Update: UnitedHealth PremiumSM Designation Programs by HC120727154814

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									                          Performance Transparency and
                       Improvement: The Uniquely American
                                    Journey
                                                                   Lewis G. Sandy MD
                                                                   American Health Quality Association
                                                                   Annual Meeting
                                                                   February 25, 2009

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  UnitedHealth Group Mission
                                                                                                                                       2




      • Our mission is to help people live healthier lives.
          We seek to enhance the performance of the health system
           and improve the overall health and well-being of the people
           we serve and their communities.

              We work with health care professionals and other key
               partners to expand access to high quality health care so
               people get the care they need at an affordable price.

              We support the physician/patient relationship and empower
               people with the information, guidance and tools they need
               to make personal health choices and decisions.




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  How Old is the Performance Measurement and
  Improvement Movement in the US?                                                                                                      3




                     "Every hospital should follow every patient it treats long enough
                     to determine whether the treatment has been successful, and
                     then to inquire ‘if not, why not’ with a view to preventing similar
                     failures in the future."
                     Ernest Codman, 1914




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  So Are We Done Yet?...
                                                                                                                                            4

                              Adherence to Quality Indicators
                Breast Cancer                                                       75.7%

                Prenatal Care                                                      73.0%

               Low Back Pain                                                    68.5%

    Coronary Artery Disease                                                    68.0%

                  Hypertension                                               64.7%
                                                                                                                Adults receive about half
    Congestive Heart Failure                                                 63.9%                              of recommended care
                   Depression                                             57.7%                                   54.9% = Overall care
      Orthopedic Conditions                                             57.2%
                                                                                                                  54.9% = Preventive care
                                                                                                                  53.5% = Acute care
            Colorectal Cancer                                         53.9%
                                                                                                                  56.1% = Chronic care
                        Asthma                                        53.5%

Benign Prostatic Hyperplasia                                          53.0%

               Hyperlipidemia                                      48.6%

             Diabetes Mellitus                                    45.4%                                             Not Getting
                     Headache                                     45.2%                                              the Right
       Urinary Tract Infection                                40.7%
                                                                                                                    Care at the
                          Ulcers                         32.7%

                  Hip Fracture                      22.8%
                                                                                                                    Right Time
        Alcohol Dependence                 10.5%

                                   0%         20%           40%        60%          80%         100%
                                        Percentage of Recommended Care Received

    Source: McGlynn EA, et al., “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of
    Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635-2645

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  And We Have A Healthcare Affordability Crisis
                                                                                                                                                       5




                                 Cumulative Changes in Health Care Cost Trends,
                                    Overall Inflation, and Workers’ Earnings
     103%
                                                                                                                               98%

                                                                                                                87%
       82%
                                                                                                  73%                              Results:
       62%
                                                                                   59%
                                                                                                                                   • 47M uninsured
                                                                                                                                   • Rising underinsured
       41%                                                           43%

                                                                                                              20%        24%
                                                       25%                                      15%
       21%                                                                        12%
                                   11%                               10%                                                   21%
                                                      7%                                          14%          18%
                                       3%                                          10%
                                                       5%             7%
         0%
                    2000          2001           2002          2003          2004           2005          2006           2007

                            Health Care Costs                    Overall Inflation                 Workers' Earnings




                                                                It’s a Crisis
  Sources: KFF/HRET 2007 Employer Health Benefits Survey, BLS Consumer Price Index




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Rx: An Integrated Approach to Quality and Affordability
                                                                                                                                        6




                                        Incentives                                                               Personal
                                                                                                               Health Support
                                                                        Consumers




                        Information                                                                                            Choice
                                                                           Clinical
                                                                            Data


                                                Employers                                        Physicians
                                                                                                 & Facilities




                                                                                                 Clinical
                                                     Affordability
                                                                                               Improvement


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      Measuring Physician Quality and Cost Efficiency
      Episodes of Care                                                                                                                             7




     Primary Care, MD         Radiologist                 Specialist              Reference Lab



                                                                                                                    Episode Example


                                                                                  ANALYSIS                        ETG 29: Type 2 Diabetes,
    Hospital B for Rehab
                                                                                                                     with comorbidity
                                                                                                                         (other illnesses)

                                          UnitedHealthcare

    Emergency Room



                                                                                                                 Now we can see all services
                                                                                                             for which we have claims across all
                                                                                                                         providers.

    Hospital A for             Ambulance                 Pharmacy II                Pharmacy I
      Surgery




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  UnitedHealth Premium Designation:
                                                                                                                                                            8




                                                                                                                    Episodes/
                                                                                                                   procedures
    24 months of                                                                                                   analyzed for
                                                                            Physicians who
        data is                                                                                                    efficiency of
                                                                              meet/exceed
    collected and                      The quality                                                                      care
                                                                               the quality                                                 Physicians
      analyzed                         screens are                                                                benchmarking
                                                                               criteria are                                                who meet or
        on all                        applied based                                                                   market
                                                                            designated by a                                                  exceed
    physicians in                      on specialty                                                                  specialty
                                                                            quality star and                                               market cost
   the specialties                     and, where                                                                 averages and
                                                                             proceed to the                                                criteria are
     eligible for                      applicable,                                                                      case
                                                                              efficiency of                                                designated
                                                                                                                   mix/severity
    designation*                        condition                             care analysis
                                                                                                                     adjusted




                                                                                                                                       Quality and
                                                                                                                                       Efficiency of Care
                                                                                                                                       Designation
                                                                                     Quality Only
                                                                                     Designation




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Designation Display on myuhc.com
                                                                                                                                                              9




                                            Individual
                                                                                                                                       Designation status
                                                                                                                                       identified online
                                                                                                                                         •   Quality and
                                                                                                                                             efficiency 

                                                                                                                                         •   Quality only 
                                                                                                                                         •   Specialty not
                                                                                                                                             evaluated
                                                                                                                                         •   Insufficient
                                                                                                                                             UnitedHealthcare
                                                                                                                                             data
                                                                                                                                         •    Not displayed
                                                                                                                                             upon physician’s
                                                                                                                                             request




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Medical Professional Practice Improvement
Online Physician Level and Detail Reports
                                                                                                                                        10
   • Actionable information comparing physician performance to national quality standards and
     market cost efficiency standards
   • A view of the entire episode of care
   • Patient level detail reports provide physicians with specific patient data attributed to their
     designation
   • Online detail reports available through the physician Web site,
     www.UnitedHealthcareOnline.com




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  Where Is This Field Today?
                                                                                                                                       11




    • Growing Sophistication and Understanding of:
        Performance Assessment Tools and Techniques
        Clinical Improvement Methods and Tools
    • Emergence of Standards:
        National Quality Forum-re-energized and focused
        AMA PCPI-evolving beyond PQRI
        NYAG/NCQA-measuring the measurers
        Consumer-Purchaser Disclosure Project-it’s about us!
        Evalu8 RFI-incenting plans
    • Promising Data Aggregation initiatives
    • Certifying Boards Mandating Improvement for MOC
    • An Important Element of Health Reform?

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UnitedHealthcare Awarded NCQA Physician and
Hospital Quality Plus Distinction
                                                                                                                                       12




        Four key principles served as the foundation for development of NCQA's
        Physician and Hospital Quality standards:

        • Standardization: NCQA supports standardized measures; where it is not
          possible, it encourages the drive towards standardization. Quality and resource
          use measures must be evidence-based, reliable and valid.

        • Transparency: These standards require that measurement specifications be
          available to the organizations being measured and the public.

        • Collaboration: These standards encourage collaboration between plans by
          streamlining the review process for organizations participating in collaborative
          initiatives. The standards also support collaboration between plans and
          providers—a key to successful measurement activities.

        • Action: The objective of measurement is quality improvement and affordability.
          Plans should take specific actions to improve performance; such as reporting
          and engaging in quality improvement activities or using payment and product
          design strategies.




                  24 UnitedHealthcare plans hold NCQA Quality Plus distinctions
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UnitedHealthcare Supports Consumer
Disclosure Project’s Patient Charter
                                                                                                                                       13




   • Standard set of principles for performance measurement and reporting assessed by an
     independent review organization.
   • Supported by Physicians, Consumers, Labor, Purchasers, and Payors including:
        American College of Physicians, American Academy of Family Physicians, American
         Medical Association, American College of Cardiology, American College of Surgeons

   Following the charter will mean that:
   • Consumers can make more informed decisions based on both quality and cost, with adequate
     guidance about how to use the information and any limitations in the data.
   • Measurement is based on sound national standards and methodology.
   • Both consumers and physicians have input into the measurement process and how results are
     reported.
   • Measurement is a transparent process so that both consumers and physicians can understand
     the basis upon which performance is being measured and reported.
   • Physicians have adequate notice and opportunity to correct any errors.
   • Physicians will have information that helps them improve the quality of care they provide.




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  QASC: A Promising Data Aggregation
  Initiative                                                                                                                           14




    • The Quality Alliance Steering Committee (QASC) is a collaborative effort
      among government agencies, physicians, nurses, pharmacists, hospitals,
      health insurers, consumers, accrediting agencies, foundations and others

    • QASC co-chairs:
           Carolyn Clancy, MD, Director, Agency for Health Care Research and Quality
           Mark McClellan, MD, PhD, Director, Engelberg Center for Health Care Reform at
            the Brookings Institution.

    • Vision: to advance a high-quality, affordable, patient-centered health care
      system through the coordination of various groups that are working to
      provide public information on health care providers’ performance.
        The QASC will actively support the implementation and use of standard
         health care performance information for:
                 • Performance improvement directly by providers;
                 • Public reporting and more informed consumer decision-
                   making;
                 • Effective public policies, payment policies, and consumer
                   incentives that reward or foster better provider performance


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                Many critical partners needed to optimize the system

                         AHRQ                                                                                             NQF National Priorities Partners*            15
                         Foundations
                         Other
                                                                                                                                            NCQA
                                                                     Continuously         Set national                                      The Joint Commission
                                                                     evaluate             priorities and goals                              AMA PCPI
     QIOs                                                            health and           to drive                                          Medical Societies
     Regional Collaboratives                                         health care          improvement and                                   Medical Specialty Boards
     Providers                                                                            affordability                                     CMS
     Oversight Organizations                                                                                                                AHRQ
     Employers                                                                                                                              Others**
     Health Plans                                 Improve quality
                                                  and reduce waste                                       Develop and test evidence-
                                                                                                         based measures
                                                                               Consumer
                                                                               Outcomes
      Fed/State Govt                       Establish effective public           High Quality                                                              NQF
                                           policies, payment policies,                                     Endorse and maintain
      Health Plans                                                                Equitable
                                           and consumer incentives to                                      measures and incorporate
      Employers                                                                   Affordable
                                           reward or foster better                                         specifications into EHRs
      Consumers                                                                Patient-Centered
      Providers                            performance

                                                                                                      Develop
                                                                                                      coordinated
                                                      Generate public                                 and streamlined
                                                      reports on quality and                          implementation
                                                      cost                                            strategies:
                                                                                Aggregate data and    prioritization,                      QASC
                                                                                pilot test and        timelines, and                       Quality Alliances
                                                                                validate standard     process solutions                    Joint Commission NCQA
                                                                                performance                                                Medical Specialty Boards
                                                                                information

         Regional Collaboratives                                                                                 QASC
         Fed/State Govt.                                                                                         Regional Collaboratives
         Health Plans                                                                                            RHIOs/HIEs
         Others                                                                                                  CMS
                                                                                                                 States
   *List of all involved partners available.                      ** Nursing, Academic Communities, etc.         Health Data Stewards
                                                                                                                                                                  15
      June 6, 2008
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       Practice-based Feedback: Regional-National
                                                                                                                                              16




                                                                     Innovation




                                                              National Coordination:

                                                            • Performance Measure Standard
          Regional                                               •Methodological Standards                                        Regional
         Experience                                                 •Technical Standards                                         Experience
                                                              • Data Aggregation Standards
                                                                • Implementation Strategies
                                                               • Promotion of Best Practices




                                                                   Consistency



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  Performance Transparency and Improvement:
  A Field With Some Evolving Coherence?                                                                                                17




    • Movement towards convergence on standard measures
      (NQF, PCPI)
    • Emerging standards for “measuring the measurers”
      (NYAG RX/NCQA/CPDP Pt. Charter)
    • Societies and Certifying Boards beginning to align:
        Guideline development
        Registry and performance improvement programs
        MOC
    • On the other hand….
        There are a plethora of regional and local initiatives…
        Many of which are naïve, are reinventing the wheel,
         and/or have no sustainable business model….
     Ongoing Communication and Collaboration are the key to continuing progress!

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  Will We Get It Right?
                                                                                                                                       18




                           “You can always trust the Americans. in the end they will
                           do the right thing, after they have eliminated all the other
                                                   possibilities”




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