Margie Shofer: As we mentioned earlier, there are two ways you can ask questions right now. You can submit a question any time to this Web conference by typing your inquiry into the Q&A box located on the right-hand toolbar of your screen beneath the participant list, or if you have a phone icon next to your name, and I saw that most of you do, you can click on the "Raise hand" button located at the bottom box containing the participants' list. Again, we would love to hear your voice, so we really encourage you to ask verbal questions. It's also a lot easier for us to clarify any questions you have if you ask it verbally. But we had a few questions submitted beforehand, so I'm going to ask those.
We have a question saying, "We are particularly interested in developing quantifiable and measurable quality metrics that can be made available to consumers in the insurance exchange. Has there been any thought dedicated to this topic by AHRQ?"
Ernest Moy: I think I can start to address that one, Margie. The quickest answer is that I think we actually have thought about this a great deal at AHRQ. There's a recognition, certainly, that there is a big difference between the kinds of measures that are good for reporting at geographic units, such as the Nation and States, and those kinds of measures that are good for public reporting and assigning accountability to specific kinds of providers. Many of the databases that we use in the production of the Quality Report and the State Snapshots are used by others like CMS to produce report cards for different kinds of providers. There are other measures that we track in the Quality Report and the State Snapshots that would not be appropriate for holding individual providers accountable.
So we had a lot of thoughts about it. If the question is do we have like a quick list that you could use for public reporting or States yet, the answer is, no, we haven't generated that. We've simply identified some of the criteria that might be used to differentiate what is good for geographic reporting, and then that subset of those overall measures that would be good for doing public reporting at the provider level.
Margie Shofer: Thank you. Another question we got ahead of time was, "On a State that receives a strong rating for health performance measures, is it noted, if Federal and State resources made the difference, for example, Federal grants and State expenditures that target specific health issues?"
Ernest Moy: Again, I think I can answer that question. We do not provide any interpretation toward performance, and we leave that up to the States, so if States want to interpret it in such a way, they can feel free to do so. But we didn't want to put any words in the mouths of anybody or try to interpret this. We think that the States are closer to the actual development. They actually care, then, what goes into these different metrics and are in a better position to make explanations for what's going on in their locality.
Margie Shofer: Okay.
Rosanna Coffey: Ernest, this is Rosanna. I think to help the States think about that, they could look at the contextual measures that we put together in the State Snapshots. On that Web page, you will find things that show where your State sits compared to other States in terms of percentage of the population in poverty. That seems to be strongly related to how the State fares in terms of quality of care. Also, there are some things on that page in terms of the resources, or maybe I should say specialty physicians per thousand population and number of admissions per thousand population. But to answer that question directly, we did not actually include State expenditures on there. I think it's a very interesting suggestion.
Margie Shofer: I have another question. "There is now substantial history of the State Snapshots, which has been around in some form since 2004. What's your experience with the extent of use of the Web site, and how might it have been used?"
Ernest Moy: I think the State Snapshots is hugely viewed. The Quality Report and the Disparities Report sites get a couple million hits every year, and about half of them actually are for the State Snapshots. We think in terms of people viewing it, the numbers are very large. I think part of that question, though, is also how the State Snapshots are being used in practice, and I think we're going to hear an example of that later. We've heard a lot of different stories of people finding different uses for the State Snapshots. In addition, we're always open to suggestions from conversations like hopefully we'll have today about how to make the State Snapshots better and more usable for specific uses that States might have.
Margie Shofer: I have another question. "Can users define State-to-State comparisons?"
Ernest Moy: Yes and no, how's that? If you're willing to put in the little bit of work to go look at the summary tables so you can make comparisons against the best performing States, under the best performing States' views you can see all the States. If there are particular States you want to compare against, you can see on that view how they're doing compared to yourself. If you mean like a customizable side-by-side view that lets you compare to some other State in the Nation that you chose for all the different metrics, we don't have that built in at this time, although it is one of the things that we're thinking about developing.
Margie Shofer: I'm going to have one more question and then we're going to move on. "What if I was interested in setting priorities for my State, how would I go about doing that?"
Ernest Moy: I'll make a couple of assumptions. First, when we hear from users of this particular product, they usually want to talk to us about areas that they're not doing well in. I'll make that assumption that you're interested in those areas that you're not doing well. I think in the very high-level dashboard, you can just scroll down across all those rainbow displays and see those areas where the performance of your State looks like it's not quite as good as that in other States.
I think you need to drill down a little farther than that. I think you then pull up the actual table and when you look at those tables and examine the different measures where you're doing better or worse than other States, that might give you some insight about what particular issues might be happening in your State. For instance, if you know that there's a clustering, which we commonly see, of preventive care measures where you're doing worse, when you see a clustering in the preventive care measures in the State, say, for instance, in influenza vaccine, then that might be a logical place for a State to then target additional resources to try to bring their rate up.
Margie Shofer: Thanks, Ernie. I think it's time for our next presentation, so I am going to hand this over to Judith Nugent.
Judith Nugent: The goal of our project was to look at enterprise flow for the entire department's accountability. Under that, we got together and we asked, Are we making a difference, have we identified the problem correctly, and are we having the impact that we intend to do, and how can we improve our services, and are we making the best use of the resources entrusted to us?
We looked at what those tools for accountability might be and broke them into three parts: performance measures, project management, and quality improvement initiatives. We looked at the key criteria for selecting performance measures, and we needed to have them align with our mission and our goals. We needed to have them related to the Governor's priorities and the national initiatives and priorities. They needed to be outcome oriented. They needed to be supported by national comparative data. And they needed to be tied to core public expectations of government.
In the process, we chose 20 high-level performance measures. We organized those into three categories of measures affecting multiple agencies within our department. We looked at health care access and quality. We looked at the underlying factors of health and health outcomes, and we needed to have each measure focus on a single overarching condition; for example, diabetes.
We decided to use the AHRQ State Snapshots, and of them, we looked at the State-level measure of diabetes-related hospital admissions among adults age 18 and over. We used that as our benchmark for preventing diabetes-related hospitalization. We looked at the composite State-level measure of health care quality to determine the overall quality of health care in Wisconsin, and we determined that we would do an annual review of other available Wisconsin snapshot measures to see if there would be any that would be useful for this project.
For health care access and accountability, we looked at diabetes management, meaning we needed to reduce the rate of preventable hospitalizations due to diabetes. The overall quality of health care in Wisconsin would be the equivalent of continuing to rank well in the Agency for Healthcare Research and Quality composite State-level measure of health care quality.
We went back through the years of the State Snapshots and we pulled together into this graphic, from 2002 through the 2006 data, and we looked at how Wisconsin was doing across the period, both against the Midwest and against the national statistics. We found this to be very powerful and it helped us to determine how we would use these measures. We determined we would use them for budget discussions and priority setting within each of the programs, in this case the diabetes program. We would use it for IT planning so that we could ensure the capacity to measure the desired outcomes we were looking for. We would use it for communication, both internally and externally, and for program coordination, because this program, especially diabetes, will cross several various bureaus.
Our goals for this effort—we had many, many meetings to work on these—were to prevent the injury, illness, and spread of disease, to create a healthy environment and protect against environmental hazards, to promote and engage healthy behaviors in mental health, to respond to disasters and assist communities in recovery, and to promote accessible high-quality health services. We meet on an annual basis—and our meetings have just started this past week—to look at the State and national data on the State Snapshots and to reevaluate and reconsider which methods we're going to use. So we think that it's marvelous. We love the fact that we can go back through the years, take a look at what we've done, and then in a given year now, we can drill down and take a look at specifics. I am open to any questions.
Margie Shofer: Thanks, Judith. Okay, everyone, we have our second and final Q&A period, and as I think you know, there are two ways you can ask questions. You can submit a question at any time by typing your inquiry into the Q&A box, or you can click the "Raise hand" button located on the bottom box containing the participants' list. Again, we'd love to hear your voice, so I encourage you to raise your hands.
Judith, I do have a question for you. Why did Wisconsin use the State Snapshots for performance measures since the data is a little older than probably what you could get internally?
Judith Nugent: That question came up, Margie, and my response was, yes, we have more recent data, but unless we use the State Snapshots, we don't have the comparative data to our region and certainly our legislators always want to know what's going on in our region, as well as to the national comparative information. So for us this is invaluable.
Margie Shofer: In general, what has the response been to your using them, if you could get a little bit more specific?
Judith Nugent: Sure. As I said, there is a real interest in making sure that we stay at the top in terms of overall quality that we either are first or second. We've become somewhat competitive, and we take a look at the States within our region to see how we have compared to them. This year, nationally on overall quality we're second, and that will be noted by legislators when they're in their home districts and visiting hospitals, et cetera. They use it a lot.
In terms of internally, some of our other customers are advocacy groups for the various chronic diseases. Because we have highlighted diabetes, the advocacy groups also want to look at it and see how we're doing, see how we compare regionally and at the national level. It's used a lot, interestingly enough. Often, when we go to some sort of an advocacy group meeting, they will point out the fact that we're doing well compared to the region, but we can improve in this area or that area so the drill-downs are really good.
Margie Shofer: Do you have any advice for States that are maybe new to the State Snapshots? You know, how do I get started?
Judith Nugent: I think one of the most useful things is to stay, first, at the very high level in terms of the overall quality measurements and take a look at previous years. Go back to the beginning and take a look at how you've done. Then once you have the big picture, then you can start drilling down in those areas that your Governor has highlighted or your secretary of your department has highlighted as an important issue, and then start digging in to the data. It's great. It's so rich.
Margie Shofer: Well, thank you, Judith. I have a question for Ernie or Rosanna. You mentioned that one of the new features is the link to the Health Care Innovations Exchange, and I was wondering if you could provide a little bit more detail about how you might use that for a quality improvement initiative.
Ernest Moy: As I mentioned, the notion here was that all this reporting is good for problem identification and prioritization, but we don't have information in the State Snapshots product itself about what you can actually do about that. We have a separate product here at AHRQ, called the Innovations Exchange, which kindly has summarized lots of different kinds of things that might be useful to quality-improvement people. There are actually three pieces of the Innovations Exchange. There are the success stories. There are the lack of success stories, I guess, and then there are actually a series of tools. If you actually click on one of our Innovations Exchange links, it will take you over to Innovations Exchange and show you three different kinds of groupings.
There are a couple of links that we built in. You can link over based upon clinical condition, and then you can also link over based upon your State and find out what else is going on in the area of quality improvement in your State.
Margie Shofer: Thanks, Ernie. I have another question. "Don't comparisons to the Nation show us how a State is doing compared to the average for the country, and shouldn't we be striving to be better than that?"
Ernest Moy: Yeah, that's why we have the special comparison with the best performing States, and that lets you see who is at the top, how they're doing, and then how you stack up against them. I think that really is the most appropriate benchmark, the one that really gets most of us to try to stretch and to do better than we're doing. We do let people compare it to the average, especially if they're below average, but the best performing, we think is probably the ideal benchmark.
Margie Shofer: I'm going to call on the audience for a moment, and I'm just wondering if anybody in the audience has used the State Snapshots and wants to share their experience with that. If you're in the audience, and we'd love to hear from you, and I'm sure everyone else would too, if you want to raise your hand, we can unmute your line, and I can give folks a couple seconds for that. I could assume that either no one is using them or people are feeling shy. I see that Foster Gesten has raised his hand.
Foster Gesten: First, I just want to congratulate you guys. I've watched the State Snapshots evolve over the past number of years, and it's really impressive. Some of the changes over the past 2 years and sort of adding information on income and race and ethnicity have been particularly important to us in New York in terms of being able to make those kinds of comparisons, which, frankly, don't really exist anywhere else. Both in terms of the simplicity of if you're just a color person or like to look at dials, or whether you're a numbers person and want to dig into the actual numbers, some very nice balance of features, and I just can't thank you enough for putting this together. I think this is the reason this is one of the sites that gets lots of hits. I think it's valuable information, much closer to where the action is at the State level versus the Federal level for quality measurement and improvement.
So your question was about specific uses of it, and a little bit about that, but I also had some questions for you all, which was, can you talk a little bit about the data sources specifically related to insurance status and race/ethnicity, since those are two of the ones that are newest, and around which there has often been lots of questions and controversy around the veracity of those fields. I'd appreciate just a word or two about the source of those and how you see them in terms of their accuracy.
Ernest Moy: I'll start, and then maybe Rosanna and Marguerite, you might have some additional comments to make as well. The information that's currently included in the disparities and the payer sections come from State administrative databases. This is hospital data, and there are many nuances, obviously, with the interpretation of race, ethnicity, and payer across the different States. I do think this comes from our HCUP database, which has attempted to standardize, at least across those different categories. In general we've been relatively conservative in terms of when we'll make a call. A lot of times you'll see that insufficient information is available being reported instead of making some kind of arrow saying you're better or worse or whatever, when the information is limited in terms of the number of different measures that we have data on.
One of the things we're thinking, we actually get this kind of information from other sources as well. One of the potential bills we have is trying to add in other sources of information that could help flesh out these two sections and not be so heavily dependent on these hospital claims.
Rosanna Coffey: On the race/ethnicity data that comes out of HCUP, we do some careful screening of those data. When we see a huge number of other or a huge number of a particular race, like American Indian, and we don't think that there are a lot of them in a particular State, we will actually drop those because we're worried about the quality of it. You're right, Foster, we do worry about that, and we look at the data and think about it, and sometimes we actually drop some things for that.
On the uninsured side, HCUP is wonderful because it's one of the few places where you can get a picture of the uninsured population. I think that's a real strength in that sense. Of course, the payers that we're looking at, private, Medicare, Medicaid, and other, I think it's pretty obvious when you go to the hospital, certainly when you're a Medicare patient, they know that. Maybe in some States the Medicaid and private gets blurred some because, particularly with Medicaid managed care, there may be a question about it doesn't really identify the recipient of the Medicaid patient. You're right, those are always concerns, and you do the best you can with the data, and hopefully over time, it gets improved just because people are now looking at it and paying attention to it.
Foster Gesten: Thanks. That's helpful. I'm getting closer to Margie's question. So my perception of some of the utility of this and ways in which we used it previously and can imagine particularly in this year wanting to use it for us is as in many States trying to pick among priorities and conditions in areas to work on with rapidly limited and finite resources and major budget problems is a real test. But it's sort of what we have to do and at the State level we have to make these decisions about where these limited investments happen.
In our experience previously, I can see being able to look at the State Snapshots and being able to understand where we are relative to other States or where we are relative to the Nation is really helpful to us in being able to highlight which areas we have major concerns with. Some of them are never surprises, but it's helpful to have it reinforced. The other part is the feature of this that sends the right message, which is trying to monetize and describe the types of savings that are potentially achievable with improvements in quality, which, for folks in finance and tight budget years and in the legislature, trying to prioritize and better understand the impact of these, it's very helpful to us to be able to use that as a mix to prioritize in our budget and legislative items.
So those are two of the other specific uses that I see being able to do this, and with some of the increased utility of this, I think it becomes easier to make use of it in that way.
Margie Shofer: Thanks, Foster. I'd be curious to see what you think of now the fact that you can break it out by Medicaid. I know that was something that folks were asking for that we were able to do with this year's version. I will be curious to hear what you think about that. I see that Mary McIntyre has her hand raised.
Mary McIntyre: Hi, this is Mary. I first wanted to say thank you for this and especially for Judith's discussion that she gave as far as some concrete examples. We are just starting to use the data, and we are actually working with a group that's basically multistakeholders made up of a major private insurer in this State, our State health department, and some others like the State Employees Insurance Board. What we are trying to do is to determine and get what we call an overall idea of where we stand, and we know it's not good. But, we want to put the picture together so that at least the group as a whole has an understanding of where we are. So we've been working through this.
We just really formed the group the beginning of last year, and so we've actually had to go through the whole process of getting admission and determining what it was that we wanted to do from the standpoint of the State and where are our priorities. We're just really going to determine what our priorities would be when it came down so that when it comes down specifically in looking at those areas for quality improvement. We're getting there. What Judith said is very helpful for letting us know that we really need to start at the bigger picture first before we start trying to drill down into specifics, and that's pretty much all I wanted to say. Thank you.
Margie Shofer: Thanks, Mary. We look forward to keeping up with your progress.
We are coming to a close to our Web conference. I want to thank you all for your thoughtful questions and your participation. We hope this discussion was helpful to you. If you have questions about technical assistance opportunities, please do not hesitate to submit them to the quality tools E-mail address, which is listed on this slide. If you have any questions or comments about the tool, please send an E-mail to the same address, and as you can see, we have also provided a link to the 2009 State Snapshots on here that you will probably want to place in your Web browsers.
Thanks again for joining us, and this concludes the Web conference today. We look forward to hearing from you. Thank you everyone.
Return to Contents
Current as of December 2010
Overview of State Snapshots: Webinar Transcript. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/kt/webinars/snapshotstrans.htm