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    "ocrText": "THE WHITE HOUSE\nDomestic Policy Council\nDATE:\nFACSIMILE FOR: Pamela Johnson\nPHONE: ( ) -\nFAX: ( ) -\nFACSIMILE FROM: Sarah Bianchi\n632 0390\nPHONE: ( ) -\nFAX: ( ) -\nNUMBER OF PAGES (INCLUDING COVER):\n[\n]\nFOR YOUR REVIEW\n[ ]\nPER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU\n[ ]\nPER YOUR REQUEST\ndight\nCOMMENTS: Few more changes on memo\nThank - SB\nWILLIAMM.\nMERCER\nMay 8, 1998\nMr. Christopher C. Jennings\nSpecial Assistant to the President for Health Policy Development\nDomestic Policy Council\nOld Executive Office Building, Room 212\n17th St. & Pennsylvania Avenue, NW\nWashington, DC 20502\nDear Mr. Jennings;\nI would like to be considered as a purchasers' clinical representative for the Vice-President's\nBlue Ribbon Panel on Quality of Care and for the subsequent Forum. I would bring following\nqualifications:\n1. Described in May 1998 New England Journal of Medicine article on employer managed\nhealth care as \"a pioneer\" in employer advocacy of quality of care.\n2. Medical Director of the largest American employer health purchasers coalition.\n(Pacific Business Group on Health - with over 3 million covered lives) and architect of its\nnationally distinguished quality advancement program.\n3. Head of clinical consulting of largest employee benefits consulting firm in U.S.\n(William M. Mercer, Incorporated).\n4. Sole consulting industry representative selected for national quality of care measures\ndevelopment committees of both NCQA and FACCT.\n5. Invited to speak on behalf of U.S. purchasers at the Institute of Medicine's 1998 Rosenthal\nlecture series on the state-of-the-art in health care performance measurement.\n6. Selected to testify on exemplary private sector health quality initiatives at March 3, 1998\nhearing of Bipartisan Congressional Task Force on Health Care Quality.\n7. Selected to review 1998 Institute of Medicine Roundtable Statements on Quality of Care.\n8. Board certified physician (in Utilization Management/Quality Assurance and Psychiatry)\n9. Associate Clinical Professor at University of California, San Francisco with more than 30\npublished articles and book chapters on performance measurement and management in\nhealth care.\n10. Selected as one of 20 people \"who have made a difference over the last 20 years\" in\nemployee benefits management by Business Insurance Magazine.\nI have attached my CV and my recent Congressional testimony.\nPlease contact me if I can be of further help. I would be honored to serve.\nYours truly,\nArme Milster\nArnold Milstein MD, MPH\nCC: Ms. Sarah Bianchi\nWilliam M. Mercer, Incorporated\nPhone 415 743 8700\nCalifornia Insurance License 0510400\n3 Embarcadero Center, Suite 1500\nFax 415 743 8950\nBox 7440/94120\nSan Francisco, CA 94111-4015\nA Marsh & McLennan Company\nMOBILIZING EMPLOYER PURCHASING POWER\nTO ADVANCE QUALITY OF CARE IN CALIFORNIA\nTESTIMONY BY ARNOLD MILSTEIN MD, MPH TO\nTHE BI-PARTISAN CONGRESSIONAL TASK FORCE ON HEALTH CARE QUALITY\nMARCH 3, 1998\nIntroduction\nI am the Medical Director of the Pacific Business Group on Health (PBGH), the\ncountry's largest employer health purchasers coalition. I am also a physician\nconsultant at William M. Mercer, specializing in reengineering clinical services and\nquality of care management. The former role is a window on employers' quality\nof care objectives; the latter role is a window on physician uptake of opportunities\nto improve health care quality and affordability.\nToday I will focus on PBGH and its quality advancement efforts.\nPBGH is a nine-year-old coalition comprising 34 large private and public California\nemployers and employer groups who collectively purchase on behalf of roughly\nthree million Americans and spend in excess of $3 billion on health care. PBGH\nincludes Fortune 500 employers such as Bank of America and General Electric; we\nalso encompass small employers which are part of CalPERS and the HIPC,\nCalifornia's small employer purchasing pool.\nOverarching Value Focus\nOur coalition's central focus is on obtaining more quality and customer service per\ndollar. While PBGH is perhaps best known for its early success in negotiating\nlower HMO premiums, the lion's share of its budget and effort has been dedicated\nto advancing quality of care and customer service.\nPrimary PBGH Quality-Advancement Activities\n1. Counting Quality and Making it Count\nPBGH's quality of care advocacy has focused on two activities: counting\nquality of care and making quality count in the market.\nCounting quality of care means taking the best-groomed quality measures from\nNCQA and nationally distinguished health service research centers; and then\nusing our purchasing power to ask California's health plans, hospitals and\nphysician groups to apply these measures and report them publicly. We have\nmade significant progress on all three levels.\nIn measuring the quality of health plans, we manage a multi-lateral California\npartnership, the California Cooperative Healthcare Reporting Initiative (CCHRI).\nCCHRI applies and publicly reports the HEDIS 3.0 quality and enrollee\nsatisfaction measures annually (see Attachment A) and is expanding into other\nN:MMAS\\MILSTEIN\\CLIENTSIAPBGH\\PBGH1.DOC\n1\n05/08/98\nquality advancement activities. In measuring the quality of hospitals, we co-\nlead with the State of California a program to measure and publicly report risk-\nadjusted hospital mortality from coronary artery bypass graft surgery and will\nseek to expand this to other measures of hospital quality. In measuring the\nquality of physician groups, we co-lead with The Medical Quality Commission,\na program to measure and publicly report patient satisfaction and quality of\ncare for more than 58 physician groups in California, as well as Oregon and\nWashington (see Attachment B).\nIt is important to note that, while in 20 years our measures will be judged to be\ncrude and non-comprehensive, they already constitute a solid starting point.\nThey encompass technical quality (such as providing retinal exams to\ndiabetics), as well as customer service (such as waiting times for a physician\nappointment); processes of care (such as whether children are getting\nimmunized) as well as outcomes (such as whether high blood pressure is\nbeing successfully reduced); preventive care as well as illness care; and\nnarrow performance measures as well as broad performance measures. With\nrespect to broad measures of outcome, within 24 months, California's\npurchasers and consumers will be able to access publicly reported, risk-\nadjusted performance measures for health plans and physician groups in\nmaintaining the longitudinal health status of seniors and of working age\npopulations, respectively.\nMaking quality count means using market incentives to reward reporting,\nimprovement or superiority in quality. PBGH is pursuing this by two types of\nincentives: incentives to reward quality by greater patient volume and by\ngreater unit prices. We create patient volume incentives by explicitly tying\npurchaser choice of health plans to comparative quality ratings and by\nsharing with consumers comparative quality ratings to support quality-based\nconsumer choice of health plans, hospitals and physician groups. Consumer\nchoice is supported via posting of comparative quality scores at a public\ninternet site (www.healthscope.org) and by 1-800 number access to a printed\nversion available in English or Spanish (see Attachment C). In addition, many\nPBGH employers provide comparative quality scores with open enrollment\nmaterial, and then pro-actively track and manage continuous improvement in\nits use by their employees. Finally, PBGH annually selects and publicly\nacknowledges the California HMO achieving the most favorable combination of\nquality, affordability, information systems advance, and customer partnership.\nThus far, unit price incentives to reward quality have been applied to health\nplans which are required to rebate up to 2% of premium to PBGH's HMO\nNegotiating Alliance, if pre-negotiated annual improvements in quality of care\nand customer service scores are not achieved. While there have been failures\nto reach improvement targets, in the majority the targets have been met and\nquality as well as customer service are steadily advancing. PBGH is now in the\nprocess of collaborating with its health plans and providers to extend unit price\nrewards for quality to physician groups and hospitals. In broad brush, via\nmultiple methods, we are aiming to create a quality-sensitive demand curve\nfor health care in California.\nN:AMAS\\MILSTEINVCLIENTSLAPBGH\\PBGH1.DOC\n2\n05/08/98\n2. Advancing Electronic Health Information Systems\nAnother critical element in our quality of care advocacy is our program to\nadvance health information systems (IS). Our efforts are rooted in recognition\nthat improved quality accountability and quality management depend on IS\nadvance. In pursuing this initiative, we have acknowledged that advances are\nrequired of employers in their enrollment and disability systems in addition to\nadvances by plans, hospitals, other providers and, most critically, of physician\noffices. The road will be challenging. We are moving in partnership with our\nplans, our providers and the California Health Care Foundation. Our initiative\nis managed by a doctorate level, full-time PBGH health informatics specialist,\npropelled by purchaser demand, and aligned with NCQA's excellent Roadmap\nfor Health Information Systems.\n3. Partner Relations\nIn advancing quality, we start with the core assumption that our target is\nquality improvement, not our suppliers. Accordingly, all that we have\naccomplished has been by collaboration with our plans, our providers, CCHRI,\nhealth industry organizations, accreditors, the State of California and visionary\nfoundations.\nFocusing on the Forest not the Trees\nUnderlying PBGH's quality advancement efforts has been the central awareness\nthat America's biggest quality problem is not the debatable gap between managed\ncare and unmanaged care. Our biggest quality problem is the gap between best\nAmerican quality and average American quality. As documented by multiple\nAmerican researchers, the latter gap is wide, comprising a silent ongoing national\ncalamity.\nDr. Lucien Leape has shown that deviation from best clinical practice results in\navoidable death or disability in 3 of every 100 American hospitalizations.\nDr. Robert Brook has shown that deviation from best clinical practice avoidably\nimpairs 11 of every 100 Americans with common chronic diseases. In contrast,\nDrs. Robert Miller and Harold Luft's analysis of available scientific evidence found\nno clear differences in quality between managed and unmanaged care. Average\nAmerican care, managed or unmanaged, is today unsafe at any price.\nClinicians, like other humans, do not embrace change. However, scientific review\nof evidence on clinician behavior change by Drs. Peter Greco and John Eisenberg\nconcludes that economic incentives can be effective. PBGH quality advancement\nactivities are using this principle to build for PBGH suppliers a business case for\nquality, both directly as purchasers as well as by supporting quality-informed\nconsumerism. My reengineering work with delivery systems continuously\nvalidates the conclusion that a strong business case will be a prerequisite for the\nhealth industry's integration of industrial-strength quality management into the\nmainstream of its daily operations.\nN:AMASAMILSTEIN\\CLIENTSLAPBGH\\PBGHL.DOC\n3\n05/08/98\nIn using market incentives to advance quality, PBGH is at the front edge of an\ninnovation adoption curve. But PBGH and other innovative, quality-focused\npurchasers cannot close America's big quality of care gap alone. The pace of\nquality advancement will depend on the level of help from regulators, accreditors,\nthe health industry, the media, and the weight of many more purchasers. There is\nmuch that each of these stakeholders can do.\nThe key is focusing on the forest, which is the gap between best and average\nAmerican care, and on the highest leverage points for closing this gap. These high\nleverage points do not include what may be popular, narrow mandates with\nequivocal evidence bases, such as minimum lengths of maternity stay. They do\nnot include shotgun attacks on the managed care industry as a whole. They do\ninclude stretching our managed care industry to be as effective in improving\nquality as it has been in improving affordability.\nThank you for the opportunity to speak with you.\nN:AMAS\\MILSTEINACLIENTSLAPBGH\\PBGH1.DOC\n4\n05/08/98\nARNOLD MILSTEIN MD, MPH\nBIOGRAPHICAL SUMMARY\nArnie directs the national clinical consulting practice at William M. Mercer Inc.\nand is the Medical Director of the Pacific Business Group on Health. His work\nfocuses on improving managed care programs for providers, large purchasers,\ninsurers and government.\nHis 30 book chapters and published articles have centered on managed care\nprogram design. Dow Jones' and McGraw-Hill's reference texts on managed\ncare contain his chapter on utilization management. His articles, which have\nencompassed quality measurement, behavioral health and workers\ncompensation performance evaluations, have been published in Barron's, HMO\nMagazine and the New England Journal of Medicine.\nA member of NCQA's national committee to develop HEDIS 3.0 and the FACCT\nMeasures Council, he also served on the National Academy of Science's\nCommittees on Utilization Management and Children's Health Insurance.\nBusiness Insurance magazine selected him as \"one of the 20 people who has\nmade a difference in employee benefits management in the past 20 years.\"\nArnie was educated at Harvard (BA-Economics), Tufts (MD) and UC-Berkeley\n(MPH-Health Services Planning). He is an associate clinical professor at the\nUniversity of California-San Francisco Medical Center and a Worldwide Partner\nat Mercer.\nThree Embarcadero Center, Suite 1250\nSan Francisco, California 94111\n(415) 393-5657\nCURRICULUM VITAE\nArnold Milstein, MD, MPH\nJanuary 1998\nGeneral Information\nAddress:\nThree Embarcadero Center, Suite 1500\nSan Francisco, California 94111\nTelephone:\n(415) 743-8803\nE-mail:\[email protected]\nDate of Birth:\nJanuary 4, 1946\nMarital Status:\nMarried\nEducation\nB.A. (cum laude)\nHarvard University\nEconomics\n1967\nM.D.\nTufts University\nGeneral Medicine\n1971\nInternship\nUCSF Mount Zion Hospital\nMedicine and Psychiatry\n1972\nResidency\nUCSF Mount Zion Hospital\nPsychiatry\n1974\nM.P.H.\nUniv. of California, Berkeley\nHealth Administration and Planning\n1975\nProfessional Certification\nLicensed Physician\nCalifornia Board of\nMedicine\n1974\nMedical Quality Assurance\nBoard Certification\nAmerican Board of\nPsychiatry\n1981\nPsychiatry and Neurology\nBoard Certification\nAmerican Board of\nUR and Quality Assurance\n1986\n(with honors)\nUtilization Review and\nQuality Assurance\nC\\HERNDONMILS\\PERS\\CV.DOC\nCurriculum Vitae\nArnold Milstein, MD, MPH\nPage 2\nEmployment\nManaging Director and Worldwide Partner, William M. Mercer, Inc., a Marsh & McLennan\nCompany, August 1986 to present.\nPresident, National Medical Audit, a Mercer consulting group specializing in the design and\nevaluation of innovations in managed health care, December 1984 to present.\nChief Medical Advisor, Health Care Financing Administration, Region IX, January 1982 to\nDecember 1984.\nDirector, Division of Professional Standards Review, Health Care Financing Administration,\nRegion IX, January 1977 to December 1981.\nRegional Program Consultant for HSA Development, U.S. Public Health Service, Region IX,\nFebruary 1976 to December 1976.\nPrivate medical practice in hospital, intermediate psychiatric facility, and outpatient settings, 1974\nto 1988.\nResearch Assistant, Department of Economics, Harvard University, Cambridge, Massachusetts,\nJune 1965 to July 1967.\nHonors and Awards\nRosenthal Lecturer, Institute of Medicine, National Academy of Sciences\n1998\n\"Using Purchasing Power to Advance Health Care Quality\"\nSelected by Business Insurance as\n1987\n\" one of the 20 people who made a difference over the last 20 years\nin employee benefit management in America =\nU.S. Public Health Service Commendation Medal for\n1981\n\"\nleadership, initiative and creativity, leading to extraordinary benefits\nto the federal government =\nU.S. Public Health Service Plaque for\n1980\n= an exceptional record in providing intelligent and perceptive leadership \"\nMount Zion Hospital Mark Berke Prize for\n1974\n\"The House Officer Best Exemplifying the Qualities of the Compleat Physician.\"\nNational Institute of Mental Health Career Development Fellowship\n1972\nHonorary Harvard College Scholarship\n1964\nK:\\users\\bios\\cv\nCurriculum Vitae\nArnold Milstein, MD, MPH\nPage 3\nConsultation and Professional Activities\nMember, Institute of Medicine Committee on Children's Health Insurance, National Academy of\nScience, 1997 to present.\nAdvisory Committee, UCSF Center for Health Professions, 1997 to present.\nMember, University of California Commission on the Future of Medical Education, 1996 to\npresent.\nBoard Member, The Medical Quality Commission, 1996 to present.\nMember, National Measures Council, Foundation for Accountability (FACCT), 1996 to present.\nMember, NCQA HEDIS 3.0 Committee on Performance Measurement, 1995 to present.\nTrustee, University of California-Mount Zion Campus, 1994 to present.\nTrustee, San Francisco University High School, 1994 to present.\nAdvisor, White House Health Care Reform Task Force, 1993.\nEditorial Board, Medical Outcomes and Guidelines, Faulkner & Gray, 1993 to present.\nMember, Institute of Medicine Committee on Utilization Management, National Academy of\nSciences, 1988 to 1990.\nMedical Director, Pacific Business Group on Health, 1988 to present.\nMedical Director, Department of Defense CHAMPUS prepaid psychiatric quality monitoring\nproject, May 1987 to 1993.\nAssociate Clinical Professor, University of California at San Francisco, July 1986 to present.\nEditor, \"Review Decisions,\" a bi-monthly UR case analysis published in Medical Utilization Review,\nMcGraw-Hill Publications, April 1986 to 1990.\nMedical Director, National SuperPRO project, July 1985 to 1992.\nMember, California Chamber of Commerce Task Force on Preferred Provider Organizations and\nUtilization Review Programs, 1983.\nAssistant Clinical Professor, University of California at San Francisco, December 1980 to 1986.\nChairman, Skilled Nursing Facility Subcommittee, California State Psychiatric Association,\nSeptember 1976 to 1979.\nK:\\users\\bios\\cv\nCurriculum Vitae\nArnold Milstein, MD, MPH\nPage 4\nConsultant, Planning Task Force, California Conference of Local Mental Health Directors,\nSeptember 1975 to December 1976.\nConsultant in clinical program evaluation, Rand Corporation, July 1974 to 1977.\nPublications and Papers\n1. \"Hospitalists and Pursuit of Value,\" Annuls of Internal Medicine, (in review) Spring, 1998.\n2. \"Bringing Outcome-Based Quality Differentiation to the Physician Group Market,\" Medical\nOutcomes Trust Monitor, January, 1998.\n3. \"Better Managing Utilization Management\" Health Affairs, Spring 1997.\n4. \"Health Education and Patient Satisfaction,\" with H. Schauffler and T. Rodiguez, The Journal\nof Family Practice, January 1996.\n5. \"Industry in Transition: Central Engines, Blooming Flowers, Batting Averages and Re-\nInvention,\" Viewpoint, Fall 1994.\n6. \"Evaluating Psychiatric and Substance Abuse Case Management Organizations,\" with M.\nHenderson, J. Berlant and D. Anderson, Managed Behavioral Health Care, S. Shueman, W.\nTroy and S. Mayhugh, eds., Charles C. Thomas Publisher, 1994.\n7. \"UR Liability: A Continuing Question,\" HMO Magazine, January/February, 1993.\n8. \"Increased Costs and Rates of Use in the California Workers' Compensation System As a\nResult of Self-Referral by Physicians,\" with A. Swedlow, G. Johnson and N. Smithline, The\nNew England Journal of Medicine, November 19, 1992.\n9. \"Utilization Management Lessons,\" HMO Magazine, March/April, 1992.\n10. \"Ambulatory Care Utilization Review,\" with T. Mayer, Ambulatory Care Management and\nPractice, A. Barnett, ed., Aspen Publishers, 1992.\n11. \"Evaluating Indemnity Plan Managed Care,\" Managing Employee Health Costs: Assuring\nQuality and Value, J. Harris, H. Belk and L. Wood, eds., OEM Press, 1992.\nK:\\users\\bios\\cv\nCurriculum Vitae\nArnold Milstein, MD, MPH\nPage 5\n12. \"Excellence in Programs to Manage Workers' Compensation Costs,\" Viewpoint, Summer\n1991.\n13. \"Mirror, Mirror on the Wall, Is My UR Program Best of All?\", Medical Interface, July, 1990.\n14. \"Managing the Medical Cost of Hospital Workers' Compensation Claims,\" Handbook of Health\nCare Human Resources Management, Norman Metzger, ed., Aspen Publishers, Inc., 1990.\n15. \"In Pursuit of Value; Fifteen Years of American Utilization Management,\" Making Managed\nHealth Care Work, P. Boland, ed., McGraw Hill, 1990.\n16. \"Controlling Workers' Compensation Medical Costs--California Style,\" Risk Management,\nSeptember, 1988.\n17. \"Second Generation Perspectives on Employer Medical Cost Controls,\" Barron's,\nJune 27, 1988.\n18. \"Controlling Medical Costs in Workers' Compensation,\" Business and Health, March, 1988.\n19. \"Enhancing Utilization Review Program Results,\" with M. Martin, Health Cost Management,\nMarch/April 1988.\n20. \"The Future of Utilization Review,\" Business Insurance, October, 1987 (invited paper for 20th\nAnniversary Issue).\n21. \"Gauging the Performance of UR Programs via Medical Record Audit,\" Business and Health,\nFebruary, 1987.\n22. \"Auditing the Quality of Care--an Employer Based Approach,\" Business and Health,\nJuly/August 1986.\n23. \"Controlling Utilization through Preferred Provider Arrangements,\" The New Health Care\nMarket, Peter Boland, ed., Dow-Jones Irwin, 1985.\n24. An Employer's Guide to Utilization Review, with Jack Bush, published by the California\nChamber of Commerce, February, 1984.\n25. An Employer's Guide to PPOs, with Dr. Joan Trauner, published by the California Chamber of\nCommerce, February, 1984.\nK:\\users\\bios\\cv\nCurriculum Vitae\nArnold Milstein, MD, MPH\nPage 6\n26. \"Factors Associated With Successful Physician Peer Review,\" with Dr. Nancy E. Adler,\nAmerican Journal of Public Health, October, 1983.\n27. \"Psychological Dimensions of Health Planning,\" (with N.E. Adler), Health Psychology,\nG. Stone, F. Cohen and N. Adler, eds., Jossey-Bass Publishers, June, 1979.\n28. \"Opportunities for Improving Mental Health Services at the Interface between PSROs and\nHSAs,\" (invited paper), Special Session on Mental Planning, American Psychiatric Association\nAnnual Meeting, May, 1978.\n29. \"Effects of the National Health Planning Act on the Use of Data Processing Hardware in\nHealth Care Institutions,\" Journal of Clinical Computing, Spring, 1977.\n30. \"Public Law 93-641 and Its Implications for the Diffusion of Ultrasonic Medical\nInstrumentation,\" Proceedings of the First Meeting of the World Federation of Ultrasound in\nMedicine and Biology, August, 1976.\n31. \"Anticipating the Impact of Public Law 93-641 on Mental Health Services,\" American Journal\nof Psychiatry, June, 1976.\nK:\\users\\bios\\cv\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP04\nFile Saralis\nMinority\nSummit Health Coalition\ntobacco\n1424 K Street, N.W., Suite 500\nWashington, D.C. 20005\n(202) 371-0277\nFax (202) 508-3826\nnote San\nBoard of Directors\nAmerican Concer Society\nAssociation of Block Cardiologista, Inc.\nTESTIMONY OF\nBlock Caucus of Health Workers\nCity of Ope-lodes, Rorido\nCongressional Block Covers Foundation, Inc.\nMedical Care Monagement Company\nMehorry Medical College\nSUMMIT HEALTH COALITION\nMorehouse School of Medicine\nNational Alliance of Community Based Care\nNational Association for the Advancement\nof Colored People\nNational Association of Block County Officials\nNational Amointion of Block Social Workers, Inc.\nVIEWS FROM THE PUBLIC\nNational Association of Health Services Executives\nNational Block Coucus of State Legislators\nNational Black Leadership Commission on AIDS\nNational Block Nurses Association\nNational Coucus and Center on\nON\nBlock Aged, Inc.\nNational Conference of Black Mayors, Inc.\nNational Dental Association\nNational Education Association\nNational Medical Association\nCOMPREHENSIVE TOBACCO CONTROL LEGISLATION\nNational Pharmaceutical Association\nNational Urban League, Inc.\nPresbyterian Church (USA),\nWashington Office\nTennessee Monaged Care Network\nThe Congress of National Block Churches, Inc.\nUnited Church Board for Homeland Ministries\nVermont Avenue Boptist Church\nExecutive Committee\nPresident\nRichard O. Butcher, M.D.\nVice President\nBEFORE THE\nRamona McCarthy Howkins\nSecretary\nHazel J. Harper, D.D.S.\nUNITED STATES HOUSE OF REPRESENTATIVES\nTreasurer\nSamuel J. Simmons\nBoard Members at Large\nRev. Bemodine Grant McRipley\nCharyl A. Townsel\nHOUSE COMMERCE COMMITTEE\nExecutive Director\nRuth T. Perol\nSUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT\nCoalition Partners\nAfrican American Healthlink\nHealth Management Resources, Inc.\nHealthy Solutions, Inc.\nHines Family Core Center, Inc.\nWASHINGTON, DC 20515\nHoward University Hospital\nllhnois Chapter, Summit\nHealth Coolition\nLamox Health Systems, Inc.\nMedical Billing Incorporated\nNational Coolition of 100\nBlock Women, Manhattan Chapter\nPrairie State Medical Society\nSoint John Baptist Church\nStudent National Dental Association\nThe Greater Maryland Coolition for\nMarch 19, 1998\nHealth Assurance, Inc.\nTennessee Block Health Core Commission\nTotal Core Home Health System, Inc.\nTristole Center of the National Podictric\nMedical Association\noctor, NY State Project\n\"Networking to ensure meaningful health care reform\"\nneilo L Thome\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP05\nTestimony of\nSummit Health Coalition\nBefore the\nUnited States House of Representatives\nHouse Commerce Committee\nSubcommittee on Health and the Environment\nMarch 19, 1998\nIntroduction\nSummit Health Coalition, the nation's largest network of organizations focused\non health policies as they affect African Americans, welcomes this opportunity to\ncommunicate with the Subcommittee on Health and the Environment of the\nHouse Commerce Committee. We are aware of the critical role this\nsubcommittee will play in developing comprehensive, bipartisan legislation\naddressing the issue of tobacco control. We are appreciative of your leadership.\nSummit Health Coalition is a national public health advocate for minorities and\nunderserved populations. It encompasses the key minority health professional\norganizations in the United States, including the National Medical Association,\nthe Association of Black Cardiologists, the National Dental Association, the\nNational Black Nurses Association, the National Pharmaceutical Association, the\nNational Association of Health Services Executives and the Black Caucus of\nHealth Workers.\nHistorically black colleges and universities are also members of Summit, along\nwith major civil rights and consumer organizations, associations representing\nelected officials, religious groups and health care businesses. At present, fifty\nnational, otatc and community based institutions and organizations comprise\nSummit Health Coalition.\nSummit also works cooperatively with coalitions and organizations that\nrepresent other communities of color and public health groups with respect to\ntobacco control and other health policy issues. Regarding tobacco, we are\ncommitted to three priority goals: 1) preventing the use of tobacco products by\nminority and other youth and adults; 2) helping minorities stop smoking; and 3)\nimproving the health of minorities and other vulnerable, underserved\npopulations.\n2\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP06\nWith this testimony we seek to convey three messages.\n1.\nBy passing comprehensive tobacco control legislation, the Congress can make a\nmajor contribution to eliminating disparities in health status among racial and\nethnic groups in the United States - disparities that limit the productivity and\npotential of far too many Americans.\n2.\nBy passing comprehensive tobacco control legislation, the Congress can reverse\nthe negative health effects of decades of targeting by the tobacco industry.\n3.\nBy passing comprehensive tobacco control legislation, the Congress can\nstrengthen the capacity of individuals and organizations throughout the nation\nto assume responsibility as partners with health providers for promoting health\nand preventing tobacco-related diseases.\nThe Impact of the Tobacco Industry's Targeting of African Americans\nIt is very appropriate that the Subcommittee on Health and the Environment is hearing\ntestimony today from representatives of both youth and minority organizations. The\ntobacco industry by its own admission has targeted both of these groups - with\ndevastating effects. For example, at a time when African Americans comprised\napproximately ten percent of the population, almost twenty percent of the advertising\nbudget for Kool cigarettes was dedicated to marketing to African Americans. The result\n- African Americans made up not twenty, but thirty percent of the Kool market.1/\nWhat has been the impact of this deliberate targeting? Consider these statistics.\nOverall cancer mortality rates among African Americans are higher than those\namong other racial or ethnic populations in the United States. Mortality rates for\nAfrican American men are about 50% higher than those for white men. Rates for\nAfrican American women are about 20% higher than those for white women.2/\nAfrican Americans have higher overall cancer incidence rates than any other\nracial or ethnic group in the United States.3/\nLung cancer is the cause of 32% of all deaths attributed to cancer among African\nAmerican men and is the leading cause of cancer deaths among black men and\nwomen.4/\nBetween 1950 and 1985, the occurrence of lung cancer increased 86% among\nwhite men while increasing 220% among African American men.5/\nCancer incidence rates for African American women increased 21% from 1973 to\n1992, a period coinciding with intensified targeted marketing. These increases\nhave been attributed to increasing rates of lung and breast cancer.6/\nIt is estimated that smoking causes 87% of all cases of lung cancer.7/\nAfrican Americans have the second highest smoking rate (27.2%) of all racial and\nethnic groups, following American Indians (42.2%).8/\n3\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP07\nSmoking among African American high school boys nearly doubled between\n1991 and 1995, from 14.1% to 24.8%, Frequent smoking among this group\nnearly doubled as well.9/\nEstimates are that 76% of all African American smokers smoke menthol\ncigarettes as compared to 23% of all white smokers.]\nAfrican Americans tend to start smoking at a later age, are more likely to attempt\nto quit smoking, are less likely to succeed that their white counterparts.11/\nAn estimated 47,000 African Americans die each year from smoking-related\ndiseases.\nThese statistics clearly suggest that a substantial reduction in smoking rates among\nAfrican Americans and other minorities would lead to a significant decrease in their\nmortality and morbidity rates. Such an outcome would lead to the accomplishment of\nthe principal goal of Healthy People 2010 and other government initiatives to eliminate\nhealth disparities among racial and ethnic groups.\nAppropriate Responses to Minority Targeting\n1. Countertargeting is Necessary.\nIn formulating its essential positions on national tobacco control policy, Summit\nHealth Coalition has proceeded from the premise that the tobacco industry has had\na disproportionate impact on minorities. This impact is evidenced by these groups'\ndisproportionate rates of tobacco use, addition, morbidity and mortality. Resources\nrequired to counter the effects and undo the damage of the industry's targeting\nshould be made available, at minimum in proportion to the incidence of minorities\nin the smoking population.\n2. Significant Reductions in Tobacco Use Require Well-Financed, Community- Wide\nParticipation\nFor most of this century, the tobacco industry has spent billions to promote its\nmessage. Undoing the damage from this propaganda barrage requires the\nengagement of all levels of government, the private sector, non-profits, colleges and\nuniversities, essential community and other health providers, schools, faith and\ncommunity-based organizations. National tobacco control policy, backed by\nadequate resources, must serve to strengthen and equip these partners to do\nbattle. A strong federal role is a prerequisite for success if national goals are to be\nmet.\n3. Diversity Is Essential to Effective Tobacco Control Policy.\nThere are significant differences among racial and ethnic groups with respect to\nmortality and morbidity rates, smoking use and patterns. The tobacco industry's\nmarketing strategies illustrate that a \"one size fits all\" approach is ineffective.\nCounter-advertising, research, prevention and cessation programs must be\nculturally sensitive and appropriate. They should be implemented by minority\ninstitutions and organizations with a history of service to and involvement with the\nracial and ethnic groups to be served.\n4\nFrom 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP08\n4. Public Health Must Be A Funding Priority\nA substantial portion of tobacco control resources will be raised from smokers,\nmany of whom have low incomes and are members of minority groups. Fairness\ndictates that most of the funds received from smokers or the tobacco industry be\nreinvested, in the communities in which these smokers reside, for the support of\nregulation, prevention, cessation and related programs.\nSummit Health Coalition's Essential Positions\non National Tobacco Control Policy\n1.\nSummit Health Coalition urges Congress and the President to ensure that\ntobacco control legislation will prohibit targeted marketing of tobacco products to\nchildren and youth, African Americans, women and other at-risk populations. At\nthe same time, such legislation must require that targeted anti-tobacco\nmarketing be aimed at these vulnerable groups with adequate funding.\n2.\nFunds must be allocated for demographic, physiological and behavioral research\nto foster better understanding of such phenomena as differing tobacco\nconsumption and use patterns, incidence, morbidity and mortality rates among\nAfrican Americans and other vulnerable populations. This research should\ninvolve historically black colleges and universities (HCBUs) and other minority\nhealth professions schools, as well as other African American institutions\ninvolved in health care delivery and research, professional associations, non-\nprofit organizations and individual African American researchers.\n3.\nFunds derived from penalties on the tobacco industry, increased excise taxes\nand other sources must be allocated in relation to tobacco-related mortality and\nmorbidity rates among various population groups, as well as past targeted\nmarketing practices by the tobacco industry. These funds should be used for\nculturally relevant and appropriate programs to support prevention, cessation,\ntreatment and rehabilitation efforts aimed at reducing and eliminating tobacco\naddiction among African Americans and other vulnerable, at-risk groups.\n4.\nIn recognition of the impact that anti-tobacco legislation and regulations will\nhave on certain communities and geographic areas, legislation should be enacted\nto protect these communities by means of economic development services and\ntargeted resources. These services may include job retraining, small business\nloans, support for community redevelopment planning and program\nimplementation, expansion or creation of empowerment zones.\n5.\nThe Food and Drug Administration (FDA) must have full jurisdiction over all\ntobacco products (i.e., cigarettes, cigars and smokeless tobacco) and nicotine\ndelivery devices immediately upon enactment of legislation. Congress must\naffirm through legislation the FDA's authority to regulate the tobacco industry's\nmarketing practices to prevent targeting of children, youth, women, African\nAmericans and other people of color, and must provide the requisite funding for\nFDA's strengthening and expansion so as to fulfill these responsibilities.\n6.\nWe urge the passage of legislation that will require all health insurers, health\nbenefit plans, managed care organizations and other entities providing health\nservices to emphasize prevention and health promotion and provide information\nto enrollees, beneficiaries and patients to help them prevent and decrease\nsmoking and improve their quality of life.\n5\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP09\n7.\nThe federal government should support international tobacco control initiatives\nthrough legislation, regulation, Executive Orders, funding and other means, as\nwell as through the dissemination of information on effective models and\nstrategies for tobacco use prevention and control.\n8.\nNational tobacco control legislation must provide for a substantial and immediate\nincrease in the price of tobacco products to support public health initiatives and\nto discourage tobacco consumption. An increase in the federal excise tax of at\nleast $2.00 per cigarette pack is recommended.\nSummit Legislative Proposals\nSummit offers the following proposals, which serve to operationalize the foregoing\nprinciples and positions, for incorporation in comprehensive tobacco control legislation.\nThe list is not exhaustive, and we would welcome an opportunity to meet with members\nof the subcommittee and staff to offer other proposals and relevant information.\n1.\nFunding of public health research, education, cessation and counter-advertising\nprograms should be distributed to the Department of Health and Human\nServices and its constituent agencies with the understanding that an appropriate\npercentage of those funds should be targeted to address the needs of\nunderserved and vulnerable racial and ethnic groups. Said percentage to be\ndetermined on the basis of such factors as: the prevalence of racial and ethnic\ngroups within the youth and adult smoking population; or the proportion of\nracial and ethnic groups within the general population (nationally or by state).\n2.\nIn addition, the Office of Minority Health (OMH) should be charged with the\nresponsibilities of oversight, coordination, monitoring and reporting with respect\nto Department-wide tobacco control activities on behalf of minorities. It should\nhave expanded grant-making authority and should be funded at a level\ncommensurate with its expanded responsibilities, including oversight,\ncoordination, monitoring and reporting with respect to state offices of minority\nhealth. An Advisory Committee should be created and appointed by the\nSecretary to provide guidance to the Department on the development of goals\nand program activities undertaken by OMH, as well as on minority-focused\nactivities undertaken by other HHS agencies.\n3.\nThere should be full participation of historically black colleges and universities\nand other minority institutions and organizations with a history of service to or\ninvolvement with the group to be served in the implementation of public health\nresearch, prevention, cessation and counter-advertising programs at federal and\nstate levels, in proportion to minority smoking prevalence rates (or in\naccordance with other appropriate standards).\n4.\nComprehensive legislation should provide for the conduct of surveys on adult\nand youth tobacco use, with data to be collected by race, ethnicity, gender and\nage.\n5.\n\"Look-back\" targets for youth should be established by gender, race and\nethnicity.\n6\nFrom : 301 567-2409 FT WASH MD USA\nApr. 22. 1998 02:03 PM\nP10\nConclusion\nTobacco claims the lives of 420,000 people in the United States each year. There is no\ntime to spare. We pledge our full support to any effort that will put an end to the\nneedless ill health, death and addiction for which tobacco is responsible.\nWe urge you therefore to seize this unprecedented opportunity and enact\ncomprehensive legislation that will attain that goal. We would welcome an opportunity\nto work with you in the days and weeks ahead.\n7\nNational Committee\nMargaret E. O'Kane\nPresident\nfor Quality Assurance\nNCQA\n2000 L Street, N.W.\nSuite 500\nWashington, D.C. 20036\n202/955-3500 FAX 202/955-3599\nwww.ncqa.org\nDirect Dial 202/955-5100\nemail: [email protected]\nNational Committee\nStephen N. Lamb\nfor Quality Assurance\nAssistant Vice President for\nPublic Policy\nNCQA\n2000 L Street, N.W.\nSuite 500\nWashington, D.C. 20036\n202/955-3500 FAX 202/955-3599\nwww.ncqa.org\nDirect Dial 202/955-5102\nemail: [email protected]\nFOR IMMEDIATE RELEASE\nFOR MORE INFORMATION:\nFile Quality\nAMAP -- Robert Mills 312-464-5970 Form\nJCAHO -- Cathy Barry-Ipema 630-792-5630\nJanet McIntyre 630-792-5175\nNCQA -- Barry Scholl 202-955-5197\nNtble\nBrian Schilling 202-955-5104\nNATION'S THREE LEADING HEALTH CARE QUALITY\nOVERSIGHT BODIES TO COORDINATE\nMEASUREMENT ACTIVITIES\nLandmark collaboration among AMAP, JCAHO, and NCQA will help ensure\nefficient collection of comprehensive performance information\nacross all levels of the health care system\nWASHINGTON - The nation's preeminent health care accrediting organizations --\nthe American Medical Accreditation ProgramSM (AMAPSM), the Joint Commission on\nAccreditation of Healthcare Organizations (JCAHO), and the National Committee for\nQuality Assurance (NCQA) -- today announced a collaborative effort designed to\ncoordinate performance measurement activities across the entire health care system. The\nagreement establishes the Performance Measurement Coordinating Council (PMCC), a\n15-member group that will work to ensure that measurement driven assessment processes\nare efficient, consistent and useful for the many parties that rely on them to help make\nimportant decisions about health care.\n\"Independently, our organizations are working aggressively to develop rigorous\nperformance measurement programs for different levels of the health care system,\" said\nNCQA President Margaret E. O'Kane. \"Working together, we can make performance\nmeasurement not only much less burdensome, but also more meaningful to consumers,\nemployers and health care professionals.\"\n\"The work of the PMCC will start a positive chain reaction,\" said Randolph D.\nSmoak, Jr., M.D., Chair AMAP Governing Body, and Vice Chair of the American\nMedical Association (AMA) Board of Trustees. \"More efficient measurement will lead to\nbroader participation in accreditation programs, which will lead to quality improvement,\nwhich will lead to better care and service. Ultimately, patients and the public are the real\nwinners.\"\nFormation of the PMCC dovetails with the recent recommendation from President\nClinton's Advisory Commission on Consumer Protection and Quality in the Health Care\nIndustry urging greater coordination in health care performance measurement efforts. In a\nrelated executive order, President Clinton has directed Vice President Gore to organize a\n\"Forum for Health Care Quality Measurement and Reporting\" that will seek to incorporate\nexisting private sector efforts. The PMCC expects to work through the Forum to help\nshape measurement priorities and approaches that serve the needs of the American public.\nThe PMCC's efforts will build on a consensus statement, \"Principles for\nPerformance Measurement in Health Care,' developed by the group's sponsoring\norganizations. The document briefly outlines:\nthe rationale behind performance measurement efforts;\nappropriate uses of performance data;\nspecific areas on which measures should focus;\nguidelines for using performance data for comparative purposes;\ngeneral requirements for cost effective measurement;\nand specific opportunities for collaboration.\n\"This is an exciting opportunity to pool and collectively expand our quality\nmeasurement expertise in service of the public interest,\" said Dennis S. O'Leary, M.D.,\n2\nPresident, JCAHO. \"Good measures and good data will eventually provide good\ninformation to drive improvement in health care services and to better inform consumer\ndecision making.\"\nCurrently, AMAP, JCAHO and NCQA each define performance measurement at\ndifferent levels of the health care system. AMAP focuses on standards of quality for the\nindividual physician. JCAHO accredits a range of health care facilities, including\norganizations providing acute care, ambulatory care, behavioral health care, home care,\nclinical laboratory services, long term care and managed care. In addition, JCAHO has\nbegun integrating performance measurement into the accreditation process.\nThe focus of NCQA Accreditation and performance measurement program\n(HEDIS) is on systems of care for defined populations, such as HMOs and point-of-\nservice plans. More than 90 percent of the nation's managed health care plans already use\nHEDIS to track and report their performance. NCQA recently announced a new\naccreditation program that will base accreditation decisions in part on a health plan's\nperformance on key HEDIS measures such as member satisfaction, immunization rates,\nand mammography screening.\nEach organization is committed to developing and advancing rigorous, dynamic\nmeasurement programs to improve care and help consumers and purchasers make\nimportant health care coverage decisions. The accreditation programs developed by\nJCAHO and NCQA already enjoy broad participation across the health care industry, and\nhave consistently drawn upon the input of various constituencies. The new AMAP\ninitiative, similarly, is gaining rapid acceptance from physicians, hospitals, health plans\nand health care purchasers.\n3\nPerformance measures currently vary from one level of the health care system to\nthe next, but there is overlap. For example, member satisfaction, immunization rates and\ncervical cancer screening rates have been used to assess providers, facilities and plans\nalike. Other broadly applied performance measures include cesarean section rates,\nmammography screening rates, measures of the accessibility of care, cost measures,\nutilization rates (e.g., coronary artery bypass graft surgeries per 1,000 members) and\naverage office wait times.\nA common criticism of performance measurement activities -- even from those\nwho appreciate their importance to quality improvement -- is that costs for data collection\nand reporting can be high. The PMCC's efforts will help to reduce those costs by:\ncoordinating identification and/or development of groups of 'universal'\nmeasures (i.e., measures that could be used to assess performance of\nphysicians, facilities or health plans in the same ways)\nstandardizing data requirements for different measurement systems;\ndevising means of coordinating measurement activities among physicians,\norganizational providers, facilities and health plans;\nestablishing more efficient verification and data quality assurance systems;\nand developing guidelines for the appropriate use of performance data.\n\"This collaborative effort represents a significant step forward toward improving\nthe delivery of health care in this country,\" said David B. Pryor, M.D., Chair of JCAHO's\nAdvisory Council on Performance Measurement and System Vice President for\nInformation Services, Allina Health System.\n4\nThe PMCC will also address other important issues such as standardization of risk\nadjustment techniques (adjusting for differences in the health of covered populations or\npatients) which is a key issue for measuring performance at the physician, facility and\nhealth plan levels. Ultimately the group expects to articulate principles to deal with risk\nadjustment that will help the science of performance measurement move forward.\nThe PMCC will begin work on these issues at its first meeting this summer. The\ngroup will meet three to four times per year. Work groups addressing specific issues will\nmeet in person and via conference call more frequently.\n#\n#\n#\nThe American Medical Association is the voice of the American medical\nprofession. The AMA is a partnership of physicians and their professional\nassociations dedicated to promoting the art and science of medicine and betterment\nof public health. AMAP sponsored by the American Medical Association - is\ndesigned to enhance the health of the public by setting standards and improving\nthe performance of individual physicians, while replacing the current duplicative\nand fragmented patchwork of existing physician review and assessment programs.\nFounded in 1951, the Joint Commission on Accreditation of Healthcare\nOrganizations' mission is to improve the quality of care provided to the public\nthrough the provision of health care accreditation and related services that support\nperformance improvement in health care organizations. The Joint Commission\nevaluates and accredits over 18,000 health care organizations and programs,\nincluding hospitals, integrated delivery networks, and organizations that provide\nhome care, long term care, behavioral health care, laboratory and ambulatory care\nservices. The Joint Commission also accredits health plans, integrated delivery\nnetworks, and other managed care entities. An independent, not-for-profit\norganization, the Joint Commission is the nation's oldest and largest standards-\nsetting and accrediting body in health care.\nA non-profit watchdog organization, the National Committee for Quality\nAssurance (NCQA) is widely recognized as the leader in the effort to assess,\nmeasure and report on the quality of care provided by the nation's managed care\norganizations. More than three quarters of Americans enrolled in HMOs are in\nplans that have been reviewed by NCQA.\n5\nNational Committee\n2000 L Street, N.W.\nMain: 202/955-3500\nfor Quality Assurance\nSuite 500\nFAX: 202/955-3599\nWashington, D.C. 20036\nhttp://www.ncqa.org\nNCQA\nEMBARGOED UNTIL:\nFOR MORE INFORMATION:\nMarch 31, 1998\nBarry Scholl or Brian Schilling\n(202) 955-5197 or 955-5104\nNCQA REDEFINES ACCREDITATION WITH HEALTH PLAN\nSTANDARDS THAT FOCUS ON RESULTS\nDraft requirements will provide more complete information to guide choice;\nprogram will require health plans to report independently audited results\nWASHINGTON - The National Committee for Quality Assurance (NCQA) today\nreleased for comment new accreditation standards for HMOs and other health plans\nwhich expand the scope of the nation's leading health care accreditation program to\nemphasize results across a range of important care and service dimensions. The standards\ninclude selected performance measures from NCQA's Health Plan Employer Data and\nInformation Set (HEDIS), making Accreditation '99 the nation's first true performance-\nbased accreditation program. As a result, consumers and employers will soon receive\nmore complete, easier-to-use information about health plan quality than ever before.\n\"With Accreditation '99, results count,\" said NCQA President Margaret E.\nO'Kane. \"Accreditation '99 uses three approaches to evaluating health plan quality -\nrigorous standards, objective measures, and customer satisfaction. That comprehensive\nassessment gives consumers and employers more information with which to make\ninformed health care coverage decisions.\"\nNCQA's HEDIS, the nation's premier performance measurement tool for health\nplans, is a set of measures related to such issues as immunization rates, mammography\nrates, member satisfaction, access, service and other areas of public concern. Many\nhealth plans already use HEDIS to comply with accreditation requirements which require\nthem to demonstrate improvement over time.\n\"Accreditation '99 is the best health plan assessment program yet. Basing\naccreditation decisions on actual performance - using standardized measures - is a\ncritical step towards moving the industry from prevailing practices to best practices,\" said\nRobert Galvin, M.D., Director of Healthcare, GE. \"That's what the quality movement is\nall about. Accreditation '99 will help us work with our employees to reward those plans\nthat are doing thing right.\"\nOther employers have expressed similar support for the program. \"Working with\nhealth plans that have achieved the highest level of NCQA Accreditation is good business\n- it helps ensure that our employees and their families get top quality care and service,\"\nsaid Kathleen Angel, Vice President, World Wide Benefits and Work Life Solutions,\nDigital Equipment Corp. \"Accreditation '99 and its emphasis on consumer information\nraises the bar on performance measurement and improves our ability to select the best\nplans for our employees.\"\nHEDIS results will initially count for 25 percent of a plan's accreditation score.\n(See page 6 for the list of measures and survey results plans will report.) The remaining\n75 percent will be based on a plan's degree of compliance with NCQA's standards. In the\nfuture, NCQA anticipates increasing the proportion of the accreditation score based on a\nhealth plan's performance. HEDIS results will initially be evaluated relative to national\nand regional averages, and national benchmarks.\n\"Accreditation should provide easy-to-understand information about a plan's\nstrengths and weaknesses; it should speak to the consumer and help make the decision\nabout what plan to choose easier,\" said Andrew Webber, Senior Associate, Consumer\nCoalition for Quality Health Care. \"Accreditation '99 does that. This represents a big\nstep forward in the national effort to promote quality in managed care.\"\n2\nTo make accreditation outcomes more intuitively understandable for consumers,\nNCQA renamed and redefined the different accreditation designations. Under\nAccreditation '99, plans will earn one of the following accreditation levels:\nExcellent\nCommendable\nAcceptable\nDenied.\n\"The distinction between the higher levels of accreditation will be based on\nresults,\" said Cary Sennett, M.D., Ph.D., NCQA Executive Vice President. \"Only those\nplans that demonstrate excellence both in terms of their quality improvement and\nconsumer protection systems, and on important measures of care and service, will achieve\nthe highest levels of accreditation.\"\nTo help consumers and others better understand each health plan's strengths and\nweaknesses, reports based on Accreditation '99 surveys will indicate plan performance in\nfive new categories, each of which reflects performance on several measures and\nstandards. The new reporting categories are:\nAccess and Service\nQualified Providers\nStaying Healthy\nGetting Better\nLiving With Illness.\nNCQA worked with the Foundation for Accountability (FACCT) and others to\ndevelop and test these categories, to ensure that they address consumers' concerns.\nNCQA will continue to work with FACCT and others to refine these categories in the\ncoming weeks.\n\"For a health plan that can demonstrate excellent care and service,\nAccreditation '99 represents an opportunity to achieve greater distinction in the market,\"\nsaid Linda Winslow, Director of Purchaser Relations and Accreditation, Harvard Pilgrim\nHealth Care. \"This program validates all the hard work we've put into improving our\nresults over the years.\"\n3\nTo aid consumers, NCQA will include a separate entry on its Accreditation Status\nList for each \"product type\" a health plan offers. Many health plans offer HMO, point-\nof-service and other plan options, and also offer separate plans for commercial, Medicare\nand Medicaid beneficiaries. NCQA's Accreditation Status List will distinguish between\nthese various product types to ensure that consumers know whether their plan has been\naccredited.\nAccreditation '99 also introduces new standards that help protect consumers by:\nprohibiting health plans from using financial incentives to encourage case\nmanagers to limit or deny care\nrequiring health plans to have a process for approving exceptions to restricted\ndrug formularies\nevaluating whether health plans unduly limit access to emergency room care\nrequiring health plans to coordinate medical and behavioral health care.\nTo ensure that quality and performance are maintained between on-site surveys\n(which occur at least every three years), plans will be required to submit independently\naudited HEDIS results to NCQA annually. Should these results, or other factors such as\nregulatory action, suggest a lapse in quality, NCQA may elect to resurvey the health plan\nsooner. NCQA will also resurvey a plan sooner if its initial compliance with NCQA\nstandards is low.\nAccreditation '99 also confronts head on the critical need to improve the state of\nhealth plan information systems. At present, most health plan information systems fall\nfar short of the ideal and cannot easily or routinely provide important data to employers,\nconsumers or care managers. New \"advisory\" standards specify the capabilities health\nplan information systems must have in the future. Acquiring these capabilities will mean\nbetter care and service for health plan members and improved coordination between\nproviders.\nSpecifically, the new Information System standards will require managed care\norganizations to be able to: ensure the security and confidentiality of members' data and\ninformation; link data from different sources and databases; ensure the accuracy and\n4\nreliability of data; use data to help manage care and improve performance; and monitor\ninternal and external data needs on an ongoing basis.\nThe standards have been mailed to approximately 2,500 business coalitions,\nemployers, health plans, medical groups, associations, regulatory bodies, and other\ngroups to encourage broad comment. The full text of the standards is also available for\ndownload from NCQA's Web site (www.ncqa.org/99draft.htm) The comment period\nruns through May 15, 1998. NCQA will accept written comments via regular mail or e-\nmail ([email protected]). The final standards will be released in August 1998. Health\nplan reviews against NCQA's 1999 MCO Accreditation requirements will commence\nJuly 1, 1999.\nA non-profit watchdog organization, NCQA is widely recognized as the leader in the\neffort to assess, measure and report on the quality of care provided by the nation's managed\ncare organizations. More than three quarters of Americans enrolled in HMOs are in plans that\nhave been reviewed by NCQA.\n#\n#\n#\n5\nThe Following HEDIS® and Consumer Survey\nMeasures\nare Required Under Accreditation '99\nEffectiveness of Care\nChildhood Immunization Status*\nAdolescent Immunization Status*\nBreast Cancer Screening\nCervical Cancer Screening\nPrenatal Care in the First Trimester*\nAdvising Smokers to Quit\nBeta-Blocker Treatment After a Heart Attack\nEye Exams for People with Diabetes\nCheck-Ups After Delivery*\nFollow-Up After Hospitalization for Mental Illness\nFlu Shots for the Elderly**\n*\nMeasures relevant to and required for commercial and Medicaid products,\nbut not Medicare products.\n** Measure relevant to and required for Medicare products only.\nConsumer Survey Results\nGetting Care Quickly\nDoctors Who Communicate\nCourteous and Helpful Office Staff\nEasy to Find a Personal Doctor or Nurse\nGetting Needed Care\nClaims Processing\nCustomer Service\nRating of Personal Doctor or Nurse\nRating of Specialist Seen Most Often\nRating of Health Care in the Past 12 Months\nRating of Experience With Health Plan\n6\nFile Quality\nFown Ntbk.\nDaniel N. Mendelson\n05/21/98 05:01:23 PM\nRecord Type: Record\nTo:\nChristopher C. Jennings/OPD/EOP, Sarah A. Bianchi/OPD/EOP\ncc:\nSubject: HHS Report on Targeting Efforts on Asthma\nHere is another disease that can be targeted in a discussion of outcomes and effectiveness\nresearch. AHCPR research creates algorithms to target potentially vulnerable kids (often minorities\nin low income areas), treat them appropriately, and save money by keeping them out of the ER.\nForwarded by Daniel N. Mendelson/OMB/EOP on 05/21/98 04:59 PM\nRichard J. Turman\n05/21/98 03:39:37 PM\nRecord Type:\nRecord\nTo:\nDaniel N. Mendelson/OMB/EOP@EOP\ncc:\nBarry T. Clendenin/OMB/EOP@EOP, Mark E. Miller/OMB/EOP@EOP\nSubject: HHS Report on Targeting Efforts on Asthma\nForwarded by Richard J. Turman/OMB/EOP on 05/21/98 03:39 PM\nFarooq Khan\n05/21/98 03:31:36 PM\nRecord Type:\nRecord\nTo:\nSee the distribution list at the bottom of this message\ncc:\nSubject: HHS Report on Targeting Efforts on Asthma\nbHHS Report on Targeting Efforts on Asthma\nTo: National Desk, Health Writer\nContact: U.S. Department of Health and Human Services\nPress Office, 202-690-6343\nWASHINGTON, May 21 /U.S. Newswire/ -- The following was released\ntoday by the U.S. Department of Health and Human Services\nHHS TARGETS EFFORTS ON ASTHMA\nOverview: Asthma is a major public health problem in the United\nStates, with prevalence increasing rapidly in recent decades,\nespecially among children. More than 15 million Americans are\naffected, some 5 million of whom are under the age of 18. Between\n1980 and 1994, the percentage of Americans with asthma increased 75\npercent, and the percentage of preschool-age children with asthma\nincreased 160 percent.\nHHS efforts to combat asthma will exceed $100 million in\ndiscretionary funding for the first time this year, up about 70\npercent from 1993. HHS agencies support a wide range of activities\nto better understand this disease and its increasing prevalence,\nand to help patients and physicians better recognize and treat it:\n-- Basic research into asthma's underlying causes and\nmechanisms, the triggers that bring on asthma symptoms, and other\nissues surrounding the disease.\n-- Treatment studies to evaluate the effects of different\nmedications on various populations.\n-- Epidemiology to more precisely identify populations at risk\nfor the disease and the factors that put them at risk in order to\nbetter understand and control it.\n-- Prevention efforts to prevent asthma onset and to reduce\nasthma symptoms, hospitalizations and deaths.\n-- Guidance and education for physicians, patients and their\nfamilies, and the general public to increase asthma awareness and\nknowledge.\nThe Medicare and Medicaid programs pay for asthma treatment for\nlow-income, elderly and disabled Americans.\nIn addition to ongoing HHS efforts, Secretary Donna E. Shalala\nand Environmental Protection Agency Administrator Carol Browner are\nalso making asthma a special focus of the Interagency Task Force on\nChildren's Environmental Health and Safety, created by President\nClinton in April 1997.\nToday, Secretary Shalala announced that a new National Heart,\nLung, and Blood Institute initiative will be launched this summer\nto better understand the role of respiratory infections in\nchildhood asthma. NHLBI will support $2.5 million per year for five\nyears of research projects to study asthma using new techniques in\ncellular and molecular biology.\nBackground\nAsthma is a chronic lung disease that is characterized by\nintermittent, recurring episodes of wheezing, breathlessness,\ntightness of the chest, and coughing. More Americans than ever\nbefore say they are suffering from asthma, according to a report\nreleased April 24 by the Centers for Disease Control and\nPrevention. The report entitled, Surveillance for Asthma --\nUnited States 1960-1995\" also concluded that the increases in\ncases, deaths, and visits to doctors occurred in persons of all\nages, spanned across all racial groups, and occurred in all regions\nof the U.S.\nPeople with asthma experience well over 100 million days of\nrestricted activity each year, and costs for asthma care exceed $6\nbillion annually. Children with asthma miss an average of twice as\nmany school days as other children. Asthma attacks can vary from\nmild symptoms to serious, life-threatening episodes. More than\n5,000 Americans died last year from asthma attacks.\nThe prevalence of asthma is greater for women (5.6 percent) than\nmen (5.1 percent) and greater for blacks (5.8 percent) than whites\n(5.1 percent). Blacks also have significantly more emergency room\nvisits, hospitalizations, and deaths from asthma than whites. From\n1993-1995, there were an average of 38.5 deaths per million from\nasthma in blacks compared to 15.1 per million in whites. In 1995,\nblacks were more than four times more likely than whites to visit\nan emergency room because of asthma.\nThe cause of asthma is not well-understood, and scientists do\nnot know why so many more people today are suffering from asthma\nand why symptoms appear more severe than they were 10 years ago. It\nis most likely that a combination of environmental and genetic\nfactors is responsible. The best documented factor contributing to\nthe development of asthma is atopy, the genetic, inherited\nsusceptibility to become allergic. In susceptible persons with\nasthma, exposure to allergens such as dust mites, cockroaches,\nmolds and dander from pets is associated with more severe symptoms.\nFurther, children of smokers are more prone to develop asthma\nbecause exposure to environmental tobacco smoke can increase\nsensitivity to allergens. Although outdoor air pollutants have not\nbeen identified as causing asthma, several of them, particularly\nozone, have been identified as triggers of asthma attacks.\nRespiratory infections in early childhood may influence the\ndevelopment of asthma. Some infections may increase the likelihood\nof developing asthma, while others might actually be protective.\nResearchers are exploring how respiratory infections early in\nchildhood might stimulate an immune response that suppresses the\ndevelopment of allergies.\nOngoing Asthma Activities at HHS\nThe National Institutes of Health (NIH)\nNIH is supporting an extensive range of research programs\nexamining asthma management, genetics, epidemiology, demonstration\nand education, and prevention. NIH estimates it spent $92 million\non asthma research in FY 1997, $99 million in FY 1998 with $107\nmillion proposed for FY 1999.\n-- Genetics of Asthma -- Researchers supported by the National\nHeart, Lung, and Blood Institute (NHLBI) and the National Institute\nof Allergy and Infectious Diseases (NIAID) are working together to\nidentify the major genes that may contribute to asthma and\nasthma-associated phenotypes such as allergy and airway\nhyper-responsiveness. Early findings confirm that multiple genes\nmay be involved in asthma and that they may vary between\nethnic/racial groups.\n-- Pathogenesis and Mechanisms of Asthma -- The National\nInstitutes of Health supports studies about the role of\ninflammation in the pathogenesis of asthma. The studies are\ndirected at the examination of the cellular and molecular events\nthat appear to initiate, direct, and perpetuate the development of\nairway inflammation. Researchers supported by NHLBI and NIAID are\nstudying how respiratory infections in early life acting\nindividually and in combination with each other, regulate airway\ninflammation, airway hyper-responsiveness, and airway remodeling,\nthus leading to the onset of asthma. A new NHLBI research\ninitiative will examine the multiple risk factors for the onset of\nasthma in early life and the mechanisms that cause them. This will\nlead to the identification of novel interventions to prevent the\ndevelopment of the disease.\n-- Epidemiologic Research -- The National Institute of\nEnvironmental Health Sciences (NIEHS) is sponsoring several studies\ninvolving asthmatics who live in areas where they are exposed to\nhigh levels of ambient air pollutants, factors that are associated\nwith the risk of asthma-related hospitalizations and death, and the\nrespiratory health status of minorities, children under age-5, and\nthe elderly. Other epidemiologic research supported by NHLBI,\nNIAID, and NIEHS include long-term studies to identify the specific\nrisk factors associated with developing asthma and the risk factors\nthat lead to severe, life-threatening asthma attacks. This research\nincreases our understanding about what causes asthma, and helps\nidentify promising new targets for asthma treatments.\n-- Clinical Studies -- NIH institutes are carrying out several\nclinical studies that focus on prevention of asthma and\neffectiveness of new treatments. Clinical studies sponsored by NIH\ninclude:\no The Environmental Intervention in the Primary Prevention of\nAsthma in Children Study (NIEHS)\no The Childhood Asthma Management Program (NHLBI)\no Asthma Clinical Research Network (NHLBI)\n0 The Asthma and Pregnancy Trial (NHLBI and the National\nInstitute of Child Health and Human Development (NICHD))\no The National Cooperative Inner-City Asthma Study (NIAID).\n-- Demonstration and Education Research -- NIH supports\ndemonstration and education (D&E) research which evaluate\neducational and behavioral approaches and organization strategies\nthat may improve the management of asthma. A major thrust of recent\nD&E research has been on identifying appropriate programs and\nmethods for extending the benefits of asthma management to\npopulations that have been traditionally harder to reach, and who\nexperience a disproportionate burden of asthma illness-for example,\nminorities and economically disadvantaged children. Outreach\neducation programs using non-medical settings (e.g. the school and\ncommunity neighborhood centers) are testing the use of\ncommunity-based and culturally sensitive behavior change strategies\nfor asthma control.\n-- Research Translation: Dissemination and Education -- An\nongoing and important part of the HHS/NIH asthma research program\nis to translate and disseminate scientific findings to improve the\nhealth and quality of life of people with asthma. The NHLBI\nestablished the National Asthma Education and Prevention Program\n(NAEPP) in 1989 to improve the diagnosis, treatment, and control of\nasthma, to enhance the quality of life of the asthma patients, and\nto decrease asthma morbidity and mortality. The NAEPP has a\nthree-pronged strategy to achieve these goals: develop\nscience-based clinical practice guidelines for the diagnosis and\nmanagement of asthma; use partnerships among federal agencies,\nprofessional societies, and voluntary and private organizations to\ndisseminate recommendations and implement asthma programs; and\norganize public communications.\nCenters for Disease Control and Prevention (CDC)\nAs the nation's disease prevention agency, the Centers for\nDisease Control and Prevention (CDC) is working with state and\nlocal partners to implement core and comprehensive asthma\nprevention programs as well as to evaluate programs' success. These\nprograms will include monitoring to identify local disease trends,\ncommunity asthma prevention interventions, intervention and\nevaluation research, and state-wide education of practitioners,\npatients, and health community organizations. CDC sponsors a number\nof local programs, working with state and local health department\npartners, to examine how a change in environmental influences can\nreduce asthma. The goal is to translate research findings into\npublic health action. These include:\n-- ZAP Asthma, Atlanta, Ga.: CDC is one of 17 partners in this\nproject that seeks to show that a comprehensive approach to\ncontrolling asthma will reduce the number of asthma\nhospitalizations for children.\n-- The California Community-Based Asthma Intervention\nDemonstrations Project: This project seeks to show that a reduction\nin exposure to environmental tobacco smoke will result in a\nreduction in asthma hospitalizations in children living in Fresno.\n-- Identification and Prevention of Air Pollutants and Other\nEnvironmental Determinants in Urban Minority Children: Los Angeles:\nThis project tracks the asthma status of 100 black children in\ncentral Los Angeles County to evaluate the effect of air pollution\non asthma among urban, minority children.\n-- Asthma Surveillance in Wisconsin: The purpose of this pilot\nproject was to identify the most effective methods to monitor the\ntrends in asthma through a consensus workshop, and pilot\nsurveillance projects based on the workshop recommendations.\n-- Out-of Hospital Asthma Deaths: North Carolina: Since\nout-of-hospital asthma deaths may be preventable, this project is\nhelping to determine what proportion of total asthma deaths they\ncomprise and what populations they affect.\n-- Asthma Prevalence Study in the Catano Area of Puerto Rico: In\ncollaboration with the Puerto Rico Department of Health, CDC and\nEPA investigated the possible relationship between air pollution\nand asthma. The study described the prevalence and severity of\nasthma among school-aged children in the Catano area, obtained\nbaseline measures for assessment of future trends in the prevalence\nand severity of asthma, identified risk factors for the disease,\nand established a framework for further research.\nFood and Drug Administration (FDA)\nThe FDA is working in partnership with the pharmaceutical\nindustry to facilitate the timely development and approval of new\ndrugs for the treatment of asthma and related conditions such as\nallergic rhinitis. This partnership has resulted in a significant\nnumber of approvals by the Agency over the past few years for new\ndrugs to treat asthma as well as a significant increase in the\nnumber of drugs specifically approved for use in children with\nasthma and allergic rhinitis. For example, in the past two years\nthe FDA approved the first three members of an entirely new class\nof asthma therapy that work by blocking leukotrienes which are\nimportant mediators of asthma. Other examples of important new\nproducts approved by the FDA for first multiple-strength\nmetered-dose inhalers (MDIs) and three new multi-dose dry powder\ninhalers (DPIs). These new drugs and devices provide physicians and\npatients with valuable new options that may help to improve the\nmanagement of asthma.\nHealth Care Financing Administration (HCFA)\nAs part of Early and Periodic Screening, Diagnosis, and\nTreatment (EPSDT), Medicaid covers all medically necessary services\nfor the diagnosis and treatment of asthma in children, including\nX-rays, drugs, inpatient stays, outpatient and emergency room\nvisits.\nMedicare provides Part B coverage for both physician visits and\ndurable medical equipment, such as nebulizers, and oxygen equipment\nrequired by some asthmatic patients, HCFA also covers the\nmedication that is put into the nebulizers as a necessary supply\nfor the operation of the equipment.\n-- HCFA recently supported the Aetna Medicare Care Counseling\nProgram in the Phoenix, Arizona, a pilot program for Part B\nbeneficiaries with diabetes and asthma. The Aetna Care Counseling\nprogram was a voluntary, confidential, telephone support service\noffered free of charge to qualifying beneficiaries with asthma or\ndiabetes. In providing care counseling by registered nurses, the\nprogram's purpose was to enhance customer service and to improve\nbeneficiaries' health and quality of life by providing a better\nunderstanding of asthma and the medications and equipment used to\ntreat the disease. HCFA is currently in the process of reviewing\nand commenting on the findings.\nAgency for Health Care Policy and Research (AHCPR)\nAHCPR is sponsoring the Pediatric Asthma Patient Outcome\nResearch Team (PORT) II\" a randomized clinical trial, co-funded by\nNHLBI. The trial tests the cost-effectiveness of NHLBI's practice\nguidelines designed to reduce asthma morbidity among children. The\nagency is supporting several other studies measuring quality of\nlife, patient outcomes and other issues related to asthma care.\n-0-\n/U.S. Newswire 202-347-2770/\nAPNP-05-21-98 1450EDT\n04/28/98 TUE 16:30 FAX\nTOOD\nSERVICES\n(\nADVISORY COMMISSION ON\nHEALTH\n3\nCONSUMER PROTECTION AND QUALITY\nIN THE HEALTH CARE INDUSTRY\nFAX TRANSMISSION\nTo: C hris Jennings\nDate: 4/28/98\nFax #:\n456-5557\nPages: 11 including this cover sheet.\nFrom: Janet Corrigon\nSubject:\nCOMMENTS:\nHUBERT H. HUMPHREY BUILDING\n200 INDEPENDENCE AVENUE, SW ROOM 118-F\nWASHINGTON, DC 20201\nPH: 202-205-3333\nFAX: 202-205-3347\n04/28/98 TUE 16:30 FAX\n0 002\nTO:\nAd Hoc Group on the Forum\nFROM:\nJanet Corrigan, PhD\nRE:\nMay 1, 1998 Meeting\nDATE:\nApril 24, 1998\nEnclosed please find the agenda and meeting materials for the May 1st meeting. Please Note:\nthe meeting will begin at 9:30 am (EST) and adjourn at 1:30 pm. The location for the meeting is\nConference Room 640H of the H.H. Humphrey Building, 200 Independence Ave., SW,\nWashington DC.\nThe objectives of this meeting are twofold: 1) to plan for the Forum kick-off meeting to be\nconvened by the Vice President in June 1998; and 2) to identify and discuss key issues related to\nthe 6 month planning process that will commence in June and culminate with the establishment\nof the Forum in early 1999.\nIf you have any questions, please contact me at 202/205-3045 (or pager #202-490-0321). I look\nforward to seeing you on May 1st.\nDistribution\nLipschitz\nToby Donnenfeld, Office of the Vice President\nJohn Eisenberg, AHCPR\nNancy Foster, AHCPR\nChris Jennings, Office of the President\nSheila Leatherman, United Health Care Corporation\nRandy MacDonald, GTE\nMeredith Miller, DOL\n10 I was >for E & Brond nox\nPaul Montrone, Fisher Scientific International\nChristopher Queram, Employer Health Care Alliance Cooperative\nThomas Reardon, Adventist Medical Group\nGerald Shea, AFL-CIO\nJames Tallon, United Hospital Fund\nPeter Thomas, Powers, Pyles, Sutter and Verville, P.C.\nGail Warden, Henry Ford Health System\n04/28/98 TUE 16:30 FAX\nU.S.) UUS\nDRAFT AGENDA\nAD Hoc GROUP ON THE FORUM\nMay 1, 1998 Meeting\n9:30 am\nWelcome and Introductory Comments\n- Introduction of participants\n- Purpose of the meeting\n9:50\nDiscussion of Forum Planning Process (draft proposal attached)\n- Facilitator and Institutional Base\n(see attached biographical sketch for James Tallon)\n- Foundation Support\n- Discussion of Process\n- Planning Committee\n-- Composition\n-- Nominees\n11:45\nBreak for Lunch\n12:15\nDiscussion of June Kick-off Event\n- Background Information on Other Activities Underway\n- Messages\n- Participants\n1:30\nAdjournment\n04/28/98 TUE 16:30 FAX\n004\nPROPOSAL TO FUND A PLANNING PROCESS\nFOR A NATIONAL\nFORUM FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING\nDRAFT - APRIL 24, 1998\nThis is a proposal to fund a process for planning the development of a Forum for Health Care\nQuality Measurement and Reporting (\"the Forum\"), a private-sector entity to be established to\nprovide coordination and guidance to the multiple public- and private-sector parties involved in\nevaluating health care quality. Creation of the Forum was one of the major recommendations of\nthe Advisory Commission on Consumer Protection and Quality in the Health Care Industry (\"the\nQuality Commission\") in its final report to the President.\nThis proposal begins by describing the need to coordinate ongoing work in the area of health care\nquality measurement and reporting, and by laying out the specific objectives, activities, and\norganizational characteristics of an entity to be created to undertake that effort. It then describes\nthe objectives, time line, and budget of the proposed process for convening key stakeholders to\nassist in operationalizing the entity.\nBACKGROUND\nNeed for Standardized Information on Health Care Quality\nRoutinely generating comparable, standardized information on the quality of health care is\ncritical for both motivating and enabling improvement. Standardized measures of quality are\nneeded to track the health care industry's progress in achieving national quality improvement\naims and to guide public planning and policy making. Comparative information on quality also\nis needed for individual consumers, employers, and others to use in selecting health care\nproviders and health plans. Furthermore, valid and stable quality measures are integral to health\ncare providers' efforts to improve their performance. When standardized, such measures provide\nan opportunity for health care organizations to make comparisons and identify \"best performers.\"\nDespite a growing number of efforts to measure and report on health care quality, useful\ninformation is neither uniformly nor widely available. Improving our ability to measure quality\nhas been the object of significant public and private-sector activity over the last decade,\nreflecting the expectation that measurement can serve as both a catalyst and a tool for\nimprovement as well as to facilitate consumer choice. While considerable advancements have\nbeen made in the quality measurement field in recent years, current efforts fall short of fully\nmeeting users' needs, do not provide measures for many of the most important health burdens\n(e.g., chronic conditions), and often are duplicative and unduly burdensome on health care\nproviders, health plans, and others.\n04/28/98 TUE 16:31 FAX\n01 005\nDraft 4/24/98\nForum for Quality Measurement and Reporting\nObjectives. The Forum for Health Care Quality Measurement and Reporting is being established\nto build the systemwide capacity to evaluate and report on the quality of care. The Forum would\ndevelop and implement effective, efficient, and coordinated strategies for focusing incentives for\nquality improvement on national priorities while assuring the public availability of information\nneeded to support the marketplace and the efforts of the various existing quality oversight\nentities.\nActivities. To achieve its objectives, the Forum will need to:\ndevelop a comprehensive plan for implementing quality measurement, data collection,\nand reporting standards to assure the widespread public availability of comparative\ninformation on the quality of care furnished by all sectors of the health care industry;\nestablish measurement priorities that address national aims for improvement and that\nmeet the common information needs of consumers, purchasers, federal and state policy\nmakers, public health officials, and other stakeholders;\nperiodically endorse core sets of quality measures and standardized methods for\nmeasurement and reporting;\nfoster an agenda for research and development needed to advance quality measurement\nand reporting and to encourage collaborative funding for such activities;\ndevelop and foster implementation of an effective public education, communication, and\ndissemination plan to make quality measures and comparative information on quality\nmost useful to consumers and other interested parties; and\nencourage the development of health information systems and technology to support\nquality measurement, reporting, and improvement needs.\nTo evaluate the success of its efforts, the Forum will need to create and utilize feedback\nmechanisms designed to assess the feasibility and acceptance of the measurement sets it\npromulgates as well as the extent to which information is reported, available, and used by\ninterested parties. Armed with this information, the Forum will be able to initiate improvement\nstrategies as necessary.\nStructure. The key organizational characteristics of the Forum that will enable it to accomplish\nits objectives are its status as a private-sector organization and its representation of key\n2\n04/28/98 TUE 16:31 FAX\nI\n006\nDraft 4/24/98\nstakeholders from both the public and private sectors.\nOperating in the private sector will provide the Forum with two needed characteristics. First, it\nwill have greater flexibility and the means to act quickly to respond to changes in the health\nsystem and advances in technology that have implications for measurement and reporting\nstrategies and capacity. Second, it will be well-positioned to harness and coordinate the market\nforces needed to drive this initiative.\nBecause the Forum will operate in the private sector as a voluntary initiative, its success will\ndepend upon the commitment and influence of a critical mass of stakeholders in the health care\nmarketplace. The Forum will therefore need to be broadly representative of stakeholders. The\nusers and potential users of information on quality must be involved in the process of identifying\ncore quality measures for reporting if those processes are to succeed in addressing their common\ninformation needs. The Forum also will need to include a core constituency of influential\nstakeholders that can assure the implementation of the measures once they are promulgated.\nCompliance with reporting requirements will be attained by purchasers and oversight bodies (i.e.,\naccreditation, certification and licensure entities) by the mechanisms available to them (e.g.,\npurchasing contracts and oversight processes). A decision to participate in the Forum would be\nviewed as constituting an endorsement of its work and an agreement to leverage compliance with\nthe results to the full extent of the participant's ability.\nAlso critical to the Forum's efforts will be the participation of key organizations involved in\npromulgating quality measures and collecting information on the performance of various sectors\nof the health care industry. Key organizations include those that undertake efforts on a national\nbasis, as well as those emerging and established groups organized at the regional, state, or local\nlevels. The Forum will need to work with these organizations to determine how best to assure\nthat information on health care quality is available, affordable, and easily accessible in the public\ndomain. The Forum itself would not compete with the innovative work already under way in the\npublic and private sectors by developing performance measures itself, but would instead seek to\nencourage the progress being made in this area and improve it through greater coordination. It\nwould help to identify areas of needed fundamental research related to quality.\nPROPOSED PLANNING PROCESS\nA planning process is needed to provide key stakeholders with the opportunity to work through\ncritical issues related to the Forum's governance, organizational structure, and source(s) of\nfinancial support. The Vice President will begin this process by inviting key stakeholders to a\nJune meeting to form a Task Force to jump-start the planning process. He will select individuals\nto participate in this planning process based on their expertise and stature, as opposed to\norganizational affiliation. The decisions to use a neutral convener and to seek funding support\nfrom a private foundation were made as a means of ensuring impartiality and promoting\n3\n04/28/98 TUE 16:31 FAX\nI\n007\nDraft 4/24/98\nparticipation by stakeholders.\nThe planning process should take place over a 6-month period, commencing in May 1998 with\nthe issuance of invitations to participate. Over the course of that time, during which three\nmeetings will be held, the Task Force will accomplish four critical objectives:\ndefine the Forum's functions, operations, working relationships and membership criteria;\ndetermine the composition of the Forum's governing board;\ndetermine the source(s) of start-up and ongoing financing; and\ninitiate a process to recruit the Forum's Executive Director.\nObjectives of the Planning Process\n1) Define the Forum's functions, operations, and working relationships.\nDefining the Forum's functions, operations, and working relationships will be among the most\nimportant objectives of the planning process. The Quality Commission's work provided a\nstarting point for defining these characteristics, but additional work is needed to refine and\noperationalize those recommendations.\nA number of issues to be addressed pertain to the manner in which the Forum will function. For\ninstance, the planning process may identify policies and procedures designed to assure the public\nof the integrity of the Forum's work, promote widespread confidence in its outcomes, and\nminimize potential conflicts of interest. The planning process can serve to articulate specific\npolicies and procedures that will provide for public input, public deliberation, and public access\nto documents produced.\nOperational issues to be addressed include the Forum's organizational structure, budget,\nfacilities, and meeting schedules. In defining these aspects, participants in the Forum's planning\nprocess may wish to look to the organizational structures of entities charged with undertaking\nfunctions that are similar in nature, scope, and scale. Entities such as the Financial Accounting\nStandards Board and the American National Standards Institute -- although not analogous to the\nForum in all respects -- may provide alternative models for examination by the Planning Task\nForce.\nTask Force Planning process participants will need to carefully consider how the Forum will\nrelate to the public- and private-sector organizations whose work will influence or be influenced\nby the Forum's activities. Formal working relationships will in some cases need to be\nestablished; for instance, in the case of organizations responsible for the development of the\nhealth care quality measures that will be evaluated for inclusion in the core sets of measures to be\n4\n04/28/98 TUE 16:32 FAA\nE UUS\nDraft 4/24/98\nperiodically endorsed by the Forum. Similarly, the ways in which the Forum will interact with\nexisting local, regional, state, and national organizations that serve as repositories of data on\nquality will need to be considered.\n2) Determine the composition of the Forum's governing board.\nThe composition of the Forum's governing board is a key issue to be addressed through the\nplanning process. Both the precise number and the allocation of slots on the Forum's governing\nboard will need to be determined.\nThe Quality Commission recommended that the Forum be governed by a board that includes:\npublic and private group purchasers;\nindividuals and organizations focused on representation of consumers/patients;\nproviders;\nlabor unions;\nexperts in quality assurance, improvement and measurement;\nquality oversight organizations;\nhealth care researchers; and\npublic health experts.\nBalancing the need to have a strong purchaser role and representation of the full array of key\nconstituencies will be a delicate and challenging task for the planning process participants.\nSubstantial representation on the board of purchasers from both the public and private sectors\nand of consumer organizations will be critical to provide strong incentives for organizations to\nparticipate in these efforts and to abide by the decisions of the Forum. Representation of the full\narray of key constituencies on the board will be equally critical, so as to assure the buy-in of all\nparticipants and the requisite expertise to effectively carry out the Forum's responsibilities.\n3) Determine source(s) of start-up and ongoing financing.\nParticipants in the planning process will need to consider alternative sources of start-up funding\nto assist in establishment of the Forum. The potential for obtaining a start-up grant from a\nfoundation or public source will need to be evaluated. Such funds may be used to allay one-time\nexpenses that will be associated with initiating the Forum (e.g., expenditures associated with\noutfitting staff offices). External funding is unlikely to be made available for ongoing financing\nof the Forum, however.\nThus, it is essential for the Planning Task Force to establish an ongoing source of financing for\nthe Forum. Participants in the planning process will need to estimate the Forum's first-year\noperating budget and develop a dues-paying schedule for members. Such a schedule will need to\naccount for the varying levels of resources available to different categories of stakeholders. For\n5\n04/28/98 TUE 16:32 FAX\n0\n009\nDraft- 4/24/98\ninstance, cross-subsidies may be required so that the Forum is able to attain adequate\nrepresentation of consumer interests.\n4) Begin Recruitment of an Executive Director.\nOnce the planning process has resolved operational, representation, and financing issues, the\nPlanning Task Force will initiate a process to identify an Executive Director capable of providing\nleadership for the Forum. This will require defining the skills and qualifications of ideal\ncandidates for the position, and seeking and conducting initial reviews of candidates.\nResponsibility for selecting an Executive Director from qualified candidates will fall to the initial\nBoard of Directors of the Forum, but the Planning Task Force can expedite this process by\ninitiating the search.\nCandidates will need to possess a variety of professional skills and expertise to be successful as\nthe Forum's Executive Director. These include strong leadership, management, and planning\nskills; a high level of credibility among the diversity of stakeholders represented at the Forum;\ntechnical knowledge regarding quality measurement, oversight, and health benefits; and the\nability to effectively communicate in support of the Forum's mission. The Planning Task Force\nwill need to determine the extent to which the Executive Director should be drawn from interests\nrepresented by the Forum. For example, a potentially highly qualified candidate may be a person\nwith experience as a corporate benefits director with first-hand knowledge of purchasers'\nperspectives on the use of quality measures; negotiating experience with hospitals, clinicians, and\noversight organizations; and an understanding of consumers' use of quality measurement\ninformation. Other individuals with the requisite experience and skills to serve as the Forum's\nExecutive Director may include health plan executives, quality oversight managers, or experts in\nquality measurement and improvement.\nThe planning process for selecting an Executive Director will require identifying the desired\nqualifications of candidates as soon as the functions and operations of the governing body of the\nForum are defined. This definition of the Executive Director position and desired skills of\ncandidates needs to occur early in the Planning Task Force's process to allow time to recruit\nhighly qualified candidates. The Task Force may elect to contract with an executive search firm\nto assist in the recruiting of suitable candidates. Once eligible candidates have been identified,\nthe Task Force will need to review the qualifications of candidates applying for the position and\nidentify top candidates for consideration by the Board of Directors.\n6\n04/28/98 TUE 16:32 FAX\n0 010\nDraft- 4/24/98\nTime Frame for Planning Process\nJune 1998\nFirst meeting of planning process\nPurpose: Define Forum's functions, operations, and working relationships\nSeptember 1998\nSecond meeting of planning process\nPurpose: Determine the composition of the governing board, sources of\nongoing financing for the Forum, and qualifications of Executive Director\nNovember 1998\nThird Meeting of planning process\nPurpose: Name governing board, and screen Executive Director candidates\nDecember 1998\nConvene prospective members of governing board, select Forum's\nExecutive Director, release start-up funds\nJanuary 1999\nFirst meeting of the Forum's Board of Directors\nBudget for Planning Process [Note: Preliminary, rough estimates]\nPersonnel costs\n$120,000\n[Estimated as I FTE . $100,000 annual compensation (including benefits) * 0.8 years + 1 FTE\n* $50,000 annual compensation (including benefits) * 0.8 years]\nAdministrative expenses and overhead\n$ 40,000\nMeeting expenses (3 meetings)\n$ 85,500\n-- facilities [estimated as $3000 * 3 meetings]\n-- travel expenses [estimated as 20 people * $800/mtg * 3 mtgs]\n-- overhead for services of contractors responsible for meeting logistics [estimated as 50 percent\nof total meeting expenses]\nHonoraria for Planning Committee\n$ 60,000\n[estimated as 6 days meeting time * 20 participants in planning committee * $500 daily rate]\nContract for executive search services\n$ 39,000\n[estimated as 30% of Executive Director's annual salary of $130,000]\nTotal\n$344,500\n7\n04/28/98 TUE 16:33 FAX\n011\nJAMES R. TALLON, JR.\nJames R. Tallon, Jr. is president of the United Hospital Fund of New York. The Fund, the\nnation's oldest federated charity, addresses critical issues affecting hospitals and health care in\nNew York City through health services research and policy analysis, education and information\nactivities, and grantmaking and voluntarism.\nMr. Tallon serves as chair of the Kaiser Commission on Medicaid and the Uninsured and is a\nmember of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). He\nserves as secretary for the Alpha Center and for the Association for Health Services Research. and\nis also on the boards of the Alliance for Health Reform. The Commonwealth Fund, and the New\nYork Academy of Medicine. He recently concluded a three-year term as a member of the\nProspective Payment Assessment Commission (ProPAC), and has held visiting lecturer\nappointments at the Columbia University and Harvard University schools of public health.\nPrior to joining the Fund in 1993. Mr. Tallon served in the New York State Assembly for nineteen\nyears. beginning in 1975. As majority leader from 1987 to 1993 and as chair of the health\ncommittee from 1979 to 1987, he spearheaded efforts to reform the Medicaid program while\nexpanding eligibility for pregnant women, and children. His 1991 legislation required the\nimplementation of Medicaid managed care programs statewide. Under his leadership. the\nAssembly also enacted measures to assure transitional health coverage for laid-off workers,\nreimburse hospitals in a fair and cost-effective manner, foster high-quality and cost-efficient home\nhealth care services, encourage organ donations, promote AIDS research and education, and\nfoster regional health planning agencies.\nMr. Tallon received a B.A., cum laude, in political science from Syracuse University and an M.A.\nin international relations from Boston University. He has also completed graduate work at the\nMaxwell School of Citizenship and Public Affairs at Syracuse University. In 1995. he was\nawarded honorary doctorates of humane letters from the College of Medicine and School of\nGraduate Studies of the State University of New York Health Science Center at Brooklyn, and\nfrom New York Medical College.\nFebruary. 1998\nI\nFAXED\nfor\nJarah\nFILE\nQUALITY\n06/02/98 10:45 FAX 202 456 5557\nDOMESTIC POLICY COUNCIL\n5.\n001\n*** MULTI TX/RX REPORT ***\nTX/RX NO\n1881\nPGS.\n27\nTX/RX INCOMPLETE\nTRANSACTION OK\n(1) 913015942168\n(2) 913015942155\n(3) 96906154\n(4) - 96906247\nERROR INFORMATION\n)\nFORUSH THE WHITE HOUSE\nNTBK Domestic Policy Council\nDATE:\nJohn Eisenbey, Nancy foster, Anthony so,\nFACSIMILE FOR: Richard Soriar 301-594-2155(5) 690 6154 (F)\n301-594-2168\n690-6343 (p)\n690-6247\nPHONE: ( ) -\nFAX: ( ) -\nFACSIMILE FROM: Sarah Bianchi\nPHONE: ( ) -\nFAX: ( ) -\nNUMBER OF PAGES (INCLUDING COVER):\n[ ]\nFOR YOUR REVIEW\n[ ]\nPER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU\n[ ]\nPER YOUR REQUEST\n1.\na\nn I\nThe\nTHE WHITE HOUSE\nDomestic Policy Council\nDATE:\nJohn Eisenbey, Nancy foster, Anthony so,\nFACSIMILE FOR: Richard Sorian 301-594-2155(c) 690- 6154 (F)\n301- 590 -2168\n690-6343 (p)\n690-6247\nPHONE: ( ) -\nFAX: ( ) -\nFACSIMILE FROM: Sarah Bianchi\nPHONE: ( ) - -\nFAX:( ) -\nNUMBER OF PAGES (INCLUDING COVER):\n[ ]\nFOR YOUR REVIEW\n[ ]\nPER MY E-MAIL OR VOICE-MAIL MESSAGE TO YOU\n[ ]\nPER YOUR REQUEST\nCOMMENTS: Report Comments on Quality\nMEMORANDUM\nJune 2, 1998\nTO: John Eisenberg, Nancy Foster, Anthony So, Richard Sorian\nFR: Chris Jennings and Sarah Bianchi\nRE:\nQuality Report\nThanks for sending us a draft of the report. You have clearly done a great deal of work\nputting this together. In addition to the handwritten edits, we thought it might be helpful to give\na few overall comments.\nYou have collected an impressive list of examples of companies and state and local\ngovernments, and others that are relying on this kind of data and information. We would suggest\nthat rather than citing all of the examples on this comprehensive list, that we focus in a more\nlimited set of examples and describe them in more detail. Specifically, we would recommend\nchoosing the examples where you believe we can describe: (1) the problem that was being\naddressed (i.e. overuse of services, high rate of diabetes, etc); (2) how the quality measure was\nimplemented to address that problem (why a certain approach was chosen, who uses it, etc.); and\n(3) what if any evidence that we have to verify that this was somewhat successful (either\nimproved consumer satisfaction, address the defined problem in some way etc.) We are aware\nthat in many cases, this level of information is not available, but we would suggest limiting the\nreport to examples that we know more about. However, you should include a paragraph or so\nthat gives a sense of how widespread the use of this information is.\nWe would also suggest defining the problem as much as possible, with using the\nexamples that you have and any others that we can find, particularly with regard to how this is\ncosting the health care system money (as well as costly in terms of human suffering) and\nimproving outcomes.\nOnce you define how this kind of information works and can be useful, the report raises\nthe question of why the existing system is not good enough and why we would need a Quality\nForum. Therefore, we would recommend that you include a section that describes why the\ncurrent system is not sufficient. This section may include a brief discussion of the fact that there\nis a patchwork of success stories with too little collaboration; that more companies have\nindicated an interest in using this type of information; and why it would be useful to have more\ncollaboration or to have people relying on similar outcome measures.\nWe would recommend that the discussion of the forum would follow this section. You\nshould discuss more fully the description of the forum -- using some of the language that is from\nthe Quality Commission report itself. This section should include a discussion of why the forum,\nand the planning process is so important. It could also include a discussion of what the potential\nis with regard to improving quality, developing a consistent set of measure, and why that is so\nimportant.\nThe outline we are suggesting is as follows:\nI.\nIntroduction\nII.\nEvidence of Quality Problems -- overuse of services, cost impact and human\nsuffering etc. etc.\nIII.\nEvidence that these problems can be addressed -- through 10 examples of how\nthis is currently working.\nIV.\nWhy the current system is not good enough and why there is great potential to do\nbetter.\nV.\nWhat the Quality Commission recommended in this regard. Why the Forum has\nso much potential to improve quality, outcomes, etc.\nVI.\nWhy the planning process is the first important step to developing this critical\nsystem.\nIs it possible for us to see a revised draft at the end of this week? Thanks again.\n1001/024\nAGENCY FOR HEALTH\nLIAISON OFFICE FOR QUALITY\nCARE POLICY AND\nSEARCH\nU.S. Department of Health and Human Services, 200 Independence Ave., S.W., Room\n638G, Washington. D.C. 20201\nFAX\nDate: 5/21/98\nNumber of pages including cover sheet: 26\n24\nTo:\nFrom:\nSarah Bianci\nANTHONY D. So, MD, MPA\nSENIOR ADVISOR TO THE\nADMINISTRATOR\nPhone:\nFax phone: 456-5557\nPhone:\n202-690-7230\nCC:\nFax phone:\n202-690-6154\nREMARKS:\nUrgent\nFor your review\nReply ASAP\nPlease comment\n05/21/98 17:35\nMemo\nTo:\nSarah Bianci\nFrom:\nAnthony So\nSubject:\nForum Background paper\nDate:\nMay 21, 1998\nOver the last few days, we have worked to move from outline to draft background paper. To\nprovide an early glimpse at this draft, Dr. Eisenberg asked that we fax to you the current version.\nIt still needs to go through Department clearance, but your input and Chris's at this stage would\nbe most helpful. As our e-mail system is down indefinitely, comments can be faxed to (202)\n690-6154.\nIf possible, we would like to discuss how the paper might be used at the event. This would help\nus in making the next round of revisions. I can be reached at (202) 690-8205 or 690-7230.\nDRAFT-PLEASE DO NOT CIRCULATE\nMeasuring and Reporting on Health Care Quality-\nFirm Foundation for the Forum\nBackground Report\nOverview\nIn December, 1994, a well-known health reporter for the Boston Globe suffered an accidental,\nbut fatal overdose of chemotherapy at a major Boston academic institution. Undergoing\n50mg\ntreatment for breast cancer, she received a fourfold miscalculation of her chemotherapy drug, and\nlater, her death became the subject of newspaper headlines. The Joint Commission on\nthis\nAccreditation of Healthcare Organizations responded to this incident and the report of a second\naccidental overdose by placing the hospital on conditional accreditation. The top leadership of\nthe hospital departed, and the Dana-Farber Cancer Institute undertook an investigation of what\nwent wrong. The result was a practical \"internal revolution,\" and significant changes-from\nthe exam isht lets\nrequiring staff physicians to countersign chemotherapy orders to a redesigning of patient charts\nand an effort to survey patient satisfaction with care-were implemented. However, more often\nthan not, measures of quality-not the media-motivate improvements in how health care is\ndelivered.\nThe real story of health care quality seldom makes the headlines. Many private and public sector\nefforts serve as example of how we can improve health care quality for all Americans.\nMeasuring and reporting on quality has resulted in real gains for consumers in terms of health\nplan choice and better care. But as the Final Report of the President's Advisory Commission on\nConsumer Protection and Quality notes, we can do better. This report focuses on the promise\nrevealed by these leading edge efforts.\nvisht\nThese activities to improve health care quality make good business sense. They can result in\nincreased productivity and decreased costs from higher quality care. The Business Roundtable\nfound that companies surveyed for a report on best practices in health care \"repeatedly\nemphasized their belief that future cost savings in health care depend on quality improvement.\"\n9 frout couple mples. ple use &\nMajor businesses have echoed this statement as well (The Business Roundtable, 1997).\nwheer\nher\n*\nInformation on quality is also the sign of a \"mature\" health care market, as measured by the level\n&\nof managed care penetration. Where managed care penetration was greater, health plans used\nquality to choose potential providers of tertiary care. In contrast, price dominated the choice of\ntertiary care providers in the less mature markets, and quality monitoring efforts in the\nnot\ncontractual arrangement were less common (Schulman, et al., 1997).\nQuality matters to consumers. By a wide margin, Americans cite high quality as their most\nimportant concern in choosing a health plan (AHCPR-Kaiser Family Foundation, 1996). To be\nsofe point Jouv .s Vare\n1\n05/21/98\nDRAFT-PLEASE DO NOT CIRCULATE\neffective, consumers must become involved in these activities. From health plan selection to\ntreatment decisions, consumers must be empowered to participate. Taking measure of quality\nmay respond to consumer concerns over managed care. Such concerns have kept some\nemployers from using managed care services.\n1st talk about why impt. to the private sector\nThe Federal government also has an important, and complementary, role to play in these efforts\nto improve quality. The government funds clinical and health services research; supports the\ndevelopment of quality measures; sponsors surveys and databases that can track and benchmark\nchanges in quality; encourages information exchange over best practices; and purchases or\ndelivers health care for millions of Americans.\nBridging the Gap in Health Care Quality\nThe President's Advisory Commission on Consumer Protection and Quality in the Health Care\nIndustry affirmed that many Americans receive quality care from dedicated health care\nprofessionals (Final Report, 1998). However, it also found wide variations in health care\nis & one la the purchasers rest\npractice, attributable in part to underuse, overuse and misuse of services.\nthasers\nFor some services, underuse poses a challenge. For example, only 66% of children enrolled in\nthe 330 managed care plans providing information to the National Committee for Quality\nAssurance (NCQA) had received appropriate immunizations by age two (NCQA, 1997). A\n&\nnationally representative sample of women age 50 and older found that only 45% had a\nof 04\nmammography, as recommended for early detection of breast cancer, in the previous year (CDC,\n1993). In another study, a third of Medicare patients who survived a heart attack failed to receive\nb/c inim mple go wwig\naspirin within two days of hospitalization (Krumholz, et al., 1995). This was despite the fact that\nthese patients had no contraindications to aspirin therapy and that aspirin use among elderly\npatients had been shown to reduce mortality by 22% in the first 30 days after a heart attack.\nOveruse of services also presents problems. Half of all patients diagnosed with a cold and 66%\nof patients diagnosed with bronchitis received antibiotics (Gonzales, et al., 1997). In 1992,\nmith 4.11 Smith 33. 104\ntwelve million antibiotic prescriptions were written during office visits for colds, upper\nrespiratory tract infections and bronchitis. Together, these prescriptions accounted for one out of\nevery five antibiotic prescriptions to adults in that year. Yet antibiotics offer little or no benefit\nfor these conditions. This overuse of antibiotics not only imposes unnecessary health care costs,\nbut also places patients at risk for adverse drug reactions and contributes to the emergence of\nantibiotic-resistant pathogens. In a study of tympanostomy tube placement in children,\nresearchers found that 23% of the procedures were performed for inappropriate indications while\nanother 35% were for equivocal indications (Kleinman, et al., 1994).\nMisuse of services and avoidable errors occur in the use of laboratory tests and medications. One\nstudy noted that 10% to 30% of laboratory test results were inappropriately classified as normal\n2\nDRAFT-PLEASE DO NOT CIRCULATE\nbased on rescreening reviews (Wilbur, 1997). These errors can result in missed or delayed\ndiagnoses. Several studies have examined medication errors in hospital settings. One conducted\nin a teaching hospital found four errors per 1,000 medication orders. Investigators classified\n70% of those errors as having the potential for serious adverse outcomes (Lesar, et al., 1997).\nMeasuring Quality\nTo address these issues, the Advisory Commission called for the creation of two entities-an\nAdvisory Council for Health Care Quality in the public sector and a Forum for Health Care\nQuality Measurement and Reporting in the private sector. Each fulfills an important and\ncomplementary role. The Forum is intended to improve the effectiveness and efficiency of\nhealth care quality measurement and reporting. Building on the promise of what public and\nmay\nprivate sectors have already achieved, the Forum has potential to take this work to the next\nquantum level.\nhow, what are the gaps that have been\nox\nwaiteefine\nTo left? realize these gains in quality improvement, coordinated efforts at quality measurement, data\ncollection and reporting are key. Through these two entities-the Council and the Forum-the\nCommission proposed coordinated efforts to improve health care quality. In its Final Report, the\nCommission found that \"incentives to improve quality have been diluted by measurement efforts\nthat vary widely in their aims and scope, and that have been, at best, only informally\ncoordinated.\" This paper focuses on the potential that coordination of this work might bring.\nSuch coordination would serve several purposes. First, it would enable the marketplace to\nunclear here is\nidentify and update core sets of quality measures and standardized reporting methods. On the\npart of health care providers and plans, this would reduce needless duplication of data collection\npurpose. Second, it would allow consumers and purchasers to comparison shop for health plans.\nwhich to assess provider performance. Finally, coordinated efforts can lead to the sharing of\nresources and best practices, both across and within private and public sectors. At present,\nemployers and other group purchasers do not have a central repository for learning about best\nwhat Cax council sho Focus uld from or J w.x 1x cave PHOTOP\n1\nand reporting efforts. Such a process would also flag what measures are important and for what\nFor employers and other purchasers, a core set of quality measures offers a common yardstick by\npurchasing practices, nor do they have affordable access to the technical assistance that would\npermit replication of the practices of pioneers (Meyer, et al., 1997).\nDeveloping core sets of quality measures. The Federal government and the private sector have\nboth contributed to sets of measures from which a single core set might emerge. Importantly,\nmany of these tools reside in the public domain, where they are more widely accessible.\nThe Health Plan Employer Data and Information Set (HEDIS), developed initially by\nDigital, GTE and Xerox and later by the National Committee on Quality Assurance\n(NCQA), is one set of quality measures widely used by health plans. In October, 1997,\n3\nDRAFT-PLEASE DO NOT CIRCULATE\nNCQA released its second version of Quality Compass, a database of HEDIS and\naccreditation information on 329 health plans across the nation. With Quality Compass\n1997, NCQA published its first \"State of Managed Care Quality,\" a report that provides\nmy of >pant S Plnons\nbenchmarks and national and regional averages based on HEDIS data.\nWorking with RAND, Research Triangle Institute and Harvard, AHCPR sponsored the\ndevelopment of the Consumer Assessment of Health Plans Survey (CAHPS). CAHPS is\nX in\na consumer satisfaction survey that gauges consumers' experiences with their health\nplans. Recently HCFA began surveying over 200 managed care plans serving Medicare\nbeneficiaries to collect and report on CAHPS data. Next spring Office of Personnel\nManagement will use CAHPS to survey Federal employees. Thus in FY 1999, over 45\nmillion Americans will have access to CAHPS reports to help them make their health\ncare choices.\nAHCPR and 19 state partners built a powerful tool for studying quality health care, the\nHealthcare Cost and Utilization Project (HCUP). This research database and tool\nprovides a comprehensive source of hospital inpatient financial and clinical information.\nAs more health care moves from inpatient to outpatient settings, the Agency plans to\ntail. shou wh we at was- describe des the services now Pro bleue a\nbroaden the database to include ambulatory surgery, and this is underway in nine of the\nparticipating states. Many organizations lack the resources to build a benchmarking\ninfrastructure to assess the impact of delivery system changes on quality. The HCUP\nQuality Indicators provides a user-friendly, standardized database and software program\nto track the impact of system changes on quality. At least ten state governments and state\nhospital associations use HCUP Quality Indicators for benchmarking and monitoring\npurposes. The Hawaii Health Information Corporation (HHIC), a non-profit organization\nthat aids hospitals with their quality improvement programs, submitted the HCUP\nQuality Indicators to JCAHO for approval for the ORYX measurement initiative.\nJCAHO approved most of the indicators, opening the door for HHIC to use these\nI\nindicators in the JCAHO accreditation process.\n\"Founded on the premise that \"a more responsive health care system depends on informed,\nabout\nempowered consumers who help shape the system, hold it accountable for quality and act\nas partners in improving health,\" FACCT-the Foundation for Accountability-also has\ndeveloped measures of health care quality. Over the past couple years, it has completed\nwork on measures focused on adult asthma, breast cancer, diabetes mellitus, major\ndepressive disorder, health status, health risks, and consumer satisfaction. Consistent\naddressed particular what etc It better don't wes thinke resulted need we a list\nwith its goals of being consumer-focused, FACCT conducts focus groups for each of its\nmeasures and combines these patient expectations with the best available clinical\nknowledge and scientific research.\nThe Health Care Financing Administration (HCFA) aided in the development of\nOASIS-the Outcomes and Assessment Information Set-a core standard assessment data\nset for home health agencies. Under a second proposed regulation in March 1997, HHS\nrequires home health agencies to use OASIS to monitor patient satisfaction and\nconditions. OASIS requires a standardized assessment of new patients within 48 hours of\n4\nwoncs.\nstuff\nwhy\nhow\nthat\nvery\nexamples\nfew\nuse\nbut\nthere\nthis\nlyonip\nDRAFT-PLEASE DO NOT CIRCULATE\nadmission to determine immediate support needs and updated assessments continuously\nuntil the patient's discharge. Additionally, health agencies must use data from OASIS to\nimprove practice through their quality improvement programs (HCFA, 1997).\nThe Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the\nmajor accreditation organization for hospitals, has developed a quality measurement\nsystem called ORYX Plus. It is a voluntary option for hospitals and offers opportunities\nfor national benchmarking and performance comparisons by stakeholder groups.\nInitially, JCAHO identified 32 measures for the system with expectations to increase the\nnumber and sophistication of measures over time (JCAHO, 1998).\nThe American Medical Association has initiated the American Medical Accreditation\nProgram (AMAP) for physicians. This voluntary program, developed in collaboration\nwith specialty, state, and local medical societies, will reduce duplication in credentialing\nrequirements. It will provide feedback on the quality of a physician's care to the\nphysicians themselves as well as health plans and hospitals. State licensing requirements\ncurrently can involve credentialing or site reviews. Adding to this information base,\nAMAP plans to include other data on the physician's personal qualifications, clinical\nperformance, and patient care satisfaction (AMA, 1998).\nThe SF-36 Health Survey remains one of the most widely used generic health-related\nquality of life measures (Ware, 1998). Researchers developed the measure in a way that\nboth allowed for group comparisons and used general health concepts not specific to age,\ndisease or treatment group. The measurement instrument provides insight to alternate\ndefinitions of health-function and dysfunction, distress and well-being, objective reports\nand subjective ratings, and favorable and unfavorable self-evaluations of health status.\nNumerous stakeholders, including health plans health services researchers, experts in\ndiabetes and primary care, HCFA, the American Diabetes Association, FACCT, and\nNCQA, have joined together for the Diabetes Quality Improvement Project (DQIP). This\ncollaborative effort has resulted in the development of an initial set of diabetes measures.\nThis project is ongoing with plans to field test new measures in the future. The\nparticipating organizations are considering this set of measures for inclusion in their\nmeasurement projects, including future versions of the HEDIS Reporting Set (NCQA,\n1998).\nComplementing core measures. The development and use of core sets of measures have\nencouraged firms and group purchasers to go a step further. Some have complemented core\nmeasurement sets with other yardsticks for health plan performance (Meyer, et al., 1997).\nIn evaluating HMO performance, General Motors blends several measures of health care\nquality into one amalgamated quality measure and draws from direct indicators of quality\nfrom HEDIS, employee satisfaction measures, accreditation status, and impressions\ngained from site visits. GM also works with its plans to develop quality improvement\nstrategies and facilitate the sharing of best practices.\nthis is a good example to spell out in much\nmore detail. Why do what motivated\nGM to do this Whin did it work? are consumers\nhappien\n05/21/98\n17:37\nNU.\n0000/024\nDRAFT-PLEASE DO NOT CIRCULATE\nDigital applies its own comprehensive set of HMO performance standards to evaluate\nquality. The company periodically updates these standards with the addition of new\nindicators, such as HEDIS, and the removal of outdated ones. Within this framework,\nDigital sets \"stretch\" goals that encourage HMOs to continuously improve their\nperformance.\nThe Chicago Business Group on Health contracted Hewitt Associate, which also\nparticipated as an employer in the group, to assess costs and quality in local health plans.\nHewitt used results from individual interviews, HEDIS indicators, its own benchmarking\ndatabase (Health Network Profiler), features of the Consumer Health Plan Value Survey,\nand other national benchmarking indicators (such as Healthy People 2000).\nFilling in the measurement gap. Still, to meet the needs of purchasers, continued work to fill the\ngaps in quality measures must be undertaken. Some of this work requires cataloguing existing\nmeasures, but much of it involves research to advance the science of measurement.\nAHCPR works to fill the gaps in quality measurement by supporting the Q-SPAN\nproject. In a series of cooperative agreements to develop and test new measures, the Q-\nSPAN project currently focuses on eight measures for specific conditions, patient\nagain\npopulations, and health care settings: clinical performance measures for dental care plans,\ndeveloping and testing asthma quality of care measures; development of a global quality\ntwo\nassessment tool for managed care, expansion of quality measures for cardiovascular\npick\ndisease, functional outcomes in patients with hip fractures, measuring quality by\n$2\nachievable benchmarks of care, ongoing development and evaluation of HEDIS\nmeasures, and quality outcomes in subacute and home care programs (AHCPR, 1998).\nIn the area of child health, AHCPR, the Maternal and Child Health Bureau and HCFA are\ntell\nthree\nfunding NCQA to pursue quality measures of relevance to children and adolescents. This\nfunding will support the collaboration of NCQA and FACCT in the development, testing\nat\nand implementation of child health measures, as well as their inclusion in future versions\nof HEDIS.\nFACCT also works to fill the measurement gap and has under development measures on\nwas\nblem\nthe\nalcohol misuse and dependency, coronary artery disease, end of life, and HIV/AIDS.\nAHCPR has developed a catalogue of existing quality measures-CONQUEST. Designed\nfor providers, managed care plans, purchasers and policymakers, it uses a common\nlanguage so that individuals can quickly identify a group of measures for use. Currently,\nCONQUEST contains 1,185 clinical performance measures and information on 52\ncommon or costly clinical conditions, such as diabetes, hypertension, depression, cancer,\nand pregnancy. Unlike some private sector databases of measures, CONQUEST is\navailable in the public domain (AHCPR, 1998).\nIn an initiative undertaken to provide a catalogue of performance measures in a\nstandardized format, the JCAHO started the National Library of Healthcare Indicators:\nA 7 plant & & is E &\nHealth Plan and Network Edition. It provides profiles of 225 performance measures that\n6\nDRAFT-PLEASE DO NOT CIRCULATE\ncan be used to assess the performance of health plans, integrated delivery networks,\nprovider sponsored organizations, and other delivery systems. Each profile adheres to a\nsophisticated classification system, and each measure is selected based on an \"expert-\nbased face validity screening process\" (JCAHO, 1998).\nMinimizing redundant efforts. Multiple competing core sets of quality measures can lead,\nhowever, to unnecessarily duplicative and expensive data collection efforts by health plans and\nproviders. Public-private partnership on developing core sets of quality measures can minimize\nthis while preserving the room required for continued development and improvement of\nmeasures. For example, the National Committee for Quality Assurance (NCQA) will merge\ntheir consumer assessment survey with the Consumer Assessment of Health Plans Survey\n(CAHPS), which was created through AHCPR funding. Along these same lines, group\npurchasing arrangements have helped consolidate the measurement requirements. Using HEDIS\n3.0 quality and enrollee satisfaction measures, the California Cooperative Healthcare Reporting\nInitiative (CCHRI) reports annually these results to purchasers in the Pacific Business Group on\nHealth and others.\nCascading effects from the development of quality measures. What cannot be measured cannot\nbe improved. Downstream, the development of quality measures has triggered a cascade of\nactivities to improve health care quality.\nDeveloped by the AHCPR-sponsored cataract Patient Outcome Research Team (PORT),\nthe VF-14 is an instrument used to measure functional status in patients with cataracts.\nNow considered the gold standard, the VF-14 has now been adopted by several Medicare\ncarriers as part of the routine pre-operative assessment of cataract patients. Based on data\ncollection strategies and tools developed by the cataract PORT, the American Academy\nof Ophthalmology launched a large national project enabling ophthalmologists to collect\novidence\nstandard clinical information on their cataract patients. The AAO has invested over $1\nmillion in this effort, called the National Eyecare Outcomes Network (NEON). The\nAAO and the physicians believe that this database enables them to provide reliable\nperformance data on their cataract surgery when competing for managed care contracts.\nThey also use the data to detect differences in patient outcomes that may allow specific\nproviders or groups to identify quality problems and improve quality of care. A national\norganization of ophthalmology residencies plans to use the database to monitor the\nquality of residency programs in the country. At least one program requires all of its\nresidents to submit data to the database and uses the information to measure performance\nof the residents.\nTo assess prostate symptoms better, the American Urological Association (AUA)\nsymptom index was developed and validated. It proved to be a superior measure of\nsymptom severity compared to various physiological and anatomic measures commonly\nused in practice. The Maine Medical Assessment Foundation has used the AUA\n7\nmc\n05/21/96\nDRAFT-PLEASE DO NOT CIRCULATE\nsymptom score along with other measures to collect outcomes on patients with benign\nprostatic hyperplasia. Over 60% of practicing urologists in Maine now use the symptom\nscore Its use has changed the way urologists practice with greater attention to informed\npatient\ndecision\nmaking.\nhow,\nwhy,\nCompeting on Quality\nevidence?\nThe public availability and public reporting of these quality measures play an important role.\nWhen used for comparisons in the marketplace, this information allows consumers and\npurchasers to evaluate and select health plans and providers on the basis of quality, not just cost.\nFor the marketplace to compete on quality, employers and coalitions must also incorporate these\nconsiderations into their purchasing strategies.\nThese measures often take the form of report cards made publicly available. Various groups\nproduce these guides, deliver them in print or electronic formats, and make them publicly\navailable for free or for purchase. For example, U.S. News & World Report and Newsweek\npublish ratings of health plans, as do consumer organizations like Washington's Consumer\nCheckbook and Consumer Reports. Using HEDIS measures and an NCQA consumer\nsatisfaction survey, U.S. News and World Report published a report card in October 1997 of 223\nmanaged care plans (Brink and Shute, 1997). Newsweek followed with a December report card\nof 88 plans based on the FACCT framework and measures (Spragins, 1997). Several states have\nfollowed suit with customized report cards examining local health plans. The New Jersey\nDepartment of Health and Senior Services and the Maryland Health Care Access and Cost\nCommission (HCACC) both present HEDIS data, and New Jersey uses the AHCPR-sponsored\nCAHPS survey for its consumer satisfaction data (New Jersey Department of Health and Senior\nServices, 1997, and Maryland HCACC, 1997). Through its Web site, the National Committee\nfor Quality Assurance provides selected findings from HEDIS measures of health plans on\n\"Quality Compass.\"\nEmployers such as Motorola and J.C. Penney also generate such reports on health plans for their\nworkers (The Business Roundtable, 1997). In fact, J.C. Penney personalizes report cards on\nHMOs to the specific home zip code of the employee. These report cards carry such information\nas NCQA accreditation status, plan member satisfaction rates, and the number of contracted plan\nspecialists. Again, some purchasers have gone beyond core measurement sets. General Motors,\nFirst Chicago NBD, and others are involved in the Southeast Michigan Health Care Consortium,\nwhich is collecting outcomes data for all health care centers in the region. They plan to publish\ndata on angioplasty and coronary artery bypass surgery in the fall of 1998 (The Business\nRoundtable, 1997).\nThis nds like posseble could example\nThis work has also arisen out of public-private partnerships. The Massachusetts Healthcare\nPurchaser Group, a statewide coalition of 67 public and private members, publicizes information\n8\nDRAFT-PLEASE DO NOT CIRCULATE\non the ability of local health plans to meet specific cost and quality goals. Public sector\nrepresentatives include the Massachusetts Division of Medical Assistance which runs the state\nMedicaid program; the Group Insurance Commission which purchases health care for state\nemployees; and several municipalities and nonprofit colleges. The group examines HEDIS data,\npublicly reports on the number of indicators that plans produce, and ranks plans relative to each\nother and to benchmarks. They developed a report card for the first time in 1996, and they hope\nto develop a group purchasing strategy by January 1999. In another example of public-private\npartnership, the California Office of Statewide Health Planning and Development and the Pacific\nBusiness Group on Health have developed the California Coronary Artery Bypass Graft (CABG)\nMortality Reporting Program. This program collects and reports risk-adjusted, hospital-level\nmortality data for California hospitals that perform bypass surgery (Meyer, et al., 1998). The\ngrowing availability of these measures speaks to consumer interest in this information.\nStudies have shown that the public reporting of quality measures can result in improvements in\nthe delivery of health care.\nSince 1989, the New York State Department of Health has collected and released\nhospital-level data on coronary artery bypass surgery. From 1989 to 1992, actual\nmortality decreased from 3.52% to 2.78%. Because average patient severity of illness\nincreased, risk-adjusted mortality decreased even more over that same period-by 41%\nfrom 4.17% to 2.45% (Hannan, et al., 1994).\nThe Missouri Department of Health developed a consumer report on obstetrical services.\nWithin 1 year of the report, approximately 50% of hospitals that did not have car seat\nprograms, formal transfer agreements for high-risk infants, or nurse educators for breast-\nfeeding prior to the report either instituted or planned to institute these services (Longo, et\nsynt\nal., 1997).\nIn 1993, 27 corporate and government health care purchasers formed the Massachusetts\nHealthcare Purchaser Group (MHPG). Sixteen health plans representing 15 different\nhealth care organizations submitted 1992 data on 6 clinical indicators. A \"clinically\nsignificant average range\" was defined and health plan performance was summarized for\neach indicator in the \"Cost/Quality Challenge Report\" released in March 1994. Most of\nthe purchasers MHPG surveyed about their assessment and use of the Cost/Quality\nChallenge Report found it useful. To promote quality improvement activities among\nhealth plans, MHPG showed purchasers how to pursue performance issues with health\nplans, held a best-practice forum on C-section, and created a follow-up endeavor, the\nCoordinated Purchasing Initiative (Jordan et al., 1995).\nApart from purchasing health care, quality measures serve an important role in flagging areas for\nimprovement and motivating practice change. Both the public and private sectors have\neffectively used quality measures to accomplish these ends. Some have done so by publicly\nreporting the information, and others, by providing feedback more directly to health plans and\n9\n36/12/C0\nNO.531 06/2/024\nDRAFT-PLEASE DO NOT CIRCULATE\nproviders. In each case, the evidence shows that quality measures can result in improvements in\nhealth care services.\nThe public release of data on quality of care has its role in ensuring public accountability.\nHowever, not all quality measures work best when used in this way. Health plans and providers\nsee patients, who may differ in their severity and pattern of illness. To compare across plans and\nproviders, risk adjustment for these differences needs to be done, and done well. Sometimes the\nmotivation can come from within these plans and practices instead of from the public release of\nsuch information. When used for improvement, quality measures can provide health plan and\nprovider feedback that changes practice behavior and results in continuous quality improvement\nefforts.\nApplying Quality Measures\nLeading the way in value-based purchasing, some firms and group purchasing coalitions have\napplied quality measures to how they contract and arrange for care, educate employees to\nbecome better health care consumers, provide incentives to reward the practices of employees or\nproviders, and become involved in improving the delivery of health care services (Meyer, et al.,\n1997). By taking responsibility for educating and offering incentives in their employees' health\ncare decisions, employers and group purchasers are forging a new relationship with their\nworkers.\nContracting and arranging for care. The use of quality measures has changed the way\nemployers and group purchasers select health plan options and offer these choices to their\nemployees. Several businesses and group purchasing coalitions provide information on quality,\nalongside benefit package comparisons, to employees and consumers. They also use such\ninformation in narrowing the choice of plans to offer. It has also become part of the process to\ninvolve employees in evaluating the health plans that the employer offers. The following\nexamples demonstrate various approaches taken by employers and group purchasers on the\nleading edge.\nInternational Paper Company has an extensive information database for use by its\nemployees. This database, called the Medical Information Resource System, includes\ninformation on physicians taken from the American Medical Association, 12 annually\ndeveloped fee schedules, surveyed physicians' fees, the frequency of performing certain\nprocedures by specialty, and contracted hospitals' charges (The Business Roundtable,\n1997).\nGTE uses a subset of HEDIS measures and looks at the accreditation status of health\nplans with which it contracts. With in-house expertise, the company has created a\ndatabase which GTE uses in lieu of NCQA's database, the Quality Compass, to evaluate\nhealth plans (Meyer, et al., 1997).\n10\nthis has with again, may due what\n05/21/98 17:39\nDRAFT-PLEASE DO NOT CIRCULATE\nThe Buyers' Health Care Action Group (BHCAG), composed of 23 self-insured, private\nemployers, collectively contract with \"care systems\" that meet a standard set of criteria.\nBHCAG provides comparative information about costs and quality to consumers (The\nMidwest Business Group on Health, 1997).\nHershey Foods Corporation used risk-adjusted mortality data from the Pennsylvania\nHealth Care Cost Containment Commission, along with other information, to select a\nnetwork of hospitals for its point-of-service plan (The Business Roundtable, 1997).\nBalancing choice and quality, Motorola sought to establish its own managed care network\nto include 80% of physicians recording at least 10 encounters a year with an employee. If\nan employee's physician was not included, Motorola encouraged them to recommend the\nphysician for inclusion and accepted all those meeting the plan's credentialing and other\nrequirements. By doing so, the company notes that it is \"primarily interested in selecting\nthe physicians based on their quality of service\" (The Business Roundtable, 1997).\nThe United Auto Workers requires NCQA accreditation for all health plans offered to its\nmemberes, and it is working on a strategy to provide information, including NCQA\naccreditation status and some quality assessment based on HEDIS measures (AFL-CIO,\n1997).\nAfter an initial screening, Ryder System brings HMO finalists before panels of\nrepresentative employees in each of 27 market areas. The employees then quiz the\nHMOs on measures such as the size of the network, the hospitals used, how doctors were\npaid, and the process for referral to a specialist. This input contributes significantly to the\nplans chosen for Ryder System employees (The Business Roundtable, 1997).\nEducating employees 10 become better health care consumers. Though more information to\ncompare health plans is now available, consumers still need programs and tools to navigate\nthrough the health care system. After the plan selection is made, difficult treatment decisions\narise, and patients sometimes require assistance in making those decisions with their providers.\nIn addition to report cards on health plans, several groups have developed interactive tools to aid\nconsumers in comparing one plan to another.\nHealth Pages publishes a magazine and offers an online service for consumers. It\nprovides information on specific health topics as well as community-specific comparative\ninformation on physicians, hospitals, allied health professionals and health plans.\nThrough its work, Health Pages has assisted the employees of General Motors,\nMcDonnell Douglas, Edison, US West, and Chevron. Its interactive Web site allows\nconsumers to search for insurance plans, dentists, physicians, maternity services, and\nmammography clinics in their area, with comparative and provider-specific information\n(e.g., board certification, fees for selected procedures, and medical school attended for\nphysicians; baseline HEDIS data and description of benefit packages for health plans)\n(Health Pages, 1998).\n11\n024\n05/21/98 17:39\nDRAFT-PLEASE DO NOT CIRCULATE\nAmerican Express makes a videotape on health plan choice available to employees. In a\nmock focus group format, the videotape discusses issues that commonly arise in deciding\namong managed care options (Maxwell, et al., 1998).\nAHCPR has sponsored a variety of interactive tools for target populations ranging from\nlow-literacy groups to families making decisions on care for the elderly. Elder Care is a\nproject that assists families in deciding on the best living and care arrangement for elderly\nrelatives. Through either a CD-ROM or its Web site, the program allows families to\nevaluate the ability of their elderly relatives to function in various settings from an\nindependent living situation to the nursing home. In addition, the program assists the\nfamily in assessing their ability to provide care for an elderly relative.\nThe Health Care Financing Administration recently debuted its Medicare Web site. The\nwww.medicare.gov Web site is designed for Medicare beneficiaries and the people who\nhelp them make choices about their health care. It contains basic information about\nMedicare as well as the Medicare Compare database, which provides consumers with the\nability to compare health plan benefit packages in their home area.\nOf course, tools-particularly for assisting treatment decision making-also belong in doctors'\noffices. The work of health services researchers has now generated promising results. On the\nnear horizon, these tools may complement the efforts of providers in better educating consumers\nabout their health care decisions. They also have a role in disease as well as demand-side\nmanagement, but importantly, they help make consumers co-producers of their care.\nThe Shared Decision Making Program for benign prostate disease is an interactive,\nvideodisc-based patient education program designed to allow patients to explore and\nmake an informed choice about whether to undergo transurethral resection of the prostate\nor follow a program of \"watchful waiting.\" In a pilot study, the results were promising\n(Wagner, et al., 1995), although a study with a larger sample is needed to gain a clearer\npicture of the impact of the program. Before viewing the videodisc, two thirds of the men\nfavored an approach of watchful waiting. Afterwards, this percentage increased to 79%.\nInvestigators found that 27% of the men who initially favored surgery changed their mind\nwhile only 1% of those initially inclined to wait opted for surgery.\nWith AHCPR funding, CHESS (Comprehensive Health Enhancement Support System)\noffers on-line computer support for patients. This includes a computer-based module to\nhelp care-givers make critical decisions in caring for Alzheimer's disease patients.\nPatients suffering from AIDS, breast cancer, or depression also can tap into the CHESS\ndatabase to find answers to personal questions. Additionally, they can use a hotline to\nspeak anonymously with a physician or to obtain peer-level support from other patients.\nEarly data show that AIDS patients who use CHESS are more efficient in their use of\nhealth resources. They actually have lower health care costs, fewer hospitalizations, and\nshorter hospital stays. HIV-infected persons who used CHESS reported fewer and\nshorter hospital stays (and a forty percent decrease in hospital costs) compared with\n12\n05/21/98 17:40\nDRAFT-PLEASE DO NOT CIRCULATE\nnonusers. By interacting with the home-based computer system, users monitored their\nhealth and spotted warning signs of serious illnesses so they could alert their doctors\nquickly. This tool will serve as an important resource for patients and their families as\nthey will have easy access to information in their home and will have a greater ability to\nparticipate in critical decision making.\nProviding incentives to reward the practices of employees and providers. Value-based\npurchasing is not only practiced at the firm level, but also encouraged at the employee level.\nTwo approaches taken by employers and group purchasers are 1) setting the premium\ncontribution to plans making a quality benchmark and 2) placing a portion of the premium at\nrisk, contingent upon performance. Involvement in total quality management efforts, standard\nsetting and quality benchmarking are part and parcel of incentive setting. Several firms have\ngained important experience in these approaches.\nDigital Equipment Corporation emphasizes value in its health care purchasing decisions.\nIt defines value as the sum of quality of care and consumer satisfaction, divided by costs.\nUsing information yielded from its performance reporting requirements, Digital identifies\neach region's best plan as the \"benchmark\" plan, and the company's contribution towards\nenrollee health care costs is based on the premium of this plan. This provides financial\nincentive to employees to purchase care from these health plans (Meyer, et al., 1997).\nThe Pacific Business Group on Health requires HMOs to set aside 2 percent of the\npremium dollar and awards this amount only if the HMO attains the performance\nstandards set in customer service, quality, data collection, and other areas (Bodenheimer,\net al., 1998).\nThe Gateway Purchasing Association provides financial incentives to health plans to\nimplement a satisfaction survey, report quality indicators, and make a subset of those\nindicators available for an independent audit. This coalition of thirty-one St. Louis\nemployers also put 4 percent of total premium dollars at risk depending on a health plan's\nwillingness to comply with these reporting requirements.\nImproving the delivery of health care services. Improving quality means improving the delivery\nof health care services. Some improvements result from the information that surfaces in plan-to-\nplan comparisons, which are shared widely. Others come from disease-specific initiatives led by\ngroup purchasers and employers in partnership with their health plans and providers.\nThe Health Care Financing Administration, the Office of Personnel Management, and\nlocal business coalitions in seven communities will be working with FACCT over the\nnext couple of years to look at treatment outcomes for specific diseases. Other large\npurchasers, such as GM, Ford, Chrysler, the State of Florida, the State of Wisconsin, the\nState of Iowa, and Washington State are also involved in this venture. The selected\ndiseases include diabetes, asthma, breast cancer, and depression (AFL-CIO, 1997).\n13\nDRAFT-PLEASE DO NOT CIRCULATE\nThe Dallas-Ft. Worth Business Coalition on Health has identified five services for\nmeasurement. In their pilot study, they sought to develop best practices for pregnancy\nand childbirth. These efforts included measuring quality across an entire episode of care,\nintegrating data across inpatient and outpatient settings, and using this information as\nfeedback to improve the quality of care. The Texas Medical Foundation took the lead to\ndefine appropriate clinical indicators while the Business Coalition planned the consumer\nsatisfaction survey (Meyer, et al., 1997).\nWith General Motors and Chrysler, the United Auto Workers (UAW) has created the\nCenter for Community Health Care Initiatives. This center will identify \"best practices\"\non both local and national levels, promote community-wide access to high quality care\nand improvement in health care delivery systems, develop prevention programs, and\nmake advancements in data collection and information systems. Several communities\ninvolved in this project have already made progress. In Flint, Michigan, the initiative has\ndeveloped \"best practices\" for both left heart catheterization and Cesarean sections. The\ninitiative has also organized a free asthma clinic in Anderson, Indiana. General Motors\nand UAW also have collaborated on disease management programs for diabetes and\nlate resting care we\ncardiac care in Flint (AFL-CIO, 1997).\nCleveland's Health Quality Choice has reduced mortality from pneumonia by 21% over a\nsix month period at one area hospital following the implementation of a critical pathway\n(Health Network & Alliance Sourcebook, 1995).\nFirms like AT&T and First Chicago NBD have disease management programs in diabetes\nand asthma. AT&T uses organization benchmark data for these programs, and these\nmeasures allow the company to ask their health care vendors to target their efforts on\nelobovate\nspecific parts of the country or to specific types of patients (The Business Roundtable,\n1997). Others have focused their efforts on unnecessary hysterectomies, clinical\ndepression, or mental health more broadly.\nSome have gone further to influence the management of the health plans with which they\ncontract. For example, Digital Equipment has applied the same principles of total quality\nmanagement (TQM) that the firm uses in purchasing electronic components to the purchase and\ndelivery of health care services for their employees (Maxwell, et al., 1998). To strike up long-\nterm partnerships with their managed care plans, Digital worked with them to improve quality.\nBy requiring managed care plans to set standards for their own suppliers, Digital implemented a\nTQM approach throughout the supply chain and anticipated lower costs over time.\nImportantly, providers have tracked their own outcomes in order to improve the quality of care.\nPresented earlier, the Maine Medical Assessment Foundation's use of AUA prostate symptom\nscores and the American Academy of Ophthalmology's National Eyecare Outcomes Network are\ncases in point.\nHealth Data Registry, Inc., provides another example. As a company that manages\n14\n05/21/96\nDRAFT-PLEASE DO NOT CIRCULATE\nclinical registries from hospitals and physicians, it has tracked data on cardiac surgery\npatients over several years and can flag performance levels that differ from other health\ncare providers. Between 1992 and 1996, the program spotted an unexpected rise in the\nincidence of severe renal failure among these surgical patients. Further study attributed\nthis complication to a \"fast track\" protocol, and subsequent work resulted in reducing this\nproblem (Page and Washburn, 1997).\nSpurred by variation in mortality rates for CABG operations across five hospitals in\nnorthern New England, a group of clinicians, scientists and hospital administrators\ninitiated the New England Cardiovascular Project in 1990. This program involved three\nphases: feedback of risk-adjusted outcome data to hospitals and surgeons; continuous\nquality improvement training for the providers; and site visits in which outside teams\nobserved the CABG system in each hospital. The researchers collected data during the\npre-intervention period and after the final report on the site visits. They found a 24%\nreduction in the mortality rate after the intervention. Four out of the five hospitals\nimproved. The one hospital that did not improve had the lowest pre-intervention\nthis\nmortality rate. Both process and system changes in the individual hospitals accounted for\nthe quality improvements (O'Connor, et al., 1996).\nWhy Businesses Need to Care: Better Quality Can Cost Less\nMembers of the Business Roundtable (1997) have sized up health care quality and what it means\nto their business. Their words, as well as their actions, speak for them:\n\"Quality health care is lower cost care.\" (Sears, Roebuck)\n\"At some point, you can't squeeze anymore. We think that [health care] finance is going\nto be driven by taking poor quality out of the process. In the final analysis, that will be\nthe value equation: doing it right the first time.\" (Allied Signal)\n\"We're not just driven by philosophy, we're driven by economics. We think that\nthis\nimproved quality inherently costs less. Improve the quality of health care and, in turn,\nimprove the quality of life.\" (GTE Corporation)\n\"Why do we care about improving health status [of employees] as a core strategy?\nThere's a business case for it. By creating enthusiastic employees, we'll build better\nproducts and services and create enthusiastic customers, which in turn will result in\nenthusiastic stockholders.\" (General Motors)\n&\nThough many of these efforts to improve health care quality are on the leading edge, the results\nindicate that quality health care not only can save lives, but can sometimes save costs as well.\nsmt\nLinch\nApart from the savings that come from negotiated discounts, business coalitions and others have\nrealized savings from improving care, avoiding unnecessary procedures, and bringing greater\nefficiency to health care delivery.\nquaber\nthat\nworks\n15\nDRAFT-PLEASE DO NOT CIRCULATE\nWorking with local hospitals, the Chicago Business Group on Health spurred the\ndevelopment of critical pathways for coronary artery bypass graft. This intervention\nsignificantly decreased the hospital length of stay for this procedure and removed delays\nthat resulted from the poor coordination of hospital services (Meyer, et al., 1996)\nAcross a range of health care services, the Business Health Care Alliance of Appleton,\nWisconsin reported successes in increasing preventive screening, boosting immunization\nrates, decreasing asthma readmission rates, and dropping Cesarean sections from 21.3 to\n13.7% in just two years (Meyer, et al., 1996).\nOne Peer Review Organization found that an education program for providers and\npatients in five hospitals based on the AHCPR-sponsored guideline for the diagnosis and\ntreatment of benign prostatic hyperplasia led to a 75% reduction in surgery and $1.3\nmillion in cost savings for Medicare (AHCPR, 1995).\nAs the following examples suggest, the potential savings may be substantially greater (AHCPR,\n1995).\nAHCPR-sponsored research suggests that providing anticoagulation therapy to prevent\nstrokes among patients over 65 with atrial fibrillation could save $660 million per year.\nIf this treatment were provided to only 20% of the eligible cases, $132 million in cost\nsavings would result.\nagain\nAppropriate eye-screening for diabetics in government programs saves up to $247.9\nmillion at a 60% screening rate.\nAHCPR research published in the New England Journal of Medicine reports that\n\"ensuring optimal antibiotic treatment\" could translate to savings of $113 million if\ntwo\none\napplied to all surgical patients.\nIf applied to only 20% of eligible patients, appropriate treatment of the opportunistic\ninfection Pneumocystis carinii among AIDS patients could lead to $48.8 million in\nXnd\nannual savings.\nThis is not to say that all quality improvement efforts reap savings. However, some initiatives to\nimprove health care quality can carry the promise of a return on investment. In July 1997, the\ntall\nwore\nWashington Business Group on Health established a Task Force on Health & Productivity\nManagement to \"identify and promote health care purchasing and human resource management\npractices that optimize workforce health and performance and demonstrate human capital\ninvestment value.\" What are the tools and measures that demonstrate the value of these health\ninvestments? That is one of the questions that the Washington Business Group on Health plans\nto begin to answer at a national conference in June of this year.\nFrom Quality Measure to Quality Care\nThe many examples of public and private sector initiatives provide a snapshot of our nation's\n16\n05/21/96 17:41\nDRAFT-PLEASE DO NOT CIRCULATE\nefforts to improve quality. However, two examples-the story of beta-blockers for heart attack\nvictims and the story of childhood immunizations-might offer a better picture of the potential of\nmoving from quality measures to quality care.\nBeta-blockers to save heart attack patients\nRandomized clinical trials have provided definitive evidence that the use of beta-blocker therapy\nafter a heart attack saves lives. Over the past two decades, these trials, including the ß-Blocker\nHeart Attack Trial, have involved more than 35,000 heart attack survivors. As a result of this\nwork, this treatment has become known as \"one of the most scientifically substantiated, cost-\neffective preventive medical services\" (Soumerai, et al., 1997). Organizations such as the\nAmerican College of Cardiology and the American Hospital Association have integrated\nrecommendations for the use of beta-blockers into their guidelines (Ryan, et al., 1996).\nDespite the demonstrable clinical benefit, beta-blockers remain underused in clinical practice. In\na study of Medicare beneficiaries in New Jersey, investigators found that only 21% of eligible\npatients received the therapy (Soumerai, et al., 1997). Patients were actually three times more\nlikely to receive a calcium channel blocker, a medication of questionable efficacy for post-AMI\npatients. In this study, the mortality rate for patients using beta blockers was 43% less than those\nnot using the medication. The use of such interventions could prevent an estimated 18,000\ndeaths each year (Chassin, 1997).\nBased on the strength of this evidence, the National Committee for Quality Assurance also\nincluded a measure for \"Beta Blocker Treatment After a Heart Attack\" into HEDIS 3.0, and the\nHealth Care Financing Administration (HCFA) will require health plans under Medicare to\nreport on this measure in 1998. Once this practice became the focus of a quality measure,\nvarious approaches to improve the care of these patients ensued.\nUnder the Cooperative Cardiovascular Project, HCFA organized the development of quality\nindicators for the treatment of patients with a heart attack. Four Peer Review Organizations\n(PROs)-Alabama, Connecticut, Iowa, and Wisconsin-refined and used the indicators to monitor\nbeta-blocker use after a heart attack in Medicare patients. The PROs provided this feedback to\nall practitioners in their states. The result was that beta blocker prescriptions climbed from\n31.8% to 49.7% during the follow-up period. Another study used local medical opinion leaders\nto influence the prescription rates of beta blockers and aspirin (Soumerai, et al., 1998). When\nlocal medical opinion leaders supplemented educational outreach programs, the prescription rate\nfor beta blockers increased 63%.\nConclusion\nQuality measures serve as an important driver for improving the quality of health care. They\n17\nDRAFT-PLEASE DO NOT CIRCULATE\noffer information for marketplace purchasing, give feedback for improving practice, and change\nthe way employers evaluate and provide health plan options to their employees. The leading\nedge work in the public and private sector reveals the potential to be gained by narrowing the gap\nbetween actual and best practices. The best practices of a few have the promise of becoming the\nbenchmark for the many.\nAs examples of these leading edge efforts reveal, success demands the involvement of a broad\nrange of stakeholders from employers and consumers to providers and health plans. Coordinated\nefforts in quality measurement and reporting can build upon and multiply the gains realized so\nfar. Both the public and private sectors have important roles to play. Research to fill the gaps in\nmeasures, model value-based purchasing efforts, tools for continuous quality improvement-tlese\nsteps will require stakeholders across the health care system to do their part. In recent months,\nemployers and business groups have come together under the umbrella of the Employer Quality\nPartnership. and three health care quality oversight organizations-AMAP, JCAHO and\nNCQA-have announced their intentions to collaborate on performance measurement activities.\nSimilarly, the President established the Quality Interagency Coordination Task Force to bring\nFederal agencies together. With this momentum in both public and private sectors, there can be\nno clearer signal that the time is right to seek greater system-wide coordination of quality\nmeasurement and reporting.\ninclude why\nis existing you energh system\n18\n10/21/00\nDRAFT-PLEASE DO NOT CIRCULATE\nReferences\nAFL-CIO. Union Guide to Quality Managed Care, 1997.\nAgency for Health Care Policy and Research. Better Quality Can Cost Less: The Evolving Role\nof AHCPR: Interim Report to the National Advisory Council, September 1995.\nAgency for Health Care Policy and Research and Kaiser Family Foundation. Americans as\nHealth Care Consumers: The Role of Quality Information. A National Survey. October 1996.\nAgency for Health Care Policy and Research. http://www.ahcpr.gov.\nAmerican Medical Association, http://www.ama-assn.org/med-sci/amapsite/qa/qa.htm 1998..\nBodenheimer T, Sullivan K. How large employers are shaping the health care marketplace?\nNew England Journal of Medicine 1998; 338(14): 1003-1007.\nBrink S, Shute N. \"Are HMOs the right prescription?\" U.S. News and World Report, October\n13, 1997, PP. 60-78.\nThe Business Roundtable. Quality Health Care is Good Business: A Survey of Health Care\nQuality Initiatives by Members of the Business Roundtable, September 1997.\nCenters for Disease Control. Mammography and clinical breast examinations for women aged\n50 years and older-behavioral risk factor surveillance system, 1992. Mcrbidity and Mortality\nWeekly Reports 1993; 42: 737-741.\nChassin MR. Assessing strategies for quality improvement. 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The State of Managed Care Quality. Washington,\nDC: NCQA, 1997.\nNational Committee for Quality Assurance. http://www.ncqa.org/hedis/nqip.htm. 1998.\nNew Jersey Department of Health and Senior Services. New Jersey HMOs: Performance Report.\nhttp://www.state.nj.us/health/hmo/report.htm, 1997.\nNew Jersey Department of Health and Senior Services. Coronary Artery Bypass Graft Surgery\nin New Jersey 1994-1995. http://www.state.nj.us/health/hcsa/cabgs.htm 1998.\nO'Connor G, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital\nmortality associated with coronary artery bypass graft surgery. JAMA 1996; 275(11): 841-846.\nPage US, Washburn T. Using tracking data to find complications that physicians miss: the case\nof renal failure in cardiac surgery. Journal of Quality Improvement 1997; 23(10): 511-520.\nRyan, et al. Management of acute myocardial infarction. Journal of the American College of\nCardiology 1996; 28(5): 1397-98.\nSchulman K, Rubenstein LE, Seils D, Harris M, Hadley J, Escarce JJ. Quality Assessment in\nContracting for Tertiary Care Services by HMOs: a case study of three markets. Journal of\nQuality Improvement 1997; 23(2): 117-127.\nSoumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse Outcomes of Underuse of ß-\nBlockers in Elderly Survivors of Acute Myocardial Infarction. JAMA 1997; 277(2): 115-121.\nSoumerai SB, McLaughlin TJ, Gurwitz JH, et al. Effect of local medical opinion leaders on\nquality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998;\n279(17): 1358-1363.\nSpragins E. \"How to Choose an HMO.\" Newsweek, December 15, 1997, pp. 72-81.\nWagner EH, Barrett P, Barry MJ, Barlow W, Fowler FJ. The effect of a shared decision making\nprogram on rates of surgery for benign prostatic hyperplasia: pilot results. Medical Care 1995;\n33(8): 765-770.\n21\n05/21/98 17:42\nDRAFT-PLEASE DO NOT CIRCULATE\nWare J. \"The SF-36 Survey.\" http://www.sf-36.com/general/sf36.html.\nWilbur DC. False negatives in focused rescreening of Papanicolaou smears: how frequently are\n'abnormal' cells detected in retrospective review of smears preceding cancer or high-grade\nintraepithelial neoplasia? Arch Path and Lab Med 1997; 121: 273-276.\n22\nJun-08-98 01:31P James Tallon\n212 494 0830\nP.01\nFile: Forum Ntbk\nUnited\nHospital Fund\nEmpire State Building\nFAX COVER PAGE\n350 Fifth Avenue, 23rd Floor\nNew York. NY 10018\nTo: Sarah Bianchi 202 456-5585\nFrom: Tracy Miller 212 494-0767\nFax Number: 202 456-5557\nCompany: UNITED HOSPITAL FUND\nDate: 6/8/98\nTotal Pages: 2\nFor Information Call: (212) 494-0722\nSubject: Addresses\nFax Number: (212) 494-0830\nNotes:\nAttached is a list of names, addresses, telephone and fax numbers for the foundation heads of\nthe foundations that will be funding the planning process. With the exception of Jim Knickman,\na Vice President at the Robert Wood Johnson Foundation, these names may already be on the\ninvitation list because I passed them on to Nancy Foster. (Please note an area code change for\nDrew Altman. The new area code is 650.)\nWe would appreciate your sending the three foundation presidents a letter of invitation to the\nJune 17 event, indicating they are welcome to bring key staff members to the event. It would\nalso be helpful if Jim Knickman received a fax of the letter sent to Steven Schroeder.\nAs I mentioned over the telephone, Commonwealth (but not Kaiser or RWJ) has confirmed the\nfunding commitment. Jim Tallon will follow up with Steve Schroeder and Drew Altman, seeking\nresolution of their commitment before the 17th so that the foundation support can be\nannounced.\nAs I mentioned in my phone message, Jim Tallon would like confirmation that Chris has no\nproblem with Jim's redrafting of the third paragraph of the letter that will be sent from the Vice\nPresident. I will be leaving the office at 2:30 pm and would appreciate your calling David Gould\n(212 494-0740), Senior Vice President for Program at United Hospital Fund, to confirm the\nchanges - if you do not have a chance to call me before I leave.\nI look forward to working with you on the planning committee process.\nJun-08-98 01:31P James Tallon\n212 494 0830\nP.02\nKaren Davis, Ph.D.\nPresident\nhe Commonwealth Fund\narkness House\nOne East 75th Street\nNew York, New York 10021\nTel: 212 606-3825\nFax: 212 606-3876\nDrew Altman, Ph.D.\nPresident\nThe Henry J. Kaiser Family Foundation\nQuadrus\n2400 Sand Hill Road\nMenlo Park, California 94025\nTel: 650 854-9400\nFax: 650 854-4800\nSteven A. Schroeder, MD\nPresident\nThe Robert Wood Johnson Foundation\nPO Box 2316\nPrinceton, New Jersey 08540 Tel: 609 452-8701\nFax: 609 243-5894\names R. Knickman, Ph.D.\nVice President for Research and Evaluation\nThe Robert Wood Johnson Foundation\nPO Box 2316\nPrinceton, New Jersey 08540 Tel: 609 452-8701 Fax: 609 987-8746"
}