Online Performance Appendix: Performance Detail, Value

Budget Estimates for Appropriations Committees, Fiscal Year 2011

This appendix provides more detailed performance information for all HHS measures related to the Agency for Healthcare Research and Quality's budget.

The cost of health care has been growing at an unsustainable rate, even as quality and safety challenges continue. Finding a way to achieve greater value in health care—reducing unnecessary costs and waste while maintaining or improving quality—is a critical national need. AHRQ's Value portfolio aims to meet this need by producing the measures, data, tools, evidence and strategies that health care organizations, systems, insurers, purchasers, and policymakers need to improve the value and affordability of health care. The aim is to create a high-value system, in which providers produce greater value, consumers and payers choose value, and the payment system rewards value. In 2010 and 2011, AHRQ will continue to support the Value portfolio through three interrelated activities:

  • Evidence and data to support reporting, payment, and improvement strategies. The Value Portfolio provides evidence to guide policy-makers and other decision-makers who are seeking to improve value through changes in legislation, payment, insurance and benefits policy, and public reporting, and to support provider efforts to increase the quality and efficiency of the delivery system. Evidence is needed on which payment strategies and community approaches are most likely to improve value, when and how public reporting strategies will work, what insurance expansions will increase access and at what cost, how consumers and patients react to financial and other incentives, what factors enable communities to improve health and efficiency of the local health care market and delivery system, and what redesign initiatives are likely to reduce waste.

    Through this activity, in 2008 we were able to provide policymakers, system leaders, and regional health improvement collaboratives with 13 new reports, and evaluations (more than double the number anticipated) on topics such as provider incentives, consumer incentives, measuring efficiency, consumer-friendly public reporting templates, ways to identify populations with high numbers of potentially preventable hospital admissions, strategies for reducing waste, etc. This material provided the core curriculum for various Learning Networks and achieved wide visibility across the country with employers, providers, consumers, and others seeking major improvements in value. In 2009, we added another 8, bringing our cumulative total to 21, exceeding our target of 18. A few examples include 1) an evidence-based decision guide developed for purchasers, health plans, providers and others who are measuring quality and efficiency of health care, and 2) new research published on the impact of safety events on costly hospital readmissions—calling for health plans to improve incentives for safety. A priority for 2010 is continuing to build the evidence base for value and efficiency, and we expect at least 10 new tools and reports, including an evidence-based decision guide on public reporting. This is supported by key output measure #1.3.31. In 2011, AHRQ expects this target to increase by an additional 10 evidence-based databases, reports and evaluations on healthcare value.

    A related effort of the Value portfolio in 2009 has been development of a plan to synchronize and improve the data available for health policymakers. The goal is to bring together and improve information from across the agency and outside the agency. In the spring of 2009 we convened a small group of policy-makers, researchers and producers of health care data to begin creation of a strategy to maximize the availability of information and data. The goal was to identify major data needs, data gaps, and strategies for filling these needs. A meeting summary has been posted on the Web (see http://www.ahrq.gov/data/hinfosum.htm).

    We already have begun implementation of several recommendations from this stakeholder meeting: We funded an initiative to begin to extend simulation capacity to provider-based data; began projects to enhance the timeliness of this data; and facilitated state efforts to develop all-claims data that cross sites of care. We also published the first National Emergency Department Database, which provides nationwide data on emergency department visits for all patients including the uninsured. Finally, we enhanced the capacity of MEPS modeling efforts to predict "future state" economic models, projecting health care expenditures and utilization, estimating the impact of changes in financing, coverage, and reimbursement policy, and determining who benefits and who bears the cost of a change in policy.

    In 2010 and 2011, we will continue to produce data and evidence to inform, track, report, and improve value and efficiency, and we will continue to implement strategies to fill the gaps identified. A major push will be developing further synergies among AHRQ's data efforts and continuing development of data and research partnerships across the department and the private sector. We also will continue to conduct, fund and publish research on some of the key policy levers, payer strategies and improvement efforts affecting the cost and value of healthcare: payment, consumer and patient incentives, insurance design, public reporting, and community-based quality improvement initiatives.

  • Measures and tools for policymaking, transparency, and improvement

    Any effort to build value must rest on evidence-based measures and solid, Federal, State and local data on cost and quality. AHRQ has a long history of development and maintenance of measures and data that the Department, private purchasers, States and providers are using for quality reporting and improvement. Examples include the Consumer Assessment of Healthcare Providers and Systems (CAHPS®), Quality Indicators, National Healthcare Quality and Disparities Reports, Culture of Safety measures, the Healthcare Cost and Utilization Project, and the Medical Expenditure Panel Surveys.

    A second major priority of the Value initiative, therefore, is development and expansion of measures and tools to support policy decision-making, public transparency, public reporting, payment initiatives, and quality improvement. We saw several major successes in FY 2008: The National Quality Forum endorsed 41 of our Quality Indicators for public reporting, and CMS selected 9 of these for use in Inpatient Payment. (Quality Indicators are measures of health care quality that make use of readily available hospital inpatient administrative data. These include measures of hospital safety, quality of care inside hospitals and potentially avoidable hospital admissions.) CMS also began to report data from AHRQ's Hospital CAHPS measure. (The Hospital CAHPS is a patient questionnaire used to assess patients' hospital care experience.) The National Healthcare Quality and Disparities Report had an efficiency chapter for the first time, and we published a comprehensive Evidence Review on Efficiency measures. The Evidence studied included peer reviewed economic and health care literature along with information collected through interviews with organizations developing efficiency measures.

    By the end of FY 2009, 17 States had public report cards on health care quality using AHRQ quality measures, more than double the number anticipated, and representing over half the U.S. population. A new Quality Indicators Learning Institute helps these States use the indicators effectively, and provides technical assistance to new States or communities as they plan their public reporting efforts. In 2009 we also did two rounds of beta-testing for a new tool—My Own Network Powered by AHRQ (MONAHRQ) that gives States, communities, and others the software they need to build their own Web sites for public reporting and quality improvement. It includes, for example, a mapping tool designed to identify the prevalence and cost of potentially preventable hospitalizations, by county; and evidence-based reporting templates to facilitate reporting of quality scores in a way consumers can understand.

    In addition, to help states estimate the burden and financial impact of chronic diseases among their Medicaid beneficiaries, a collaboration with CDC, RTI International, the National Association of Chronic Disease Directors, and the National Pharmaceutical Council, led to the development of a Chronic Disease Cost Calculator. The Chronic Disease Cost Calculator is a downloadable tool that supports states in: (1) Estimating state Medicaid expenditures for six chronic diseases—congestive heart failure, heart disease, stroke, hypertension, cancer, and diabetes, and (2) Generating estimates of the costs to Medicaid of selected chronic diseases using customized inputs (e.g., prevalence rates and treatment costs).

    In 2010 and 2011, we will continue to build and refine measures of quality and efficiency, and to develop tools to facilitate their use. This will include the development of hospital readmission measures. MONAHRQ will go live in early FY 2010, and a new Learning Network will help states and communities make maximum use of this new tool. In the meantime, we will be working to expand and improve it to include new measures and new capabilities.

  • Implementation Partnerships. Because the goal of the portfolio is not simply to produce evidence but to facilitate evidence-based improvements in efficiency and value, a central component of the portfolio is working with key stakeholders who are using measures, data and evidence to bring about change. For example:

    • Practice-Based Networks: AHRQ works with practice-based networks to identify and roll out practices to reduce waste and improve quality. One such network is the Accelerating Change and Transformation in Organizations and Communities (ACTION), a network of 15 practice-based consortia that are based in hospitals, nursing homes, home care agencies, and group practices and that have expertise in rapid deployment of proven best practices. In 2008 and 2009, for example, Denver Health's safety net hospital launched a system redesign project based on Lean/Toyota Production Systems where staff were trained to analyze sources of waste, solve problems, and start implementing solutions in just one week. Teams and individuals came up with short-turnaround ideas for improving care and reducing waste, saving over $11 million to date. Another ACTION project to develop and implement novel strategies to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections in hospitals resulted in a new hybrid approach that was implemented in intensive care units (ICUs) in several hospital systems in Indianapolis. A follow-on project will enhance, expand, and spread these implementation approaches to new hospitals and to additional non-ICU hospital units in the previously participating hospitals.

      A second AHRQ initiative supports primary care practice-based research networks (PBRNS). PBRNs are groups of primary care clinicians and practices working together to answer community-based health care questions and translate research findings into practice PBRNs engage primary care clinicians and the communities they serve in both research and quality improvement activities and strive to build an evidence-based culture in primary care practice to improve the health of all Americans. In addition to hosting a national online PBRN resource center, AHRQ maintains master contracts with a group of 10 PBRN consortia to conduct rapid-cycle research. In 2009, PBRNs in Colorado and North Carolina conducted ground breaking work to determine the costs of data collection and reporting related to external quality measurement initiatives. The findings will be published in the Annals of Family Medicine (scheduled for publication in 2010)

      Similarly, an HIV Research Network (HIVRN) has identified and implemented strategies to reduce the number of drug interactions. Through its data collection across 19 sites of HIV patient care, the HIVRN routinely alerts individual sites about patients who were receiving inappropriate combinations of antiretroviral drugs. This has significantly reduced the number of HIV patients receiving inappropriate HIV drug regimens. For example, over a 2-year period, patients receiving a particular inappropriate drug combination (tenofovir and unboosted atazanavir) was reduced by 34 percent within the network of 19 sites.

  • Community-Based Networks: AHRQ's partnership with a set of 24 Community Quality Collaboratives (known as Chartered Value Exchanges) provides a vehicle for community-wide improvement in quality and value. These collaboratives include representatives of four key stakeholder groups (public and private purchasers, providers, health plans, and consumers), and in some cases also include State data organizations, Quality Improvement Organizations, and health information exchanges. They take research findings on public reporting, payment, waste reduction, and quality improvement and implement them across communities and entire States.

    AHRQ began chartering Community Quality Collaboratives in 2008, and currently 24 communities are chartered. AHRQ originally expected the groups to represent 300,000 people by the end of 2008, but they actually represented more than one-third of the U.S. population (124 million people) and include over 450 health care leaders—primarily because the collaboratives themselves are large, in most cases covering entire States.

    Given the broad areas and populations represented by the 24 Community Quality Collaboratives, we plan to focus on meeting the needs of these existing collaboratives through 2010 and 2011 rather than forming new ones. To help us do so, in 2009 AHRQ recompeted a contract for a Learning Network to provide them with technical assistance and new evidence-based tools for quality/efficiency measurement, public reporting, and quality improvement. This Learning Network gives all the Community Quality Collaboratives access to organized peer learning, webinars, one-on-one consulting, and other support by top researchers and consultants.

  • Federal policy-makers and public payers. Federal policy-makers are a critical audience for the Value Portfolio. Particularly at a time when the nation is focused on ways to improve quality and safety, reduce waste, and improve access, there is considerable policy interest in AHRQ analyses, data, measures and tools on the impact of insurance design, payment strategies, consumer financial incentives on costs and expenditures, access and quality. During 2009, the Portfolio published statistical briefs on policy-related issues related to costs, expenditures, shared peer-reviewed articles on critical policy-related findings, and provided substantive assistance to federal policymakers in DHHS, the Office of the Secretary and Congress to inform health initiatives under consideration focused on issues of efficiency and value. The Portfolio also works closely with the Centers for Medicare and Medicaid Services and other sister agencies in their role as purchasers of care. Because the Federal Government is the largest purchaser of health care, major improvements in Value will require the active collaboration of Federal payers. In FY 2008 AHRQ established a forum to facilitate coordination across public payers and this work will continue. AHRQ convened a series of meetings among Federal departments and agencies with health care responsibilities to discuss issues related to payment and quality of care. Currently, AHRQ continues to communicate with Federal partners (e.g., CMS, CDC, DOD, etc.) to harmonize efforts in the areas of payment, quality improvement, and creating incentives for providers and beneficiaries to seek high-value care.

In FY 2011, we will maintain the following measures:

1.3.29: Increase the number of States or communities reporting market-level hospital cost data. This measure was implemented in FY 2008, and the target for FY 2008 was 4 states. However, staff realized that it would be more efficient to work with all 16 states in the 1st year rather than incrementally over several years as originally planned. Further, AHRQ believes 16 states is the maximum number achievable to date, since other states do not appear to be receptive to reporting market-level hospital cost data at present. Therefore, the maximum number achievable (16), was reached in FY 2009. Although the program does not anticipate an increase in the number of States or communities reporting data, total target levels for FY 2010 and FY 2011 will be maintained at 16.

1.3.30: Increase the number of communities or States with public report cards. We only anticipate the total number of public report cards to increase by 1 each year (2010, 2011). Given that the science behind public reporting is so new, communities and States are currently focused on improving their current report cards rather than creating new ones.

1.3.31: Increase the cumulative number of databases, data enhancements, articles, analyses, reports, and evaluations on healthcare value.

In 2010, we plan to retire the following measures and replace them with new measures:

1.3.27: Increase the number of people who are served by community collaboratives that are using evidence-based measures, data, and interventions to increase health care efficiency and quality.
Reason for Retirement: The original target for this measure was 300,000, but by 2008, 124 million was achieved. Since we far exceeded the original target, we plan to now focus on working with the existing 24 Chartered Value Exchanges (CVEs) and the populations they serve.

1.3.28: Increase the # of CVEs
Reason for Retirement: 25 value exchanges were chartered in 2008, and 24 are currently chartered (1 collaborative was de-chartered when it failed to meet the chartering criteria). Given the broad areas and populations represented, we plan to focus on the 24 existing CVEs, to help them in their community-wide and statewide public reporting, payment, and quality improvement efforts, rather than recruit more CVEs. Prior to chartering CVEs, AHRQ was aware of at least 50 "community leaders" that might have the potential to become CVEs. However, some of these community leaders did not qualify to become CVEs since they did not meet the criteria of representation from all 4 stakeholder groups (purchaser, health plan, provider, and consumer). Therefore, we've chartered the maximum number of community quality collaboratives that meet the criteria to become Chartered Value Exchanges.

The new proposed measures are:

1.3.50: Synthesis. Increase the cumulative number of AHRQ measures, tools, upgrades, and syntheses available on healthcare value.

1.3.51: Dissemination. Increase the cumulative number of measures, datasets, tools, articles, analyses, reports, and evaluations on healthcare value that are disseminated. These products will be disseminated by AHRQ and its learning networks.

1.3.53: Increase the cumulative number of AHRQ measures and tools used in national, state, or community public report cards.

1.3.54: Increase the cumulative use of AHRQ articles, analyses, reports, evaluations, measures, datasets, and tools on healthcare value by various stakeholder groups such as purchasers of health care, health plans, providers and consumers. We will measure use through the AHRQ Learning Networks targeting these stakeholders (e.g., Learning Network for Community Quality Collaboratives, MONAHRQ Learning Network, etc.).

Performance Trends: The FY 2009 target for Measure 1.3.31 was 18, but the actual result was 21. The target was exceeded because of articles that were published sooner than we had anticipated. The remaining measures are new and will not have baseline results until 2010.

Long-Term Objective: Consumers and patients are served by health care organizations that reduce unnecessary costs (waste) while maintaining or improving quality.

MeasureFYTargetResult
1.3.29: Increase the total number of States or communities reporting market-level hospital cost data2011 Sep 30, 2011
2010Maintain at 16Sep 30, 2010
20091616
2008416
2007N/AN/A
2006N/AN/A
1.3.30: Increase the total number of communities or States with public report cards201120Dec 30, 2011
201019Dec 30, 2010
20091818
2008515
2007N/AN/A
2006N/AN/A
1.3.31: Increase the cumulative number of databases, data enhancements, articles, analyses, reports, and evaluations on health care value that are disseminated
(Output)
201138Oct 30, 2011
2010N/AOct 31, 2010
20092821
(Target Exceeded)
20081813
(Target Exceeded)
2007N/AN/A
2006N/AN/A

1.3.50: Synthesis Increase the cumulative number of AHRQ measures, tools upgrades, and syntheses available on healthcare value.
(Output)

201146Oct 31, 2011
201041Oct 31, 2010
2009NANA
2008NANA
2007NANA
2006NANA

1.3.51: Dissemination Increase the cumulative number of measures, datasets, tools, articles, analyses, reports, and evaluations on healthcare value that are disseminated.
(Output)

201120Oct 31, 2011
201010Oct 31, 2010
2009NANA
2008NANA
2007 NANA
2006NANA

1.3.53: Increase the cumulative number of AHRQ measures and tools used in national, state, or community public report cards. (Output)

201121Oct 31, 2011
201018Oct 31, 2010
2009NANA
2008NANA
2007NANA
2006NANA

1.3.54: Increase the cumulative use of AHRQ articles, analyses, reports, evaluations, measures, datasets, and tools on healthcare value and strategies. (Output)

201120Oct 31, 2011
201010Oct 31, 2010
2009NANA
2008NANA
2007NANA
2006NANA

 

MeasuresData SourceData Validation
1.3.29AHRQ staff and contractors for Quality Indicators and Chartered Value Exchanges Learning NetworkA yearly review of the posted National State or Community report cards and the number of AHRQ measures they contain, plus the number of report cards that rely upon the use of AHRQ tools such as EQUIPS and the Quality Indicators Learning Institute contractor.
1.3.30AHRQ staff and contractors for Quality Indicators and Chartered Value Exchanges Learning NetworkA yearly review of the posted National State or Community report cards and the number of AHRQ measures they contain, plus the number of report cards that rely upon the use of AHRQ tools such as EQUIPS and the Quality Indicators Learning Institute contractor.
1.3.31AHRQ staff and contractors for Quality Indicators, Chartered Value Exchanges Learning Network, MEPSAnnual review of AHRQ and contractor tracking systems of completed databases, articles, etc. on health care value.
1.3.50AHRQ staff and contractors for QIs, HCUP, MEPSAnnual review of AHRQ and contractor tracking systems of new measures, tools, etc. on health care value.
1.3.51AHRQ staff and AHRQ Learning Network contractorsAnnual review of AHRQ and contractor tracking systems of measures, datasets, etc. disseminated via various mechanisms such as webinars and Web page downloads.
1.3.53AHRQ staff and QI, MONAHRQ, CVE contractorsAnnual review of AHRQ and contractor tracking systems of measures and tools used in public report cards.
1.3.54AHRQ staff and AHRQ Learning Network contractorsAnnual review of AHRQ and contractor tracking systems of use of AHRQ articles, analyses, etc.

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Current as of February 2010
Internet Citation: Online Performance Appendix: Performance Detail, Value: Budget Estimates for Appropriations Committees, Fiscal Year 2011. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/mission/budget/2011/opa5.html