Online Performance Appendix: Performance Detail, Value

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, AHRQ will continue to support the Value Portfolio through four interrelated activities:

• Measures, Data, and Tools for Transparency. 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 CAHPS®, Quality Indicators, National Healthcare Quality and Disparities Reports, Culture of Safety measures, the Healthcare Cost and Utilization Project, and the Medical Expenditure Panel Survey.

  A major priority of the Value initiative is development and expansion of measures, data, and tools to support 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. CMS also began to report data from AHRQ's Hospital CAHPS measure. 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. By the end of FY 2008, 15 States had public report cards on health care quality, more than double the number anticipated.

  Most of the States doing public reporting are also opting to use AHRQ measures. By summer of 2009, 15 States, covering more than half the U.S. population, will be publicly reporting on hospital quality using AHRQ's Quality Indicators. 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 began beta-testing a new tool—My Own Network AHRQ (MonAHRQ) that gives States, communities, and others the software they need to build their own Web sites for public reporting and quality improvement.

  Another major effort of the Value Portfolio in 2009 has been development of a plan to synchronize and improve the information available for health care reform. The goal is to bring together and improve information from across the Agency and outside the Agency. In spring of 2009 we held an expert meeting on Data for Health Care Reform designed to identify major data needs, data gaps, and strategies for filling these needs. In 2010, we will continue to build and refine measures of quality and efficiency, and produce data and tools to track, report, and improve value and efficiency. A major push for 2010 will be developing further synergies among AHRQ's measurement and data efforts particularly as they relate to health care reform.

• Evidence to support reporting, payment, and improvement strategies. A second component of the Value-Driven Healthcare Initiative is to provide evidence on when and how public reporting strategies are most likely to work, what payment strategies and community approaches are most likely to improve value, 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 tools, 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 achieving 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. 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. This is supported by key output measure #1.3.31.

• 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.

    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.

  • Community-Based Networks: AHRQ's partnership with a set of 24 regional health improvement collaboratives (RHICs—formerly known as Chartered Value Exchanges) provide a vehicle for community-wide improvement. It takes research findings on public reporting, payment, waste reduction, and quality improvement and implements them across communities and entire States. The regional health improvement collaboratives are regional and State collaboratives, which consist of representatives of at least four stakeholder groups (public and private purchasers, providers, health plans, and consumers) and, in some cases, State data organizations, Quality Improvement Organizations, and health information exchanges. These organizations work in tandem to improve community-wide quality and value, through public reporting, payment incentives, and quality improvement initiatives.

    AHRQ began chartering regional health improvement collaboratives in 2008, and currently 24 communities are chartered (Chartered Value Exchanges). Although AHRQ originally expected the regional health improvement collaboratives to represent 300,000 people by the end of 2008, they currently represent more than one-third of the U.S. population (124 million people) and include over 450 health care leaders. This is primarily because the regional health improvement collaboratives themselves are large, in most cases covering entire States.

    Given the broad areas and populations represented by the 24 regional health improvement collaboratives, we plan to focus on meeting the needs of these existing collaboratives through 2010 rather than competing 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 regional health improvement collaboratives access to organized peer learning, Webinars, one-on-one consulting, and other support by top researchers and consultants.

• Coordination Forum for Public Payers: The Federal Government is the largest purchaser of health care, and therefore value-driven health care cannot succeed without the active collaboration of Federal payers in this effort. In FY 2008, AHRQ established a forum to facilitate coordination across public payers and this work will continue.

In 2010, We Propose to Retire the Following 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.

1.3.29: Increase the number of States or communities reporting market-level hospital cost data.

Reason for Retirement: The original target was for 4 States, but we have already reached the maximum target of 16 States producing cost-level data.

1.3.30: Increase the number of communities or States with public report cards.

Reason for Retirement: This measure should be replaced with one that reflects our work with greater precision—rather than measure the number of States/communities with public report cards, we will measure the number of AHRQ measures and tools used in public report cards.

We plan to replace these retired measures with measures that reflect the work we're planning for 2010—to build and refine measures of quality and efficiency and produce data and tools to track, report, and improve value and efficiency; to build the evidence base for value and efficiency and produce new evidence-based reports and tools; and to disseminate measures, products, and tools to key stakeholders who can use them to improve value.

Long-Term Objective 1: Consumers and patients are served by health care organizations that reduce unnecessary costs (waste) while maintaining or improving quality.

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