to the Forum's efforts will be the participation of key organizations involved in
promulgating quality measures and collecting information on the performance of various sectors
of the health care industry. Key organizations include those that undertake efforts on a national
basis, as well as those emerging and established groups organized at the regional, state, or local
levels. The Forum will need to work with these organizations to determine how best to assure
that information on health care quality is available, affordable, and easily accessible in the public
domain. The Forum itself would not compete with the innovative work already under way in the
public and private sectors by developing performance measures itself, but would instead seek to
encourage the progress being made in this area and improve it through greater coordination. It
would help to identify areas of needed fundamental research related to quality.
PROPOSED PLANNING PROCESS
A planning process is needed to provide key stakeholders with the opportunity to work through
critical issues related to the Forum's governance, organizational structure, and source(s) of
financial support. The Vice President will begin this process by inviting key stakeholders to a
June meeting to form a Task Force to jump-start the planning process. He will select individuals
to participate in this planning process based on their expertise and stature, as opposed to
organizational affiliation. The decisions to use a neutral convener and to seek funding support
from a private foundation were made as a means of ensuring impartiality and promoting
3
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Draft 4/24/98
participation by stakeholders.
The planning process should take place over a 6-month period, commencing in May 1998 with
the issuance of invitations to participate. Over the course of that time, during which three
meetings will be held, the Task Force will accomplish four critical objectives:
define the Forum's functions, operations, working relationships and membership criteria;
determine the composition of the Forum's governing board;
determine the source(s) of start-up and ongoing financing; and
initiate a process to recruit the Forum's Executive Director.
Objectives of the Planning Process
1) Define the Forum's functions, operations, and working relationships.
Defining the Forum's functions, operations, and working relationships will be among the most
important objectives of the planning process. The Quality Commission's work provided a
starting point for defining these characteristics, but additional work is needed to refine and
operationalize those recommendations.
A number of issues to be addressed pertain to the manner in which the Forum will function. For
instance, the planning process may identify policies and procedures designed to assure the public
of the integrity of the Forum's work, promote widespread confidence in its outcomes, and
minimize potential conflicts of interest. The planning process can serve to articulate specific
policies and procedures that will provide for public input, public deliberation, and public access
to documents produced.
Operational issues to be addressed include the Forum's organizational structure, budget,
facilities, and meeting schedules. In defining these aspects, participants in the Forum's planning
process may wish to look to the organizational structures of entities charged with undertaking
functions that are similar in nature, scope, and scale. Entities such as the Financial Accounting
Standards Board and the American National Standards Institute -- although not analogous to the
Forum in all respects -- may provide alternative models for examination by the Planning Task
Force.
Task Force Planning process participants will need to carefully consider how the Forum will
relate to the public- and private-sector organizations whose work will influence or be influenced
by the Forum's activities. Formal working relationships will in some cases need to be
established; for instance, in the case of organizations responsible for the development of the
health care quality measures that will be evaluated for inclusion in the core sets of measures to be
4
04/28/98 TUE 16:32 FAA
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Draft 4/24/98
periodically endorsed by the Forum. Similarly, the ways in which the Forum will interact with
existing local, regional, state, and national organizations that serve as repositories of data on
quality will need to be considered.
2) Determine the composition of the Forum's governing board.
The composition of the Forum's governing board is a key issue to be addressed through the
planning process. Both the precise number and the allocation of slots on the Forum's governing
board will need to be determined.
The Quality Commission recommended that the Forum be governed by a board that includes:
public and private group purchasers;
individuals and organizations focused on representation of consumers/patients;
providers;
labor unions;
experts in quality assurance, improvement and measurement;
quality oversight organizations;
health care researchers; and
public health experts.
Balancing the need to have a strong purchaser role and representation of the full array of key
constituencies will be a delicate and challenging task for the planning process participants.
Substantial representation on the board of purchasers from both the public and private sectors
and of consumer organizations will be critical to provide strong incentives for organizations to
participate in these efforts and to abide by the decisions of the Forum. Representation of the full
array of key constituencies on the board will be equally critical, so as to assure the buy-in of all
participants and the requisite expertise to effectively carry out the Forum's responsibilities.
3) Determine source(s) of start-up and ongoing financing.
Participants in the planning process will need to consider alternative sources of start-up funding
to assist in establishment of the Forum. The potential for obtaining a start-up grant from a
foundation or public source will need to be evaluated. Such funds may be used to allay one-time
expenses that will be associated with initiating the Forum (e.g., expenditures associated with
outfitting staff offices). External funding is unlikely to be made available for ongoing financing
of the Forum, however.
Thus, it is essential for the Planning Task Force to establish an ongoing source of financing for
the Forum. Participants in the planning process will need to estimate the Forum's first-year
operating budget and develop a dues-paying schedule for members. Such a schedule will need to
account for the varying levels of resources available to different categories of stakeholders. For
5
04/28/98 TUE 16:32 FAX
0
009
Draft- 4/24/98
instance, cross-subsidies may be required so that the Forum is able to attain adequate
representation of consumer interests.
4) Begin Recruitment of an Executive Director.
Once the planning process has resolved operational, representation, and financing issues, the
Planning Task Force will initiate a process to identify an Executive Director capable of providing
leadership for the Forum. This will require defining the skills and qualifications of ideal
candidates for the position, and seeking and conducting initial reviews of candidates.
Responsibility for selecting an Executive Director from qualified candidates will fall to the initial
Board of Directors of the Forum, but the Planning Task Force can expedite this process by
initiating the search.
Candidates will need to possess a variety of professional skills and expertise to be successful as
the Forum's Executive Director. These include strong leadership, management, and planning
skills; a high level of credibility among the diversity of stakeholders represented at the Forum;
technical knowledge regarding quality measurement, oversight, and health benefits; and the
ability to effectively communicate in support of the Forum's mission. The Planning Task Force
will need to determine the extent to which the Executive Director should be drawn from interests
represented by the Forum. For example, a potentially highly qualified candidate may be a person
with experience as a corporate benefits director with first-hand knowledge of purchasers'
perspectives on the use of quality measures; negotiating experience with hospitals, clinicians, and
oversight organizations; and an understanding of consumers' use of quality measurement
information. Other individuals with the requisite experience and skills to serve as the Forum's
Executive Director may include health plan executives, quality oversight managers, or experts in
quality measurement and improvement.
The planning process for selecting an Executive Director will require identifying the desired
qualifications of candidates as soon as the functions and operations of the governing body of the
Forum are defined. This definition of the Executive Director position and desired skills of
candidates needs to occur early in the Planning Task Force's process to allow time to recruit
highly qualified candidates. The Task Force may elect to contract with an executive search firm
to assist in the recruiting of suitable candidates. Once eligible candidates have been identified,
the Task Force will need to review the qualifications of candidates applying for the position and
identify top candidates for consideration by the Board of Directors.
6
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Draft- 4/24/98
Time Frame for Planning Process
June 1998
First meeting of planning process
Purpose: Define Forum's functions, operations, and working relationships
September 1998
Second meeting of planning process
Purpose: Determine the composition of the governing board, sources of
ongoing financing for the Forum, and qualifications of Executive Director
November 1998
Third Meeting of planning process
Purpose: Name governing board, and screen Executive Director candidates
December 1998
Convene prospective members of governing board, select Forum's
Executive Director, release start-up funds
January 1999
First meeting of the Forum's Board of Directors
Budget for Planning Process [Note: Preliminary, rough estimates]
Personnel costs
$120,000
[Estimated as I FTE . $100,000 annual compensation (including benefits) * 0.8 years + 1 FTE
* $50,000 annual compensation (including benefits) * 0.8 years]
Administrative expenses and overhead
$ 40,000
Meeting expenses (3 meetings)
$ 85,500
-- facilities [estimated as $3000 * 3 meetings]
-- travel expenses [estimated as 20 people * $800/mtg * 3 mtgs]
-- overhead for services of contractors responsible for meeting logistics [estimated as 50 percent
of total meeting expenses]
Honoraria for Planning Committee
$ 60,000
[estimated as 6 days meeting time * 20 participants in planning committee * $500 daily rate]
Contract for executive search services
$ 39,000
[estimated as 30% of Executive Director's annual salary of $130,000]
Total
$344,500
7
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011
JAMES R. TALLON, JR.
James R. Tallon, Jr. is president of the United Hospital Fund of New York. The Fund, the
nation's oldest federated charity, addresses critical issues affecting hospitals and health care in
New York City through health services research and policy analysis, education and information
activities, and grantmaking and voluntarism.
Mr. Tallon serves as chair of the Kaiser Commission on Medicaid and the Uninsured and is a
member of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). He
serves as secretary for the Alpha Center and for the Association for Health Services Research. and
is also on the boards of the Alliance for Health Reform. The Commonwealth Fund, and the New
York Academy of Medicine. He recently concluded a three-year term as a member of the
Prospective Payment Assessment Commission (ProPAC), and has held visiting lecturer
appointments at the Columbia University and Harvard University schools of public health.
Prior to joining the Fund in 1993. Mr. Tallon served in the New York State Assembly for nineteen
years. beginning in 1975. As majority leader from 1987 to 1993 and as chair of the health
committee from 1979 to 1987, he spearheaded efforts to reform the Medicaid program while
expanding eligibility for pregnant women, and children. His 1991 legislation required the
implementation of Medicaid managed care programs statewide. Under his leadership. the
Assembly also enacted measures to assure transitional health coverage for laid-off workers,
reimburse hospitals in a fair and cost-effective manner, foster high-quality and cost-efficient home
health care services, encourage organ donations, promote AIDS research and education, and
foster regional health planning agencies.
Mr. Tallon received a B.A., cum laude, in political science from Syracuse University and an M.A.
in international relations from Boston University. He has also completed graduate work at the
Maxwell School of Citizenship and Public Affairs at Syracuse University. In 1995. he was
awarded honorary doctorates of humane letters from the College of Medicine and School of
Graduate Studies of the State University of New York Health Science Center at Brooklyn, and
from New York Medical College.
February. 1998
I
FAXED
for
Jarah
FILE
QUALITY
06/02/98 10:45 FAX 202 456 5557
DOMESTIC POLICY COUNCIL
5.
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FORUSH THE WHITE HOUSE
NTBK Domestic Policy Council
DATE:
John Eisenbey, Nancy foster, Anthony so,
FACSIMILE FOR: Richard Soriar 301-594-2155(5) 690 6154 (F)
301-594-2168
690-6343 (p)
690-6247
PHONE: ( ) -
FAX: ( ) -
FACSIMILE FROM: Sarah Bianchi
PHONE: ( ) -
FAX: ( ) -
NUMBER OF PAGES (INCLUDING COVER):
[ ]
FOR YOUR REVIEW
[ ]
PER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU
[ ]
PER YOUR REQUEST
1.
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The
THE WHITE HOUSE
Domestic Policy Council
DATE:
John Eisenbey, Nancy foster, Anthony so,
FACSIMILE FOR: Richard Sorian 301-594-2155(c) 690- 6154 (F)
301- 590 -2168
690-6343 (p)
690-6247
PHONE: ( ) -
FAX: ( ) -
FACSIMILE FROM: Sarah Bianchi
PHONE: ( ) - -
FAX:( ) -
NUMBER OF PAGES (INCLUDING COVER):
[ ]
FOR YOUR REVIEW
[ ]
PER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU
[ ]
PER YOUR REQUEST
COMMENTS: Report Comments on Quality
MEMORANDUM
June 2, 1998
TO: John Eisenberg, Nancy Foster, Anthony So, Richard Sorian
FR: Chris Jennings and Sarah Bianchi
RE:
Quality Report
Thanks for sending us a draft of the report. You have clearly done a great deal of work
putting this together. In addition to the handwritten edits, we thought it might be helpful to give
a few overall comments.
You have collected an impressive list of examples of companies and state and local
governments, and others that are relying on this kind of data and information. We would suggest
that rather than citing all of the examples on this comprehensive list, that we focus in a more
limited set of examples and describe them in more detail. Specifically, we would recommend
choosing the examples where you believe we can describe: (1) the problem that was being
addressed (i.e. overuse of services, high rate of diabetes, etc); (2) how the quality measure was
implemented to address that problem (why a certain approach was chosen, who uses it, etc.); and
(3) what if any evidence that we have to verify that this was somewhat successful (either
improved consumer satisfaction, address the defined problem in some way etc.) We are aware
that in many cases, this level of information is not available, but we would suggest limiting the
report to examples that we know more about. However, you should include a paragraph or so
that gives a sense of how widespread the use of this information is.
We would also suggest defining the problem as much as possible, with using the
examples that you have and any others that we can find, particularly with regard to how this is
costing the health care system money (as well as costly in terms of human suffering) and
improving outcomes.
Once you define how this kind of information works and can be useful, the report raises
the question of why the existing system is not good enough and why we would need a Quality
Forum. Therefore, we would recommend that you include a section that describes why the
current system is not sufficient. This section may include a brief discussion of the fact that there
is a patchwork of success stories with too little collaboration; that more companies have
indicated an interest in using this type of information; and why it would be useful to have more
collaboration or to have people relying on similar outcome measures.
We would recommend that the discussion of the forum would follow this section. You
should discuss more fully the description of the forum -- using some of the language that is from
the Quality Commission report itself. This section should include a discussion of why the forum,
and the planning process is so important. It could also include a discussion of what the potential
is with regard to improving quality, developing a consistent set of measure, and why that is so
important.
The outline we are suggesting is as follows:
I.
Introduction
II.
Evidence of Quality Problems -- overuse of services, cost impact and human
suffering etc. etc.
III.
Evidence that these problems can be addressed -- through 10 examples of how
this is currently working.
IV.
Why the current system is not good enough and why there is great potential to do
better.
V.
What the Quality Commission recommended in this regard. Why the Forum has
so much potential to improve quality, outcomes, etc.
VI.
Why the planning process is the first important step to developing this critical
system.
Is it possible for us to see a revised draft at the end of this week? Thanks again.
1001/024
AGENCY FOR HEALTH
LIAISON OFFICE FOR QUALITY
CARE POLICY AND
SEARCH
U.S. Department of Health and Human Services, 200 Independence Ave., S.W., Room
638G, Washington. D.C. 20201
FAX
Date: 5/21/98
Number of pages including cover sheet: 26
24
To:
From:
Sarah Bianci
ANTHONY D. So, MD, MPA
SENIOR ADVISOR TO THE
ADMINISTRATOR
Phone:
Fax phone: 456-5557
Phone:
202-690-7230
CC:
Fax phone:
202-690-6154
REMARKS:
Urgent
For your review
Reply ASAP
Please comment
05/21/98 17:35
Memo
To:
Sarah Bianci
From:
Anthony So
Subject:
Forum Background paper
Date:
May 21, 1998
Over the last few days, we have worked to move from outline to draft background paper. To
provide an early glimpse at this draft, Dr. Eisenberg asked that we fax to you the current version.
It still needs to go through Department clearance, but your input and Chris's at this stage would
be most helpful. As our e-mail system is down indefinitely, comments can be faxed to (202)
690-6154.
If possible, we would like to discuss how the paper might be used at the event. This would help
us in making the next round of revisions. I can be reached at (202) 690-8205 or 690-7230.
DRAFT-PLEASE DO NOT CIRCULATE
Measuring and Reporting on Health Care Quality-
Firm Foundation for the Forum
Background Report
Overview
In December, 1994, a well-known health reporter for the Boston Globe suffered an accidental,
but fatal overdose of chemotherapy at a major Boston academic institution. Undergoing
50mg
treatment for breast cancer, she received a fourfold miscalculation of her chemotherapy drug, and
later, her death became the subject of newspaper headlines. The Joint Commission on
this
Accreditation of Healthcare Organizations responded to this incident and the report of a second
accidental overdose by placing the hospital on conditional accreditation. The top leadership of
the hospital departed, and the Dana-Farber Cancer Institute undertook an investigation of what
went wrong. The result was a practical "internal revolution," and significant changes-from
the exam isht lets
requiring staff physicians to countersign chemotherapy orders to a redesigning of patient charts
and an effort to survey patient satisfaction with care-were implemented. However, more often
than not, measures of quality-not the media-motivate improvements in how health care is
delivered.
The real story of health care quality seldom makes the headlines. Many private and public sector
efforts serve as example of how we can improve health care quality for all Americans.
Measuring and reporting on quality has resulted in real gains for consumers in terms of health
plan choice and better care. But as the Final Report of the President's Advisory Commission on
Consumer Protection and Quality notes, we can do better. This report focuses on the promise
revealed by these leading edge efforts.
visht
These activities to improve health care quality make good business sense. They can result in
increased productivity and decreased costs from higher quality care. The Business Roundtable
found that companies surveyed for a report on best practices in health care "repeatedly
emphasized their belief that future cost savings in health care depend on quality improvement."
9 frout couple mples. ple use &
Major businesses have echoed this statement as well (The Business Roundtable, 1997).
wheer
her
*
Information on quality is also the sign of a "mature" health care market, as measured by the level
&
of managed care penetration. Where managed care penetration was greater, health plans used
quality to choose potential providers of tertiary care. In contrast, price dominated the choice of
tertiary care providers in the less mature markets, and quality monitoring efforts in the
not
contractual arrangement were less common (Schulman, et al., 1997).
Quality matters to consumers. By a wide margin, Americans cite high quality as their most
important concern in choosing a health plan (AHCPR-Kaiser Family Foundation, 1996). To be
sofe point Jouv .s Vare
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effective, consumers must become involved in these activities. From health plan selection to
treatment decisions, consumers must be empowered to participate. Taking measure of quality
may respond to consumer concerns over managed care. Such concerns have kept some
employers from using managed care services.
1st talk about why impt. to the private sector
The Federal government also has an important, and complementary, role to play in these efforts
to improve quality. The government funds clinical and health services research; supports the
development of quality measures; sponsors surveys and databases that can track and benchmark
changes in quality; encourages information exchange over best practices; and purchases or
delivers health care for millions of Americans.
Bridging the Gap in Health Care Quality
The President's Advisory Commission on Consumer Protection and Quality in the Health Care
Industry affirmed that many Americans receive quality care from dedicated health care
professionals (Final Report, 1998). However, it also found wide variations in health care
is & one la the purchasers rest
practice, attributable in part to underuse, overuse and misuse of services.
thasers
For some services, underuse poses a challenge. For example, only 66% of children enrolled in
the 330 managed care plans providing information to the National Committee for Quality
Assurance (NCQA) had received appropriate immunizations by age two (NCQA, 1997). A
&
nationally representative sample of women age 50 and older found that only 45% had a
of 04
mammography, as recommended for early detection of breast cancer, in the previous year (CDC,
1993). In another study, a third of Medicare patients who survived a heart attack failed to receive
b/c inim mple go wwig
aspirin within two days of hospitalization (Krumholz, et al., 1995). This was despite the fact that
these patients had no contraindications to aspirin therapy and that aspirin use among elderly
patients had been shown to reduce mortality by 22% in the first 30 days after a heart attack.
Overuse of services also presents problems. Half of all patients diagnosed with a cold and 66%
of patients diagnosed with bronchitis received antibiotics (Gonzales, et al., 1997). In 1992,
mith 4.11 Smith 33. 104
twelve million antibiotic prescriptions were written during office visits for colds, upper
respiratory tract infections and bronchitis. Together, these prescriptions accounted for one out of
every five antibiotic prescriptions to adults in that year. Yet antibiotics offer little or no benefit
for these conditions. This overuse of antibiotics not only imposes unnecessary health care costs,
but also places patients at risk for adverse drug reactions and contributes to the emergence of
antibiotic-resistant pathogens. In a study of tympanostomy tube placement in children,
researchers found that 23% of the procedures were performed for inappropriate indications while
another 35% were for equivocal indications (Kleinman, et al., 1994).
Misuse of services and avoidable errors occur in the use of laboratory tests and medications. One
study noted that 10% to 30% of laboratory test results were inappropriately classified as normal
2
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based on rescreening reviews (Wilbur, 1997). These errors can result in missed or delayed
diagnoses. Several studies have examined medication errors in hospital settings. One conducted
in a teaching hospital found four errors per 1,000 medication orders. Investigators classified
70% of those errors as having the potential for serious adverse outcomes (Lesar, et al., 1997).
Measuring Quality
To address these issues, the Advisory Commission called for the creation of two entities-an
Advisory Council for Health Care Quality in the public sector and a Forum for Health Care
Quality Measurement and Reporting in the private sector. Each fulfills an important and
complementary role. The Forum is intended to improve the effectiveness and efficiency of
health care quality measurement and reporting. Building on the promise of what public and
may
private sectors have already achieved, the Forum has potential to take this work to the next
quantum level.
how, what are the gaps that have been
ox
waiteefine
To left? realize these gains in quality improvement, coordinated efforts at quality measurement, data
collection and reporting are key. Through these two entities-the Council and the Forum-the
Commission proposed coordinated efforts to improve health care quality. In its Final Report, the
Commission found that "incentives to improve quality have been diluted by measurement efforts
that vary widely in their aims and scope, and that have been, at best, only informally
coordinated." This paper focuses on the potential that coordination of this work might bring.
Such coordination would serve several purposes. First, it would enable the marketplace to
unclear here is
identify and update core sets of quality measures and standardized reporting methods. On the
part of health care providers and plans, this would reduce needless duplication of data collection
purpose. Second, it would allow consumers and purchasers to comparison shop for health plans.
which to assess provider performance. Finally, coordinated efforts can lead to the sharing of
resources and best practices, both across and within private and public sectors. At present,
employers and other group purchasers do not have a central repository for learning about best
what Cax council sho Focus uld from or J w.x 1x cave PHOTOP
1
and reporting efforts. Such a process would also flag what measures are important and for what
For employers and other purchasers, a core set of quality measures offers a common yardstick by
purchasing practices, nor do they have affordable access to the technical assistance that would
permit replication of the practices of pioneers (Meyer, et al., 1997).
Developing core sets of quality measures. The Federal government and the private sector have
both contributed to sets of measures from which a single core set might emerge. Importantly,
many of these tools reside in the public domain, where they are more widely accessible.
The Health Plan Employer Data and Information Set (HEDIS), developed initially by
Digital, GTE and Xerox and later by the National Committee on Quality Assurance
(NCQA), is one set of quality measures widely used by health plans. In October, 1997,
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NCQA released its second version of Quality Compass, a database of HEDIS and
accreditation information on 329 health plans across the nation. With Quality Compass
1997, NCQA published its first "State of Managed Care Quality," a report that provides
my of >pant S Plnons
benchmarks and national and regional averages based on HEDIS data.
Working with RAND, Research Triangle Institute and Harvard, AHCPR sponsored the
development of the Consumer Assessment of Health Plans Survey (CAHPS). CAHPS is
X in
a consumer satisfaction survey that gauges consumers' experiences with their health
plans. Recently HCFA began surveying over 200 managed care plans serving Medicare
beneficiaries to collect and report on CAHPS data. Next spring Office of Personnel
Management will use CAHPS to survey Federal employees. Thus in FY 1999, over 45
million Americans will have access to CAHPS reports to help them make their health
care choices.
AHCPR and 19 state partners built a powerful tool for studying quality health care, the
Healthcare Cost and Utilization Project (HCUP). This research database and tool
provides a comprehensive source of hospital inpatient financial and clinical information.
As more health care moves from inpatient to outpatient settings, the Agency plans to
tail. shou wh we at was- describe des the services now Pro bleue a
broaden the database to include ambulatory surgery, and this is underway in nine of the
participating states. Many organizations lack the resources to build a benchmarking
infrastructure to assess the impact of delivery system changes on quality. The HCUP
Quality Indicators provides a user-friendly, standardized database and software program
to track the impact of system changes on quality. At least ten state governments and state
hospital associations use HCUP Quality Indicators for benchmarking and monitoring
purposes. The Hawaii Health Information Corporation (HHIC), a non-profit organization
that aids hospitals with their quality improvement programs, submitted the HCUP
Quality Indicators to JCAHO for approval for the ORYX measurement initiative.
JCAHO approved most of the indicators, opening the door for HHIC to use these
I
indicators in the JCAHO accreditation process.
"Founded on the premise that "a more responsive health care system depends on informed,
about
empowered consumers who help shape the system, hold it accountable for quality and act
as partners in improving health," FACCT-the Foundation for Accountability-also has
developed measures of health care quality. Over the past couple years, it has completed
work on measures focused on adult asthma, breast cancer, diabetes mellitus, major
depressive disorder, health status, health risks, and consumer satisfaction. Consistent
addressed particular what etc It better don't wes thinke resulted need we a list
with its goals of being consumer-focused, FACCT conducts focus groups for each of its
measures and combines these patient expectations with the best available clinical
knowledge and scientific research.
The Health Care Financing Administration (HCFA) aided in the development of
OASIS-the Outcomes and Assessment Information Set-a core standard assessment data
set for home health agencies. Under a second proposed regulation in March 1997, HHS
requires home health agencies to use OASIS to monitor patient satisfaction and
conditions. OASIS requires a standardized assessment of new patients within 48 hours of
4
woncs.
stuff
why
how
that
very
examples
few
use
but
there
this
lyonip
DRAFT-PLEASE DO NOT CIRCULATE
admission to determine immediate support needs and updated assessments continuously
until the patient's discharge. Additionally, health agencies must use data from OASIS to
improve practice through their quality improvement programs (HCFA, 1997).
The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the
major accreditation organization for hospitals, has developed a quality measurement
system called ORYX Plus. It is a voluntary option for hospitals and offers opportunities
for national benchmarking and performance comparisons by stakeholder groups.
Initially, JCAHO identified 32 measures for the system with expectations to increase the
number and sophistication of measures over time (JCAHO, 1998).
The American Medical Association has initiated the American Medical Accreditation
Program (AMAP) for physicians. This voluntary program, developed in collaboration
with specialty, state, and local medical societies, will reduce duplication in credentialing
requirements. It will provide feedback on the quality of a physician's care to the
physicians themselves as well as health plans and hospitals. State licensing requirements
currently can involve credentialing or site reviews. Adding to this information base,
AMAP plans to include other data on the physician's personal qualifications, clinical
performance, and patient care satisfaction (AMA, 1998).
The SF-36 Health Survey remains one of the most widely used generic health-related
quality of life measures (Ware, 1998). Researchers developed the measure in a way that
both allowed for group comparisons and used general health concepts not specific to age,
disease or treatment group. The measurement instrument provides insight to alternate
definitions of health-function and dysfunction, distress and well-being, objective reports
and subjective ratings, and favorable and unfavorable self-evaluations of health status.
Numerous stakeholders, including health plans health services researchers, experts in
diabetes and primary care, HCFA, the American Diabetes Association, FACCT, and
NCQA, have joined together for the Diabetes Quality Improvement Project (DQIP). This
collaborative effort has resulted in the development of an initial set of diabetes measures.
This project is ongoing with plans to field test new measures in the future. The
participating organizations are considering this set of measures for inclusion in their
measurement projects, including future versions of the HEDIS Reporting Set (NCQA,
1998).
Complementing core measures. The development and use of core sets of measures have
encouraged firms and group purchasers to go a step further. Some have complemented core
measurement sets with other yardsticks for health plan performance (Meyer, et al., 1997).
In evaluating HMO performance, General Motors blends several measures of health care
quality into one amalgamated quality measure and draws from direct indicators of quality
from HEDIS, employee satisfaction measures, accreditation status, and impressions
gained from site visits. GM also works with its plans to develop quality improvement
strategies and facilitate the sharing of best practices.
this is a good example to spell out in much
more detail. Why do what motivated
GM to do this Whin did it work? are consumers
happien
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17:37
NU.
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Digital applies its own comprehensive set of HMO performance standards to evaluate
quality. The company periodically updates these standards with the addition of new
indicators, such as HEDIS, and the removal of outdated ones. Within this framework,
Digital sets "stretch" goals that encourage HMOs to continuously improve their
performance.
The Chicago Business Group on Health contracted Hewitt Associate, which also
participated as an employer in the group, to assess costs and quality in local health plans.
Hewitt used results from individual interviews, HEDIS indicators, its own benchmarking
database (Health Network Profiler), features of the Consumer Health Plan Value Survey,
and other national benchmarking indicators (such as Healthy People 2000).
Filling in the measurement gap. Still, to meet the needs of purchasers, continued work to fill the
gaps in quality measures must be undertaken. Some of this work requires cataloguing existing
measures, but much of it involves research to advance the science of measurement.
AHCPR works to fill the gaps in quality measurement by supporting the Q-SPAN
project. In a series of cooperative agreements to develop and test new measures, the Q-
SPAN project currently focuses on eight measures for specific conditions, patient
again
populations, and health care settings: clinical performance measures for dental care plans,
developing and testing asthma quality of care measures; development of a global quality
two
assessment tool for managed care, expansion of quality measures for cardiovascular
pick
disease, functional outcomes in patients with hip fractures, measuring quality by
$2
achievable benchmarks of care, ongoing development and evaluation of HEDIS
measures, and quality outcomes in subacute and home care programs (AHCPR, 1998).
In the area of child health, AHCPR, the Maternal and Child Health Bureau and HCFA are
tell
three
funding NCQA to pursue quality measures of relevance to children and adolescents. This
funding will support the collaboration of NCQA and FACCT in the development, testing
at
and implementation of child health measures, as well as their inclusion in future versions
of HEDIS.
FACCT also works to fill the measurement gap and has under development measures on
was
blem
the
alcohol misuse and dependency, coronary artery disease, end of life, and HIV/AIDS.
AHCPR has developed a catalogue of existing quality measures-CONQUEST. Designed
for providers, managed care plans, purchasers and policymakers, it uses a common
language so that individuals can quickly identify a group of measures for use. Currently,
CONQUEST contains 1,185 clinical performance measures and information on 52
common or costly clinical conditions, such as diabetes, hypertension, depression, cancer,
and pregnancy. Unlike some private sector databases of measures, CONQUEST is
available in the public domain (AHCPR, 1998).
In an initiative undertaken to provide a catalogue of performance measures in a
standardized format, the JCAHO started the National Library of Healthcare Indicators:
A 7 plant & & is E &
Health Plan and Network Edition. It provides profiles of 225 performance measures that
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can be used to assess the performance of health plans, integrated delivery networks,
provider sponsored organizations, and other delivery systems. Each profile adheres to a
sophisticated classification system, and each measure is selected based on an "expert-
based face validity screening process" (JCAHO, 1998).
Minimizing redundant efforts. Multiple competing core sets of quality measures can lead,
however, to unnecessarily duplicative and expensive data collection efforts by health plans and
providers. Public-private partnership on developing core sets of quality measures can minimize
this while preserving the room required for continued development and improvement of
measures. For example, the National Committee for Quality Assurance (NCQA) will merge
their consumer assessment survey with the Consumer Assessment of Health Plans Survey
(CAHPS), which was created through AHCPR funding. Along these same lines, group
purchasing arrangements have helped consolidate the measurement requirements. Using HEDIS
3.0 quality and enrollee satisfaction measures, the California Cooperative Healthcare Reporting
Initiative (CCHRI) reports annually these results to purchasers in the Pacific Business Group on
Health and others.
Cascading effects from the development of quality measures. What cannot be measured cannot
be improved. Downstream, the development of quality measures has triggered a cascade of
activities to improve health care quality.
Developed by the AHCPR-sponsored cataract Patient Outcome Research Team (PORT),
the VF-14 is an instrument used to measure functional status in patients with cataracts.
Now considered the gold standard, the VF-14 has now been adopted by several Medicare
carriers as part of the routine pre-operative assessment of cataract patients. Based on data
collection strategies and tools developed by the cataract PORT, the American Academy
of Ophthalmology launched a large national project enabling ophthalmologists to collect
ovidence
standard clinical information on their cataract patients. The AAO has invested over $1
million in this effort, called the National Eyecare Outcomes Network (NEON). The
AAO and the physicians believe that this database enables them to provide reliable
performance data on their cataract surgery when competing for managed care contracts.
They also use the data to detect differences in patient outcomes that may allow specific
providers or groups to identify quality problems and improve quality of care. A national
organization of ophthalmology residencies plans to use the database to monitor the
quality of residency programs in the country. At least one program requires all of its
residents to submit data to the database and uses the information to measure performance
of the residents.
To assess prostate symptoms better, the American Urological Association (AUA)
symptom index was developed and validated. It proved to be a superior measure of
symptom severity compared to various physiological and anatomic measures commonly
used in practice. The Maine Medical Assessment Foundation has used the AUA
7
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symptom score along with other measures to collect outcomes on patients with benign
prostatic hyperplasia. Over 60% of practicing urologists in Maine now use the symptom
score Its use has changed the way urologists practice with greater attention to informed
patient
decision
making.
how,
why,
Competing on Quality
evidence?
The public availability and public reporting of these quality measures play an important role.
When used for comparisons in the marketplace, this information allows consumers and
purchasers to evaluate and select health plans and providers on the basis of quality, not just cost.
For the marketplace to compete on quality, employers and coalitions must also incorporate these
considerations into their purchasing strategies.
These measures often take the form of report cards made publicly available. Various groups
produce these guides, deliver them in print or electronic formats, and make them publicly
available for free or for purchase. For example, U.S. News & World Report and Newsweek
publish ratings of health plans, as do consumer organizations like Washington's Consumer
Checkbook and Consumer Reports. Using HEDIS measures and an NCQA consumer
satisfaction survey, U.S. News and World Report published a report card in October 1997 of 223
managed care plans (Brink and Shute, 1997). Newsweek followed with a December report card
of 88 plans based on the FACCT framework and measures (Spragins, 1997). Several states have
followed suit with customized report cards examining local health plans. The New Jersey
Department of Health and Senior Services and the Maryland Health Care Access and Cost
Commission (HCACC) both present HEDIS data, and New Jersey uses the AHCPR-sponsored
CAHPS survey for its consumer satisfaction data (New Jersey Department of Health and Senior
Services, 1997, and Maryland HCACC, 1997). Through its Web site, the National Committee
for Quality Assurance provides selected findings from HEDIS measures of health plans on
"Quality Compass."
Employers such as Motorola and J.C. Penney also generate such reports on health plans for their
workers (The Business Roundtable, 1997). In fact, J.C. Penney personalizes report cards on
HMOs to the specific home zip code of the employee. These report cards carry such information
as NCQA accreditation status, plan member satisfaction rates, and the number of contracted plan
specialists. Again, some purchasers have gone beyond core measurement sets. General Motors,
First Chicago NBD, and others are involved in the Southeast Michigan Health Care Consortium,
which is collecting outcomes data for all health care centers in the region. They plan to publish
data on angioplasty and coronary artery bypass surgery in the fall of 1998 (The Business
Roundtable, 1997).
This nds like posseble could example
This work has also arisen out of public-private partnerships. The Massachusetts Healthcare
Purchaser Group, a statewide coalition of 67 public and private members, publicizes information
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on the ability of local health plans to meet specific cost and quality goals. Public sector
representatives include the Massachusetts Division of Medical Assistance which runs the state
Medicaid program; the Group Insurance Commission which purchases health care for state
employees; and several municipalities and nonprofit colleges. The group examines HEDIS data,
publicly reports on the number of indicators that plans produce, and ranks plans relative to each
other and to benchmarks. They developed a report card for the first time in 1996, and they hope
to develop a group purchasing strategy by January 1999. In another example of public-private
partnership, the California Office of Statewide Health Planning and Development and the Pacific
Business Group on Health have developed the California Coronary Artery Bypass Graft (CABG)
Mortality Reporting Program. This program collects and reports risk-adjusted, hospital-level
mortality data for California hospitals that perform bypass surgery (Meyer, et al., 1998). The
growing availability of these measures speaks to consumer interest in this information.
Studies have shown that the public reporting of quality measures can result in improvements in
the delivery of health care.
Since 1989, the New York State Department of Health has collected and released
hospital-level data on coronary artery bypass surgery. From 1989 to 1992, actual
mortality decreased from 3.52% to 2.78%. Because average patient severity of illness
increased, risk-adjusted mortality decreased even more over that same period-by 41%
from 4.17% to 2.45% (Hannan, et al., 1994).
The Missouri Department of Health developed a consumer report on obstetrical services.
Within 1 year of the report, approximately 50% of hospitals that did not have car seat
programs, formal transfer agreements for high-risk infants, or nurse educators for breast-
feeding prior to the report either instituted or planned to institute these services (Longo, et
synt
al., 1997).
In 1993, 27 corporate and government health care purchasers formed the Massachusetts
Healthcare Purchaser Group (MHPG). Sixteen health plans representing 15 different
health care organizations submitted 1992 data on 6 clinical indicators. A "clinically
significant average range" was defined and health plan performance was summarized for
each indicator in the "Cost/Quality Challenge Report" released in March 1994. Most of
the purchasers MHPG surveyed about their assessment and use of the Cost/Quality
Challenge Report found it useful. To promote quality improvement activities among
health plans, MHPG showed purchasers how to pursue performance issues with health
plans, held a best-practice forum on C-section, and created a follow-up endeavor, the
Coordinated Purchasing Initiative (Jordan et al., 1995).
Apart from purchasing health care, quality measures serve an important role in flagging areas for
improvement and motivating practice change. Both the public and private sectors have
effectively used quality measures to accomplish these ends. Some have done so by publicly
reporting the information, and others, by providing feedback more directly to health plans and
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providers. In each case, the evidence shows that quality measures can result in improvements in
health care services.
The public release of data on quality of care has its role in ensuring public accountability.
However, not all quality measures work best when used in this way. Health plans and providers
see patients, who may differ in their severity and pattern of illness. To compare across plans and
providers, risk adjustment for these differences needs to be done, and done well. Sometimes the
motivation can come from within these plans and practices instead of from the public release of
such information. When used for improvement, quality measures can provide health plan and
provider feedback that changes practice behavior and results in continuous quality improvement
efforts.
Applying Quality Measures
Leading the way in value-based purchasing, some firms and group purchasing coalitions have
applied quality measures to how they contract and arrange for care, educate employees to
become better health care consumers, provide incentives to reward the practices of employees or
providers, and become involved in improving the delivery of health care services (Meyer, et al.,
1997). By taking responsibility for educating and offering incentives in their employees' health
care decisions, employers and group purchasers are forging a new relationship with their
workers.
Contracting and arranging for care. The use of quality measures has changed the way
employers and group purchasers select health plan options and offer these choices to their
employees. Several businesses and group purchasing coalitions provide information on quality,
alongside benefit package comparisons, to employees and consumers. They also use such
information in narrowing the choice of plans to offer. It has also become part of the process to
involve employees in evaluating the health plans that the employer offers. The following
examples demonstrate various approaches taken by employers and group purchasers on the
leading edge.
International Paper Company has an extensive information database for use by its
employees. This database, called the Medical Information Resource System, includes
information on physicians taken from the American Medical Association, 12 annually
developed fee schedules, surveyed physicians' fees, the frequency of performing certain
procedures by specialty, and contracted hospitals' charges (The Business Roundtable,
1997).
GTE uses a subset of HEDIS measures and looks at the accreditation status of health
plans with which it contracts. With in-house expertise, the company has created a
database which GTE uses in lieu of NCQA's database, the Quality Compass, to evaluate
health plans (Meyer, et al., 1997).
10
this has with again, may due what
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The Buyers' Health Care Action Group (BHCAG), composed of 23 self-insured, private
employers, collectively contract with "care systems" that meet a standard set of criteria.
BHCAG provides comparative information about costs and quality to consumers (The
Midwest Business Group on Health, 1997).
Hershey Foods Corporation used risk-adjusted mortality data from the Pennsylvania
Health Care Cost Containment Commission, along with other information, to select a
network of hospitals for its point-of-service plan (The Business Roundtable, 1997).
Balancing choice and quality, Motorola sought to establish its own managed care network
to include 80% of physicians recording at least 10 encounters a year with an employee. If
an employee's physician was not included, Motorola encouraged them to recommend the
physician for inclusion and accepted all those meeting the plan's credentialing and other
requirements. By doing so, the company notes that it is "primarily interested in selecting
the physicians based on their quality of service" (The Business Roundtable, 1997).
The United Auto Workers requires NCQA accreditation for all health plans offered to its
memberes, and it is working on a strategy to provide information, including NCQA
accreditation status and some quality assessment based on HEDIS measures (AFL-CIO,
1997).
After an initial screening, Ryder System brings HMO finalists before panels of
representative employees in each of 27 market areas. The employees then quiz the
HMOs on measures such as the size of the network, the hospitals used, how doctors were
paid, and the process for referral to a specialist. This input contributes significantly to the
plans chosen for Ryder System employees (The Business Roundtable, 1997).
Educating employees 10 become better health care consumers. Though more information to
compare health plans is now available, consumers still need programs and tools to navigate
through the health care system. After the plan selection is made, difficult treatment decisions
arise, and patients sometimes require assistance in making those decisions with their providers.
In addition to report cards on health plans, several groups have developed interactive tools to aid
consumers in comparing one plan to another.
Health Pages publishes a magazine and offers an online service for consumers. It
provides information on specific health topics as well as community-specific comparative
information on physicians, hospitals, allied health professionals and health plans.
Through its work, Health Pages has assisted the employees of General Motors,
McDonnell Douglas, Edison, US West, and Chevron. Its interactive Web site allows
consumers to search for insurance plans, dentists, physicians, maternity services, and
mammography clinics in their area, with comparative and provider-specific information
(e.g., board certification, fees for selected procedures, and medical school attended for
physicians; baseline HEDIS data and description of benefit packages for health plans)
(Health Pages, 1998).
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American Express makes a videotape on health plan choice available to employees. In a
mock focus group format, the videotape discusses issues that commonly arise in deciding
among managed care options (Maxwell, et al., 1998).
AHCPR has sponsored a variety of interactive tools for target populations ranging from
low-literacy groups to families making decisions on care for the elderly. Elder Care is a
project that assists families in deciding on the best living and care arrangement for elderly
relatives. Through either a CD-ROM or its Web site, the program allows families to
evaluate the ability of their elderly relatives to function in various settings from an
independent living situation to the nursing home. In addition, the program assists the
family in assessing their ability to provide care for an elderly relative.
The Health Care Financing Administration recently debuted its Medicare Web site. The
www.medicare.gov Web site is designed for Medicare beneficiaries and the people who
help them make choices about their health care. It contains basic information about
Medicare as well as the Medicare Compare database, which provides consumers with the
ability to compare health plan benefit packages in their home area.
Of course, tools-particularly for assisting treatment decision making-also belong in doctors'
offices. The work of health services researchers has now generated promising results. On the
near horizon, these tools may complement the efforts of providers in better educating consumers
about their health care decisions. They also have a role in disease as well as demand-side
management, but importantly, they help make consumers co-producers of their care.
The Shared Decision Making Program for benign prostate disease is an interactive,
videodisc-based patient education program designed to allow patients to explore and
make an informed choice about whether to undergo transurethral resection of the prostate
or follow a program of "watchful waiting." In a pilot study, the results were promising
(Wagner, et al., 1995), although a study with a larger sample is needed to gain a clearer
picture of the impact of the program. Before viewing the videodisc, two thirds of the men
favored an approach of watchful waiting. Afterwards, this percentage increased to 79%.
Investigators found that 27% of the men who initially favored surgery changed their mind
while only 1% of those initially inclined to wait opted for surgery.
With AHCPR funding, CHESS (Comprehensive Health Enhancement Support System)
offers on-line computer support for patients. This includes a computer-based module to
help care-givers make critical decisions in caring for Alzheimer's disease patients.
Patients suffering from AIDS, breast cancer, or depression also can tap into the CHESS
database to find answers to personal questions. Additionally, they can use a hotline to
speak anonymously with a physician or to obtain peer-level support from other patients.
Early data show that AIDS patients who use CHESS are more efficient in their use of
health resources. They actually have lower health care costs, fewer hospitalizations, and
shorter hospital stays. HIV-infected persons who used CHESS reported fewer and
shorter hospital stays (and a forty percent decrease in hospital costs) compared with
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nonusers. By interacting with the home-based computer system, users monitored their
health and spotted warning signs of serious illnesses so they could alert their doctors
quickly. This tool will serve as an important resource for patients and their families as
they will have easy access to information in their home and will have a greater ability to
participate in critical decision making.
Providing incentives to reward the practices of employees and providers. Value-based
purchasing is not only practiced at the firm level, but also encouraged at the employee level.
Two approaches taken by employers and group purchasers are 1) setting the premium
contribution to plans making a quality benchmark and 2) placing a portion of the premium at
risk, contingent upon performance. Involvement in total quality management efforts, standard
setting and quality benchmarking are part and parcel of incentive setting. Several firms have
gained important experience in these approaches.
Digital Equipment Corporation emphasizes value in its health care purchasing decisions.
It defines value as the sum of quality of care and consumer satisfaction, divided by costs.
Using information yielded from its performance reporting requirements, Digital identifies
each region's best plan as the "benchmark" plan, and the company's contribution towards
enrollee health care costs is based on the premium of this plan. This provides financial
incentive to employees to purchase care from these health plans (Meyer, et al., 1997).
The Pacific Business Group on Health requires HMOs to set aside 2 percent of the
premium dollar and awards this amount only if the HMO attains the performance
standards set in customer service, quality, data collection, and other areas (Bodenheimer,
et al., 1998).
The Gateway Purchasing Association provides financial incentives to health plans to
implement a satisfaction survey, report quality indicators, and make a subset of those
indicators available for an independent audit. This coalition of thirty-one St. Louis
employers also put 4 percent of total premium dollars at risk depending on a health plan's
willingness to comply with these reporting requirements.
Improving the delivery of health care services. Improving quality means improving the delivery
of health care services. Some improvements result from the information that surfaces in plan-to-
plan comparisons, which are shared widely. Others come from disease-specific initiatives led by
group purchasers and employers in partnership with their health plans and providers.
The Health Care Financing Administration, the Office of Personnel Management, and
local business coalitions in seven communities will be working with FACCT over the
next couple of years to look at treatment outcomes for specific diseases. Other large
purchasers, such as GM, Ford, Chrysler, the State of Florida, the State of Wisconsin, the
State of Iowa, and Washington State are also involved in this venture. The selected
diseases include diabetes, asthma, breast cancer, and depression (AFL-CIO, 1997).
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The Dallas-Ft. Worth Business Coalition on Health has identified five services for
measurement. In their pilot study, they sought to develop best practices for pregnancy
and childbirth. These efforts included measuring quality across an entire episode of care,
integrating data across inpatient and outpatient settings, and using this information as
feedback to improve the quality of care. The Texas Medical Foundation took the lead to
define appropriate clinical indicators while the Business Coalition planned the consumer
satisfaction survey (Meyer, et al., 1997).
With General Motors and Chrysler, the United Auto Workers (UAW) has created the
Center for Community Health Care Initiatives. This center will identify "best practices"
on both local and national levels, promote community-wide access to high quality care
and improvement in health care delivery systems, develop prevention programs, and
make advancements in data collection and information systems. Several communities
involved in this project have already made progress. In Flint, Michigan, the initiative has
developed "best practices" for both left heart catheterization and Cesarean sections. The
initiative has also organized a free asthma clinic in Anderson, Indiana. General Motors
and UAW also have collaborated on disease management programs for diabetes and
late resting care we
cardiac care in Flint (AFL-CIO, 1997).
Cleveland's Health Quality Choice has reduced mortality from pneumonia by 21% over a
six month period at one area hospital following the implementation of a critical pathway
(Health Network & Alliance Sourcebook, 1995).
Firms like AT&T and First Chicago NBD have disease management programs in diabetes
and asthma. AT&T uses organization benchmark data for these programs, and these
measures allow the company to ask their health care vendors to target their efforts on
elobovate
specific parts of the country or to specific types of patients (The Business Roundtable,
1997). Others have focused their efforts on unnecessary hysterectomies, clinical
depression, or mental health more broadly.
Some have gone further to influence the management of the health plans with which they
contract. For example, Digital Equipment has applied the same principles of total quality
management (TQM) that the firm uses in purchasing electronic components to the purchase and
delivery of health care services for their employees (Maxwell, et al., 1998). To strike up long-
term partnerships with their managed care plans, Digital worked with them to improve quality.
By requiring managed care plans to set standards for their own suppliers, Digital implemented a
TQM approach throughout the supply chain and anticipated lower costs over time.
Importantly, providers have tracked their own outcomes in order to improve the quality of care.
Presented earlier, the Maine Medical Assessment Foundation's use of AUA prostate symptom
scores and the American Academy of Ophthalmology's National Eyecare Outcomes Network are
cases in point.
Health Data Registry, Inc., provides another example. As a company that manages
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clinical registries from hospitals and physicians, it has tracked data on cardiac surgery
patients over several years and can flag performance levels that differ from other health
care providers. Between 1992 and 1996, the program spotted an unexpected rise in the
incidence of severe renal failure among these surgical patients. Further study attributed
this complication to a "fast track" protocol, and subsequent work resulted in reducing this
problem (Page and Washburn, 1997).
Spurred by variation in mortality rates for CABG operations across five hospitals in
northern New England, a group of clinicians, scientists and hospital administrators
initiated the New England Cardiovascular Project in 1990. This program involved three
phases: feedback of risk-adjusted outcome data to hospitals and surgeons; continuous
quality improvement training for the providers; and site visits in which outside teams
observed the CABG system in each hospital. The researchers collected data during the
pre-intervention period and after the final report on the site visits. They found a 24%
reduction in the mortality rate after the intervention. Four out of the five hospitals
improved. The one hospital that did not improve had the lowest pre-intervention
this
mortality rate. Both process and system changes in the individual hospitals accounted for
the quality improvements (O'Connor, et al., 1996).
Why Businesses Need to Care: Better Quality Can Cost Less
Members of the Business Roundtable (1997) have sized up health care quality and what it means
to their business. Their words, as well as their actions, speak for them:
"Quality health care is lower cost care." (Sears, Roebuck)
"At some point, you can't squeeze anymore. We think that [health care] finance is going
to be driven by taking poor quality out of the process. In the final analysis, that will be
the value equation: doing it right the first time." (Allied Signal)
"We're not just driven by philosophy, we're driven by economics. We think that
this
improved quality inherently costs less. Improve the quality of health care and, in turn,
improve the quality of life." (GTE Corporation)
"Why do we care about improving health status [of employees] as a core strategy?
There's a business case for it. By creating enthusiastic employees, we'll build better
products and services and create enthusiastic customers, which in turn will result in
enthusiastic stockholders." (General Motors)
&
Though many of these efforts to improve health care quality are on the leading edge, the results
indicate that quality health care not only can save lives, but can sometimes save costs as well.
smt
Linch
Apart from the savings that come from negotiated discounts, business coalitions and others have
realized savings from improving care, avoiding unnecessary procedures, and bringing greater
efficiency to health care delivery.
quaber
that
works
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Working with local hospitals, the Chicago Business Group on Health spurred the
development of critical pathways for coronary artery bypass graft. This intervention
significantly decreased the hospital length of stay for this procedure and removed delays
that resulted from the poor coordination of hospital services (Meyer, et al., 1996)
Across a range of health care services, the Business Health Care Alliance of Appleton,
Wisconsin reported successes in increasing preventive screening, boosting immunization
rates, decreasing asthma readmission rates, and dropping Cesarean sections from 21.3 to
13.7% in just two years (Meyer, et al., 1996).
One Peer Review Organization found that an education program for providers and
patients in five hospitals based on the AHCPR-sponsored guideline for the diagnosis and
treatment of benign prostatic hyperplasia led to a 75% reduction in surgery and $1.3
million in cost savings for Medicare (AHCPR, 1995).
As the following examples suggest, the potential savings may be substantially greater (AHCPR,
1995).
AHCPR-sponsored research suggests that providing anticoagulation therapy to prevent
strokes among patients over 65 with atrial fibrillation could save $660 million per year.
If this treatment were provided to only 20% of the eligible cases, $132 million in cost
savings would result.
again
Appropriate eye-screening for diabetics in government programs saves up to $247.9
million at a 60% screening rate.
AHCPR research published in the New England Journal of Medicine reports that
"ensuring optimal antibiotic treatment" could translate to savings of $113 million if
two
one
applied to all surgical patients.
If applied to only 20% of eligible patients, appropriate treatment of the opportunistic
infection Pneumocystis carinii among AIDS patients could lead to $48.8 million in
Xnd
annual savings.
This is not to say that all quality improvement efforts reap savings. However, some initiatives to
improve health care quality can carry the promise of a return on investment. In July 1997, the
tall
wore
Washington Business Group on Health established a Task Force on Health & Productivity
Management to "identify and promote health care purchasing and human resource management
practices that optimize workforce health and performance and demonstrate human capital
investment value." What are the tools and measures that demonstrate the value of these health
investments? That is one of the questions that the Washington Business Group on Health plans
to begin to answer at a national conference in June of this year.
From Quality Measure to Quality Care
The many examples of public and private sector initiatives provide a snapshot of our nation's
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efforts to improve quality. However, two examples-the story of beta-blockers for heart attack
victims and the story of childhood immunizations-might offer a better picture of the potential of
moving from quality measures to quality care.
Beta-blockers to save heart attack patients
Randomized clinical trials have provided definitive evidence that the use of beta-blocker therapy
after a heart attack saves lives. Over the past two decades, these trials, including the ß-Blocker
Heart Attack Trial, have involved more than 35,000 heart attack survivors. As a result of this
work, this treatment has become known as "one of the most scientifically substantiated, cost-
effective preventive medical services" (Soumerai, et al., 1997). Organizations such as the
American College of Cardiology and the American Hospital Association have integrated
recommendations for the use of beta-blockers into their guidelines (Ryan, et al., 1996).
Despite the demonstrable clinical benefit, beta-blockers remain underused in clinical practice. In
a study of Medicare beneficiaries in New Jersey, investigators found that only 21% of eligible
patients received the therapy (Soumerai, et al., 1997). Patients were actually three times more
likely to receive a calcium channel blocker, a medication of questionable efficacy for post-AMI
patients. In this study, the mortality rate for patients using beta blockers was 43% less than those
not using the medication. The use of such interventions could prevent an estimated 18,000
deaths each year (Chassin, 1997).
Based on the strength of this evidence, the National Committee for Quality Assurance also
included a measure for "Beta Blocker Treatment After a Heart Attack" into HEDIS 3.0, and the
Health Care Financing Administration (HCFA) will require health plans under Medicare to
report on this measure in 1998. Once this practice became the focus of a quality measure,
various approaches to improve the care of these patients ensued.
Under the Cooperative Cardiovascular Project, HCFA organized the development of quality
indicators for the treatment of patients with a heart attack. Four Peer Review Organizations
(PROs)-Alabama, Connecticut, Iowa, and Wisconsin-refined and used the indicators to monitor
beta-blocker use after a heart attack in Medicare patients. The PROs provided this feedback to
all practitioners in their states. The result was that beta blocker prescriptions climbed from
31.8% to 49.7% during the follow-up period. Another study used local medical opinion leaders
to influence the prescription rates of beta blockers and aspirin (Soumerai, et al., 1998). When
local medical opinion leaders supplemented educational outreach programs, the prescription rate
for beta blockers increased 63%.
Conclusion
Quality measures serve as an important driver for improving the quality of health care. They
17
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offer information for marketplace purchasing, give feedback for improving practice, and change
the way employers evaluate and provide health plan options to their employees. The leading
edge work in the public and private sector reveals the potential to be gained by narrowing the gap
between actual and best practices. The best practices of a few have the promise of becoming the
benchmark for the many.
As examples of these leading edge efforts reveal, success demands the involvement of a broad
range of stakeholders from employers and consumers to providers and health plans. Coordinated
efforts in quality measurement and reporting can build upon and multiply the gains realized so
far. Both the public and private sectors have important roles to play. Research to fill the gaps in
measures, model value-based purchasing efforts, tools for continuous quality improvement-tlese
steps will require stakeholders across the health care system to do their part. In recent months,
employers and business groups have come together under the umbrella of the Employer Quality
Partnership. and three health care quality oversight organizations-AMAP, JCAHO and
NCQA-have announced their intentions to collaborate on performance measurement activities.
Similarly, the President established the Quality Interagency Coordination Task Force to bring
Federal agencies together. With this momentum in both public and private sectors, there can be
no clearer signal that the time is right to seek greater system-wide coordination of quality
measurement and reporting.
include why
is existing you energh system
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Agency for Health Care Policy and Research. Better Quality Can Cost Less: The Evolving Role
of AHCPR: Interim Report to the National Advisory Council, September 1995.
Agency for Health Care Policy and Research and Kaiser Family Foundation. Americans as
Health Care Consumers: The Role of Quality Information. A National Survey. October 1996.
Agency for Health Care Policy and Research. http://www.ahcpr.gov.
American Medical Association, http://www.ama-assn.org/med-sci/amapsite/qa/qa.htm 1998..
Bodenheimer T, Sullivan K. How large employers are shaping the health care marketplace?
New England Journal of Medicine 1998; 338(14): 1003-1007.
Brink S, Shute N. "Are HMOs the right prescription?" U.S. News and World Report, October
13, 1997, PP. 60-78.
The Business Roundtable. Quality Health Care is Good Business: A Survey of Health Care
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Centers for Disease Control. Mammography and clinical breast examinations for women aged
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Weekly Reports 1993; 42: 737-741.
Chassin MR. Assessing strategies for quality improvement. Health Affairs 1997; 16(3): 151-
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Foundation for Accountability (FACCT). http://www.facct.org.
Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for adults with colds, upper
respiratory tract infections, and bronchitis by ambulatory care physicians. JAMA 1997; 278(11):
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Hannan EL, Kilburn H, Racz M, Shields E, Chassin MR. JAMA 1994; 271: 761-766.
Health Network & Alliance Sourcebook. Washington, DC: Faulkner and Gray's Healthcare
Information Center, 1995.
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Health Care Financing Administration "Home Health Care: Improving Quality, Tightening
Standards." HCFA Press Office Fact Sheet, August 8, 1997. http://www.hcfa.gov/facts
f970808.htm.
Health Pages. Web site - http://www.thehealthpages.com 1998
Joint Commission on Accreditation of Healthcare Organizations. http://www.jcaho.org.
Jordan HS, Straus JH, Bailit MH. Reporting and using health plan performance information in
Massachusetts. Joint Commission Journal on Quality Improvement 1995; 21(4): 167-177.
Kleinman LC, Kosecoff J, Dubois RW, Brook RH. The medical appropriateness of
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Krumholz H, Radford M, Ellerbeck E, et al. Aspirin in the treatment of acute myocardial
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Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA
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Maryland Health Care Access & Cost Commission, http://www.hcacc.state.md.us/hmo/hmo.htm,
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Maxwell J, Briscoe F, Davidson S, Eisen L, Robbins M, Temin P, Young C. Managed
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New Jersey Department of Health and Senior Services. New Jersey HMOs: Performance Report.
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Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse Outcomes of Underuse of ß-
Blockers in Elderly Survivors of Acute Myocardial Infarction. JAMA 1997; 277(2): 115-121.
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Wilbur DC. False negatives in focused rescreening of Papanicolaou smears: how frequently are
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22
Jun-08-98 01:31P James Tallon
212 494 0830
P.01
File: Forum Ntbk
United
Hospital Fund
Empire State Building
FAX COVER PAGE
350 Fifth Avenue, 23rd Floor
New York. NY 10018
To: Sarah Bianchi 202 456-5585
From: Tracy Miller 212 494-0767
Fax Number: 202 456-5557
Company: UNITED HOSPITAL FUND
Date: 6/8/98
Total Pages: 2
For Information Call: (212) 494-0722
Subject: Addresses
Fax Number: (212) 494-0830
Notes:
Attached is a list of names, addresses, telephone and fax numbers for the foundation heads of
the foundations that will be funding the planning process. With the exception of Jim Knickman,
a Vice President at the Robert Wood Johnson Foundation, these names may already be on the
invitation list because I passed them on to Nancy Foster. (Please note an area code change for
Drew Altman. The new area code is 650.)
We would appreciate your sending the three foundation presidents a letter of invitation to the
June 17 event, indicating they are welcome to bring key staff members to the event. It would
also be helpful if Jim Knickman received a fax of the letter sent to Steven Schroeder.
As I mentioned over the telephone, Commonwealth (but not Kaiser or RWJ) has confirmed the
funding commitment. Jim Tallon will follow up with Steve Schroeder and Drew Altman, seeking
resolution of their commitment before the 17th so that the foundation support can be
announced.
As I mentioned in my phone message, Jim Tallon would like confirmation that Chris has no
problem with Jim's redrafting of the third paragraph of the letter that will be sent from the Vice
President. I will be leaving the office at 2:30 pm and would appreciate your calling David Gould
(212 494-0740), Senior Vice President for Program at United Hospital Fund, to confirm the
changes - if you do not have a chance to call me before I leave.
I look forward to working with you on the planning committee process.
Jun-08-98 01:31P James Tallon
212 494 0830
P.02
Karen Davis, Ph.D.
President
he Commonwealth Fund
arkness House
One East 75th Street
New York, New York 10021
Tel: 212 606-3825
Fax: 212 606-3876
Drew Altman, Ph.D.
President
The Henry J. Kaiser Family Foundation
Quadrus
2400 Sand Hill Road
Menlo Park, California 94025
Tel: 650 854-9400
Fax: 650 854-4800
Steven A. Schroeder, MD
President
The Robert Wood Johnson Foundation
PO Box 2316
Princeton, New Jersey 08540 Tel: 609 452-8701
Fax: 609 243-5894
ames R. Knickman, Ph.D.
Vice President for Research and Evaluation
The Robert Wood Johnson Foundation
PO Box 2316
Princeton, New Jersey 08540 Tel: 609 452-8701 Fax: 609 987-8746