Cindy DiBiasi: And Bruce, we are going to get back to you. Bruce mentioned the media coverage that the Niagara Health Quality Coalition has received. You can find out more in The New York Times, The Buffalo News and Consumer Reports. Additional information can also be obtained by contacting Bruce or by visiting www.myhealthfinder.com.
Now I would like to turn to Vi Naylor who has been patiently standing by here. She is the executive vice president of the Georgia Hospital Association and Vi joins us today to discuss how the Georgia Hospital Association has used and modified AHRQ tools to better understand and improve healthcare service delivery. Vi, tell us about your project.
Vi Naylor: Well, the Partnership for Health and Accountability is a public-private collaborative. It is composed of many voluntary and professional organizations, as well as state entities who have not only an interest but a passion for improving health and quality for the patients that we serve. We are ending our fourth year now. The vision of the partnership is for stakeholders to collaboratively and proactively use data to improve quality, patient safety and health and also to communicate the results across the publics they serve. We provide the community and individuals information in one format that they can use to make better healthcare decisions and policy. We provide the providers information in another feedback methodology so that they can compare themselves to other peer groups and continuously improve the quality of care and safety of the care that they provide to their patients.
Cindy DiBiasi: Which of the AHRQ quality improvement tools did you use for your project?
Vi Naylor: Actually we have used all three of the AHRQ quality indicators. In addition to some other indicators, we have incorporated modifications of the AHRQ inpatient quality indicators into our collaborative approach to resource effectiveness program, otherwise known as The Care Program. That is our web-delivered UB92 or administrative databased hospital performance measurement system. Rather than restricting the volume and mortality indicators to a few of the high-risk conditions, our member actually asked us to have those indicators applied across all discharges so that they can evaluate the full range of services that they provide. We have also had hospitals ask for a module related to high-risk patient safety indicators. As we speak, we are now incorporating patient safety indicators into The Care Program.
What I am going to talk about most today is the prevention quality indicators. We have used them since 2000 in the first publication of our State of the Health of Georgia Report, which was updated in 2002.
Cindy DiBiasi: Now because of the results of the prevention quality indicators, I understand that you decided to focus your quality improvement efforts on diabetes care. How did this come about?
Vi Naylor: Actually we have a pretty comprehensive and complex organizational structure within the Partnership for Health and Accountability and as we provided the data from our care program and the AHRQ prevention quality indicators to the advisory council, they selected diabetes as one of the areas that we needed to target for health improvement. That is one of the major roles of the advisory council has is to determine tools and resources that will help communities improve health in specific areas that are appropriate for them.
Another committee is the Accountability and Health Safety Committee. One of its roles is to select study areas for improving quality and safety. We had some strong physician discussion at one of the meetings. They wanted diabetes to be one of the clinical conditions that we would study as part of our safety program. We had already selected four areas and hospitals felt that was stretching them a bit so they agreed to at a later time include diabetes as an area for study. One of the physicians that presented and made a strong case for diabetes also became our physician champion for the diabetes special interest group, or as I will refer to it later, the Diabetes SIG.
Cindy DiBiasi: Let's talk about some of the activities you have undertaken to improve diabetes care.
Vi Naylor: As I mentioned, one of the physicians has become a champion for our diabetes SIG and through his efforts we were able to get CDC funding to do a study, a statewide study of cardiovascular disease and diabetes. That study is currently underway, but as we looked at the data, it appeared that some of the better outcome or indicator data was in those areas that had certified diabetes teaching programs. The SIG was also interested in knowing more about inpatient diabetes care. There had been a lot of outpatient diabetes studies done but not quite as many inpatients. So they developed a diabetes resource assessment tool, tested it and conducted that survey. The analysis is currently being done, but some of the things that we have learned already in the preliminary analysis are that not all of our hospitals use insulin protocols. So we have an educational opportunity there.
We also know that 75% of the hospitals allow physicians to use individualized protocols, which it can have a negative impact on safety so we will be working with our council on pharmacotherapeutics to come up with a standard insulin protocol or process for developing a standard insulin protocol.
We have also learned that there is opportunity for disease management of diabetes. Hospitals who have not done so before are now beginning to add phone follow up, home health and outpatient. We have also been able to use some of the information from the PQIs to provide to the Medicaid department, the governor and others to encourage them to pay for organized disease management for some of the ambulatory care-sensitive conditions.
We also know that there are not enough diabetes clinics around the state. Urban hospitals use those for referral for diabetic instruction almost two to one compared to our rural hospitals so we have some opportunity there.
Cindy DiBiasi: What are some of the challenges and successes you have faced in using the data to improve quality and how did you address them?
Vi Naylor: Well I guess the biggest challenge, which I don't have listed, is the length of time it takes for some of these things to get going and change to actually be seen and measured. Many times working on a group like this is just one more thing to add to a long list of already established priorities.
The next greatest challenge I think has been trying to promote collaboration among the existing programs so that we don't duplicate what others are doing but rather build on their efforts. We think we can do a lot more by using resources that are already out there instead of reinventing the wheel.
When you bring together folks like we have, it gets more and more difficult to maintain the focus. That has been another challenge of staff to try to keep the special interest group focused on specific activities. One of the things that also stymies our progress is resource availability. It is not interest or enthusiasm but with staff turnover and limited availability and an increasing workload, staff has less and less time to volunteer for some of these activities. Because of all of these challenges, it places a lot of responsibility on the staff to keep the momentum going.
I would like to share some of the successes that we have also had and while they are still early and small, I think they are things that lay the foundation for longer-term improvements. In addition to the strong physician and pharmacy champions that we have, we also have a very committed staff who really go that extra mile in trying to do the work, if you will, for the participants so that we take the best advantage of their time.
We do have a number of successful diabetes education programs that can assist the rural areas or others that are having difficulties. They know what our best practices and things that work that we can share with others. The partnership has a very strong history and experience in collaboration and this is just one more activity that the partnership's structure promotes and can encourage the involvement of all healthcare organizations. In fact, in the survey that was done, about 90% of those surveyed want to continue to be involved in activities to improve diabetes care.
Cindy DiBiasi: OK, Vi, thank you. We will be back to you in a few minutes. But for more information on the Partnership for Health and Accountability, you can visit the website at www.gha.org/pha.
In a moment we will open up the lines for questions from the listening audience, but first let me tell you how to communicate with us. There are two ways you can send in your questions. The first is by telephone. If you already are listening on the phone, press "*1" to indicate that you have a question. If you are listening through your computer and want to call in with a question, dial 1-888-840-0794. Use the password "quality tools", then press "*1".
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Now why don't we go to questions from the audience. The first one is for Joe Anarella. The question from Tina Hartley. "Is the auto-assignment algorithm used to recommend providers to clients based in part on the provider's CAHPS® score shortening the list of providers to those with higher scores?"
Joseph Anarella: It is not done on provider basis. It will be done on a plan basis. So right now we currently reward plans that score higher on our quality measures or our HEDIS® measures. What we soon plan on doing is incorporating CAHPS® measures data into that algorithm and the plans that do better, have higher scores, will receive a larger percentage of the auto-assigned.
Cindy DiBiasi: OK. For Michael Belman, "You said earlier your goal is to emphasize the business capability for quality. Have you been able to demonstrate a link between quality care and the overall performance of your company?"
Dr. Michael Belman: I think it is probably a little early to see that. The major incentive that we introduced was in 2002 with the first incentive paid in July of 2003. What I did emphasize in the talk was the fact that we have seen a link between the incentives and changes within the medical groups to meet the new expectations. So we are optimistic that there will be improvements, but I think the definite proof would have to wait another year or two until we get additional cycles of information.
Cindy DiBiasi: Vi, how did you get a physician champion?
Vi Naylor: Well as I mentioned, we had several physicians that served on our accountability and health safety committee and so we just went to the physician who seemed to have the most interest in diabetes care and he was quite happy to work with us. It was also one of his research areas of interest as well so we were able to help each other.
Cindy DiBiasi: Bruce, a question about patient understanding. "Do patients understand what these reports really mean? You talked about coordinating with hospitals, but down at the consumer level with you getting so many hits on the Web site are you finding out that they get it?"
Bruce Boissonnault: We did a good deal of study, probably for I want to say three or four years. Prior to doing statewide hospital quality indicators reporting, we worked with the automakers, Ford, General Motors and the auto workers' union. We were on the national advisory panel for that group. What we found, I guess, let me use an illustration. If you take 20 children who are seven years old who don't have asthma and you ask them what is albuterol? Virtually none of them, unless their brothers have asthma, will know what that is. But if you take that same cohort of seven year olds who have asthma and you put them in a room, all of them will know what albuterol is. So we find that if it is your surgery, if it is your congestive heart failure, your are going to know what congestive heart failure means.
Cindy DiBiasi: And are you seeing when they are hitting, when they are going to your site which parts are the most sought after?
Bruce Boissonnault: Yes, they really are going right for the measures. The one thing that we continue to drill in all the media messages is people shouldn't just use these measures without talking with their doctor.
Cindy DiBiasi: Joe, do you have any concerns about adding questions to what is already a lengthy survey tool?
Joseph Anarella: We do and that is why I mentioned the fact that we actually removed some of the questions from the CAHPS® tool. I think overall we are probably down several questions. It is a long survey tool and it takes Medicaid recipients a fair amount of time to complete it and we have some data on call abandonment and partial surveys that are mailed back to us. We think if we want to have information plans you can use and we want a high response rate, to get that high response rate we think keeping the tool to key questions is important.
Cindy DiBiasi: Vi, a question from Stuart Martin. He wants to know, "Was the partnership in place before using the tools and if so, how did the group decide to use the specific tool and how has that data driven the partnership's decisions?"
Vi Naylor: The partnership is ending its fourth year so the inpatient quality indicators of course were there before the partnership. The Georgia Hospital Association is an HCUP partner. We provide data to AHRQ for the HCUP database so we have been aware of the things that AHRQ has done related to the quality indicators and one of our basic philosophies within the partnership and other activities that we do with the associations is to try to use national indicators and national tools. So as we became aware of and were asked to test these indicators, we then took them to our members and they saw the value in it and since then vision is to proactively use data to improve health and safety, it was natural to bring those indicators into the partnership.
Cindy DiBiasi: Michael, you said you had been working with the Pacific Business Group on health on this project. How did that liaison come about?
Dr. Michael Belman: Well, it probably dates back almost ten years now when the Pacific Business Group On Health initiated discussions with the health plans in California to start looking at coordinating the activities, the quality activities. So from the early days, it became very obvious that working together facilitated a lot of the administrative processes. One thing for example as far as HEDIS® data collection in California, instead of having the individual health plans to go to each individual medical group and/or to physician office independently to request information for the HEDIS® members, a coalition was formed of the major health plans through the Pacific Business Group and the HEDIS® pursuit was in fact unified under their umbrella. Just one person went to one medical group and all the information was extracted for all the health plans at once rather than having multiple visits.
I think that was the start of the initiative and then subsequently the Pacific Business Group on Health has been a very useful mechanism for the employers in California. In fact, the Pacific Business Group represents large employers in California so that if you took the 30 or 40 employers that are part of the Pacific Business Group, you are probably looking at about three million members of health plans in California that are represented through these large employers. So it has become a very useful mechanism to direct the employer concerns regarding healthcare quality and so I think that way it has also helped the health plans understand what the employer's perspectives are and what they are interested in. So the collaboration has in fact increased over the years and probably will continue to do so.
Cindy DiBiasi: You see that as a growing trend. I think that is a question I have for most all of you because you have very specific and interesting programs. I am assuming you have gotten out, broken through to a certain level. Do you see it now taking off and do you see that expanding exponentially?
Dr. Michael Belman: I think so. I think the other component, which has been helpful through the Pacific Business Group, is that it has helped pave the way for the acceptability of report cards. These were very, I wouldn't necessarily say controversial, but they were not universally embraced at the outset. But now I think through organizations such as these business groups and the health plans, they are so commonplace now that people just take them for granted. So the challenge now in fact with the report cards is to make them useful to everybody that uses them rather than have to fight for just putting them out.
Cindy DiBiasi: Bruce?
Bruce Boissonnault: Yeah, I think as States look at this, one of the things that they need to be thoughtful of is how do you keep from having, for example, twenty different report cards on the same folks? There is some information in the literature in some western states where that occurred, where every health plan did their own separately and it created some confusion for the consumers. That is why we have every health plan signing on to this one in New York State.
Cindy DiBiasi: On the other hand, it might be interesting to see what different health plans are saying about the same, how they are judging. Vi?
Vi Naylor: I would like to add to that. We do want to have one report card, if you will, and Georgia has signed on to the American Hospital Association and CMS Quality Initiative and are promoting our hospitals participating in the public reporting of that information. We also, in addition to having this scorecard, if you will, present information on our web in our publication that is known as Insights, information on each hospital and the kinds of patient safety and quality improvement activities that they are engaged in. Our belief is that numbers can only tell you so much, as you have sort of alluded to before, Bruce. But if a hospital has an infrastructure and a total commitment to being engaged in quality improvement studies, then Joint Commission for Accreditation of Healthcare Organizations, accreditation and other activities like that, if they submit studies for our quality and safety award and they become quality and safety award winners, that is something that the public can also use with any kind of scorecard in making a better informed decision about where they want to go for their healthcare.
Cindy DiBiasi: We have a Linda Bartanista on the phone from the Maryland Healthcare Commission in Baltimore. Hello?
Linda Bartanista: Hi. I have a question for Joseph Anarella. On your slide number six, which was your quality improvement matrix, I understood sort of that the Y axis had to do with better and worse scores, but I wasn't quite sure what was on the X axis where it said "state significance".
Joseph Anarella: The X is the statewide significance. So for example, a measure is benchmarked to a statewide average and then depending on where you fall...
Linda Bartanista: So zero is the statewide average?
Joseph Anarella: Correct.
Cindy DiBiasi: OK.
Linda Bartanista: Thank you.
Cindy DiBiasi: A question from Peter Brown asking all the participants this question. "What behavioral health measures are in use, are you using?"
Male: I think that is a topic actually for another conference.
Vi Naylor: Actually in our State of the Health report, we took our discharge data and actually looked at some of the behavioral health diagnoses and co-morbid physical conditions as well to show that these folks are coming into our hospitals and that we need to give attention to payment for those patients. In our state, payment for adult psychiatric care I guess is not what it should be and so we were trying to demonstrate for policymakers that if they don't go into behavioral health facilities, they are also coming in to the hospital with a physical condition as a result of that underlying behavioral health issue.
Cindy DiBiasi: Do any of your organizations have small case numbers? If so, how is this communicated in the public reports as far as educating the consumer on statistical significance?
Bruce Boissonnault: I can answer how we handle hospitals with small case numbers. In New York State, there is approximately 270 hospitals. Of course for some of the hospitals they are going to have too few cases. If you are doing public reporting especially I think you have to be very cautious about this and we use a threshold of 30 cases. If there is a hospital which has fewer than 30 cases, we do not publish a star rating or a confidence interval. We merely publish the volume itself, which is sometimes in itself a useful piece of information. If the literature is clear that a hospital should do at least 51 of a procedure in order to reach, what is the word I am looking for, in order to have statistically significantly better outcomes, then you might want to ask your doctor why are you sending me to a facility that did three last year?
Cindy DiBiasi: Go ahead, Joe.
Joseph Anarella: We similarly don't publish numbers, small numbers. However, as our managed care program has grown, that has become less and less of an issue.
Dr. Michael Belman: We, as far as (unclear) goes, there is a sample, a minimal sample size that is required in order for the results to be published and there is information actually on the healthscope.org, the Pacific Business Group side, I think the statistical methodology behind the presentation of the results is well described.
Cindy DiBiasi: OK, a question from Richard Carr, "Since you are presenting comparison data across hospitals and provider groups, how do you risk-adjust your data so that comparisons take into account things like illness burden, etc.?"
Male: The inpatient quality indicator, the AHRQ IQIs, reference the use of the three MAPDRGs risk adjustment software. We are, in our organization and I know in Texas, we were particularly pleased with that decision for two reasons. The APDRGS that 3-M puts out are not a black box so you can literally go on the Internet and see how every formula works. There is no secret and because it is a private vendor, there is a mechanism, a funding mechanism, which keeps the risk adjustment getting better and better every year.
Cindy DiBiasi: Michael?
Dr. Michael Belman: That is an important point and with regards to the survey, we take into account chronic illness as one of the variables in the survey because it is recognized that people who use the health system frequently may have more chance to be dissatisfied. They are putting more stress on the system and so that is taken into account and adjusted in the results.
Another factor which has been adjusted in the most recent year, which is interesting and is important in California is ethnic adjustment. It became apparent from the results that there were differences amongst different communities in terms of their perception of the same healthcare. So that is also taken into account in the final results.
Male: By the way, this year we are going to start looking at data stratified by ethnicity as well.
Vi Naylor: That is one of the reasons why we use the inpatient quality indicators as an internal tool for hospitals for their improvement process, but do publish the CMS data because the necessity for having a severity or risk adjustment when you are measuring compliance with evidence-based practices is not as important and so you move out of that picture the noise of people saying "I have sicker patients" or what have you.
Cindy DiBiasi: A question from Pat Jones from the Vermont Division of Healthcare Administration to Vi: "Did Georgia publish data by hospital for consumers as it appears New York did? If so, did you use the AHRQ patient safety indicators or did you opt not to publish them and if not, why not?"
Vi Naylor: We are publishing the CMS data for hospital-specific reports as part of the AHA Quality Initiative. As I just mentioned, we are keeping the inpatient quality indicators and the patient safety indicators as an internal tool for some of the reasons that have already been mentioned here.
Cindy DiBiasi: Joe, tell us more about the quality matrix. How does that encourage plans to improve?
Joseph Anarella: Well, it is a tool we use to highlight areas where we think a plan needs to focus their efforts. When you are measuring plans on a number of different parameters, I am sure most of the listeners are familiar with the HEDIS® measures and probably the CAHPS® measures as well. You realize how plans have limited resources and you want to help plans focus those resources on areas of particular importance. We think, and we have information that our plan managers collect from the plans that I think bears this out, that by having them focus and devote resources to the areas where they are furthest behind their peers and where they have maybe fallen from one year's higher performance, is an effective way to promote improvement. It is better than the broad rush to fix everything that is below average or that you have fallen down on.
Cindy DiBiasi: Just to provide some context for the work you are doing, what amount and types of resources does it take to produce your specific products? Joe?
Joseph Anarella: Well, I will just, the CAHPS® survey is expensive because we are surveying a huge number of plans. I think very few states in the country have as many plans as we do, but we are spending close to three quarters of a million every other year. That is money going to our vendor. That doesn't include staff time.
Vi Naylor: We have the discharge data available to us already through our health-planning program that we offer. We are the data vendor for the State of Georgia and because we have the data already because the tools are free from AHRQ, there is not a lot of cost associated. It takes staff time, probably half time, FT, would probably account for publishing the patient safety and the PQIs.
Cindy DiBiasi: I guess the question is how replicable?
Male: I actually was going to answer as well. This is for (unclear) and all. We had actually, if a State were going to start with an empty room, with no equipment, no software, no people, I think they'd spend a couple of hundred thousand dollars getting staff, getting the risk adjustment methodology, especially if they wanted to use it all the time for a lot of different things, getting the computers. But the truth is, for States that are getting started in this, we have already been approached by two States and for a very few thousand dollars, we will do all the calculations for a state and show them how to do it on the website. The other thing is we have an informal collaboration amongst the states that are publishing that we started and that collaboration works with AHRQ to make sure feedback on the measures, making sure they we are not only users of the measures but that we also are giving value back.
Cindy DiBiasi: Mike?
Dr. Michael Belman: I think on the CAHPS® surveys or the satisfaction surveys, there is a fair amount of time and effort required. Originally we were doing it as our own, as a health plan. We now use the Pacific Business Group as the mechanism to administer the survey through multiple health plans. Each health plan would then put in a sizable contribution to (unclear) the survey each year. Then there is also a payment from the individual (unclear) that goes into it. If we are talking numbers, we are probably talking in a state like California for a couple of million dollars are necessary in order to administer the survey to 200+ medical groups.
Part of the requirement also, particularly with surveys, is to make ensure a reasonable response rate so that just sending out the survey and sitting back for several months waiting for the responder results is not going to work. It does require follow up, a second survey to non-responders and a third telephone call. In a state again like California, there is a need for surveys in at least two languages other than English and in some cases more. Then also some kind of way for people with non-English speaking people to get information on how to fill the survey out. So this can get, it can become a little more complicated once you want to get into it.
Cindy DiBiasi: But your philosophy is that the return on investment is worth that...
Dr. Michael Belman: We think that the information that one gets from the members and the fact that this information comes back to health plans and to the medical groups is a stimulus for quality improvement.
Vi Naylor: I would just like to expand on my answer. It was based on just making the data available and as an association we never believe in data just for the sake of data, but trying to make improvements. Our Partnership for Health and Accountability actually has nine or ten staff members that work with communities and hospitals in knowing how to use the data to make improvements and so you are talking probably $750,000 for a program like that.
Cindy DiBiasi: Has HIPAA changed the tools you use? Any impact in that? No?
Bruce Boissonnault: I think the only thing relevant to HIPAA is there are some folks I think who want to amend it so that even for public hospital report cards you would be required to get a signature from every patient to use the data even blinded. So that is something the folks in the states are going to want to watch, but right now HIPAA is not relevant to this.
Cindy DiBiasi: Joe, how many of the questions in the CAHPS® are really within the plan's control?
Joseph Anarella: Good question. I obviously don't have an exact number, but there are some domains that definitely relate more to the practice level. As an example, and somebody back home will be laughing, the question related to courtesy and respect. That is hard for a plan to influence. For example, I am a plan with a 1,500-physician panel, largely IPA structured. It is hard to feed that type of information back and say, "OK, everyone, let's work on our courtesy and respect." That is an example. I think probably well over half of the questions relate to things that a plan can work on and improve. I will leave it at that.
Cindy DiBiasi: Michael?
Male not Michael: Just the data, though, no matter what the domain is, tends to make it change if the doctors know that somebody is looking at that measure by plan and it gets some attention, I don't know; we have seen it in our numbers. It does make a difference that it is out there in the public domain.