03. Quality Measurement and Report: Implications for Disparities
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Transcript of 03. Quality Measurement and Report: Implications for Disparities
www.CenterForUrbanHealth.org
Using Quality Measurement and Reporting to Confront
Disparities
Yiscah Bracha, M.S.Research Director
Center for Urban Health at HCMCMinneapolis Medical Research Foundation
www.CenterForUrbanHealth.org
Today’s presentation will discuss:
• Goals & presumed mechanisms of QM&R• Reason to use QM&R to address disparities
Locus of Minnesota’s problems in population health
Demographic changes in the state
• Ways to use QM&R to address disparities Disparities-relevant measures Disparities-relevant reports
Stratified measures Structure reports to favor providers who do most with
least
• Conclusions
www.CenterForUrbanHealth.org
Today’s presentation will discuss:
• Goals & presumed mechanisms of QM&R • Reason to use QM&R to address disparities
Locus of Minnesota’s problems in population health
Demographic changes in the state
• Ways to use QM&R to address disparities Disparities-relevant measures Disparities-relevant reports
Stratified measures Structure reports to favor providers who do most with
least
• Conclusions
www.CenterForUrbanHealth.org
Goal of Quality Measurement & Reporting
• Improve population health by• Improving the quality of medical care
delivered to the population• Assumed mechanisms:
Individual patients choose providers of highest reported quality
Providers improve quality in order to earn: Increased market share Improved public image Bonus payments from health plans
www.CenterForUrbanHealth.org
When does care most matter to health?
• Improved quality of medical care makes the most difference to health among those: Who are acutely ill With complex chronic disease With lifestyles and exposures that place
them at high risk for ill health
www.CenterForUrbanHealth.org
Who is most sick and at risk in Minnesota?
• Racial and ethnic minorities• Persons of low SES
www.CenterForUrbanHealth.org
Premature mortality in MN by race:
www.CenterForUrbanHealth.org
Child health indicators in MN by race
02468
1012141618
Inadequateprenatal
care
Lowbirthweight
babies
Infantmortality
rate
Rat
es
White
Asian
Hispanic
African American
Native American
*Source: Minnesota Department of Health, Spring 2006
www.CenterForUrbanHealth.org
Indicators of SES by Minnesota race
0
10
20
30
40
50
60
70
80
Poverty EmployerInsurance
Medicaid
Pe
rce
nt
of
Min
ne
so
tan
s
White
Black
Hispanic
Other
46 14 23 12 6 16 11 8 39 4 n/a 6
Numbers inside bars represent Minnesota’s rank among states.Employer-sponsored insurance and Medicaid for non-elderly.
www.CenterForUrbanHealth.org
Ways to improve MN’s overall health:
• Improve quality of medical care for majority population, which already is healthiest in the nation?
-OR-
• Improve quality of medical care for minority populations, which have some of the lowest health indicators in the nation?
www.CenterForUrbanHealth.org
Today’s presentation will discuss:
• Goals & presumed mechanisms of QM&R • Reason to use QM&R to address disparities
Locus of Minnesota’s quality problem Demographic changes in the state
• Ways to use QM&R to address disparities Disparities-relevant measures Disparities-relevant reports
Stratified measures Structure reports to favor providers who do most with
least
• Conclusions
www.CenterForUrbanHealth.org
Growth in MN non-white population:
Source: Minnesota State Demographic Center, August 2006
www.CenterForUrbanHealth.org
Change in MN youth population:
Source: Minnesota State Demographic Center, August 2006
www.CenterForUrbanHealth.org
Projected changes in MN population:
Source: Minnesota State Demographic Center, August 2006
www.CenterForUrbanHealth.org
Conclusions:
• Our state is rapidly diversifying• Much more diversity expected in the
future• Reasons to target resources to disparities:
Justice: Gaps are indefensible Efficiency: Direct resources to places where
there is most room to improve Sustainability: As the state grows more
diverse, the minority in poor health may become the majority
www.CenterForUrbanHealth.org
Today’s presentation will discuss:
• Goals & presumed mechanisms of QM&R• Reason to use QM&R to address disparities
Locus of Minnesota’s quality problem Demographic changes in the state
• Ways to use QM&R to address disparities Disparities-relevant measures Disparities-relevant reports
Stratified measures Structure reports to favor providers who do most with
least
• Conclusions
www.CenterForUrbanHealth.org
How QM&R could address disparities:
1. Help low-income patients use reports 2. Develop disparities-relevant measures
3. Develop disparities-relevant reportsa. Stratify reports to reveal disparitiesb. Structure reports to reward providers who
i. Do the best with the most challenging patientsii. Do the best with the most limited resources
www.CenterForUrbanHealth.org
Helping ptts use reports (?)
• Empirical Q: Do patients switch providers on the basis of quality reports? Research: Few patients consult reports. Workers switch health plans on the basis of
cost, not reported quality
• Normative Q: Should patients switch providers on the basis of quality reports? Many say no. Switching disrupts continuity,
which is necessary for quality
www.CenterForUrbanHealth.org
How QM&R could address disparities:
Help low-income patients better use reports
1. Develop disparities-relevant measures
2. Develop disparities-relevant reportsa. Stratify reports to reveal disparitiesb. Structure reports to reward providers who
i. Do the best with the most challenging patientsii. Do the best with the most limited resources
www.CenterForUrbanHealth.org
Goal of Quality Measurement & Reporting
• Improve population health by• Improving the quality of medical care
delivered to the population• Assumed mechanism:
Individual patients choose providers of highest reported quality
Providers improve quality in order to earn: Increased market share Improved public image Bonus payments from health plans
www.CenterForUrbanHealth.org
How QM&R could address disparities:
1. Develop disparities-relevant measures
2. Develop disparities-relevant reportsa. Stratify reports to reveal disparitiesb. Structure reports to reward providers
whoi. Do the best with the most challenging
patientsii. Do the best with the most limited resources
www.CenterForUrbanHealth.org
1. Measures relevant to disparities
• Diversity measures: % patients served proportionate to
demographics in community % health care workers with demographics
proportionate to those in community
• Access measures: Cancelled appointment rates Availability of transportation and child care % patients served who are uninsured or MA
www.CenterForUrbanHealth.org
Other measures relevant to disparities:
• Patient-centeredness. Develop indicators of good care specific to: Multiple chronic conditions Gender and age Patient stated preferences for
aggressive vs. conservative medical therapy
www.CenterForUrbanHealth.org
How QM&R could address disparities:
1. Develop disparities-relevant measures
2. Develop disparities-relevant reportsa. Stratify reports to reveal disparitiesb. Structure reports to reward providers
whoi. Do the best with the most challenging
patientsii. Do the best with the most limited resources
www.CenterForUrbanHealth.org
2a. Stratify reports
• For all measures, show outcomes within strata such as: Race/ethnicity Estimate of SES (from census data) Number of co-morbidities
• For all strata, show % patients served within stratum
www.CenterForUrbanHealth.org
How QM&R could address disparities:
1. Develop disparities-relevant measures
2. Develop disparities-relevant reportsa. Stratify reports to reveal disparitiesb. Structure reports to reward providers
whoi. Do the best with the most challenging
patientsii. Do the best with the most limited resources
www.CenterForUrbanHealth.org
2b. Structure of reports
• All structure decisions favor some at the expense of others; thus choice of structure reflects normative values.
• Two critical dimensions of structure: Use raw outcomes vs. outcomes
adjusted by patient characteristics Display attainment of absolute threshold
vs. attainment of improvement
www.CenterForUrbanHealth.org
Who is favored by what structure decision?
Outcome measure is:
Reward Based on Achieving
Absolute target Improvement
Unadjusted
High resource providersHigh resource patients
Low resource providers High resource patients
Adjusted or stratified:
High resource providersAny kind of patient
Low resource providersAny kind of patient
Observed to Expected
High resource providersLow resource patients
Low resource providersLow resource patients
www.CenterForUrbanHealth.org
Decisions now favor:
Outcome measure is:
Reward Based on Achieving
Absolute target Improvement
Unadjusted
High resource providersHigh resource patients
Low resource providers High resource patients
Adjusted or stratified:
High resource providersAny kind of patient
Low resource providersAny kind of patient
Observed to Expected
High resource providersLow resource patients
Low resource providersLow resource patients
www.CenterForUrbanHealth.org
Decisions could favor:
Outcome measure is:
Reward Based on Achieving
Absolute target Improvement
Unadjusted
High resource providersHigh resource patients
Low resource providers High resource patients
Adjusted or stratified:
High resource providersAny kind of patient
Low resource providersAny kind of patient
Observed to Expected
High resource providersLow resource patients
Low resource providersLow resource patients
www.CenterForUrbanHealth.org
Today’s presentation will discuss:
• Goals & presumed mechanisms of QM&R• Reason to use QM&R to address disparities
Locus of Minnesota’s quality problem Demographic changes in the state
• Ways to use QM&R to address disparities Disparities-relevant measures Disparities-relevant reports
Stratified measures Structure reports to favor providers who do most with
least
• Conclusions
www.CenterForUrbanHealth.org
Questions, answers & implications:
Question Answer Policy implicationsDo existing measures assess equity or equality in quality?
NoDevelop & use new measures relevant to disparities.
Does patient race & SES affect MNCM outcomes measures?
Very likely. Known that low SES worse outcomes
Stratify reports by SESUse SES to risk-adjust or calculate observed-to-expected outcomes
Which non-medical agents affect MNCM outcome measures?
Family, patient, community, public policies
Reimbursement higher when contributions from non-medical agents are low
www.CenterForUrbanHealth.org
The Bad News:
• Minnesota has a disparities problem• If not addressed, this problem will:
Challenge our commitment to equality Waste health improvement resources by not
directing them to the places they can do the most good
Undermine the future vitality of the state, as low-income, minority populations continue to grow
• Quality measurement & reporting methods Currently do not address the problem May exacerbate it
www.CenterForUrbanHealth.org
The good news:
• Quality measurement & reporting framework is state-of-the-art: Excellent cooperation among health
plans Strong support from business and state Willingness to address the disparities
issue
• We can utilize the existing framework to address disparities
www.CenterForUrbanHealth.org
This problem is solvable!Let’s start.
Extra slides
www.CenterForUrbanHealth.org
Chronic Care Model
from E.H. Wagner 1998. What will it take to improve care for chronic illness? Effective Clinical Practice. 1(1):2-4
www.CenterForUrbanHealth.org
Visioning a new reimbursement structure:
• Based on episodes of care
• Fosters collaboration and mutual accountability among all responsible actors: Schools and community based social agencies Municipalities & counties (e.g. public health
impact of development decisions) State (e.g. MA eligibility & reimbursement
policies)
www.CenterForUrbanHealth.org
How healthy is Minnesota?
• Minnesota has ranked as one of the top two healthiest states since1990*
• According to United Health Foundation, our strengths include: Low uninsurance rate Low CVD death rate Low premature death rate Low infant mortality rate
* Source: United Health Foundation’s America’s Health Rankings.
www.CenterForUrbanHealth.org
MN Health Strengths by Race*
*Source: Minnesota Department of Health, Spring 2006.
www.CenterForUrbanHealth.org
MN population growth rates by race:
www.CenterForUrbanHealth.org
Changes in MN demography by county
www.CenterForUrbanHealth.org
Some answers to empirical Qs:
• Effect of patient characteristics on measures of diabetes quality: Low SES patients have higher rates of smoking,
higher BP, higher chol, higher HbA1c. Reductions in HbA1c less likely in patients with
multiple chronic conditions, have diabetes of longer duration, youngest & oldest, racial minorities, low SES.
Risk-adjusting provider report card by patient SES can eliminate apparent outliers
• Strength of this knowledge claim: Very good.