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Quality Measurement and Disparities
 

Quality Measurement and Disparities

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  • February 7, 2007. Quality Measurement & Reporting. Conference hosted by MN Community Measurement, in collaboration with Halleland Health Consulting, National Institute of Health Policy, University of St. Thomas. St. Paul, MN.
  • Source: Kaiser Family Foundation State Health Facts.
  • http://www.demography.state.mn.us/documents/NonwhiteLatinoPopulationsinMNContinueToGrowRapidly.pdf
  • http://www.demography.state.mn.us/documents/NonwhiteLatinoPopulationsinMNContinueToGrowRapidly.pdf
  • http://www.demography.state.mn.us/documents/NonwhiteLatinoPopulationsinMNContinueToGrowRapidly.pdf
  • * Source: United Health Foundation’s America’s Health Rankings. http://www.unitedhealthfoundation.org/ahr2006/states/Minnesota.html
  • Populations of Color in Minnesota . Health Status Report. Update Summary Spring 2006. http://www.health.state.mn.us/divs/chs/POC/State_POCUpdate2006_final.pdf 1. 2004. 2. Years of potential life lost before age 65 per 100 in population ages 0-64; 2000-2004 3. Number of infant (less than 12 months) deaths per 1000 live births; 1999-2003 4. 2000-2004.

Quality Measurement and Disparities Quality Measurement and Disparities Presentation Transcript

  • U s in g Q u a lit y www.CenterForUrbanHealth.org Me a s ure me nt a ndR e p o r t in g t o C o n f r o n t D is p a r it ie s Yiscah Bracha, M.S. Research Director Center for Urban Health at HCMC Minneapolis Medical Research Foundation
  • T o d a y ’ s p r e s e n t a t io n w ill d is c u s s : www.CenterForUrbanHealth.org• 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
  • T o d a y ’ s p r e s e n t a t io n w ill d is c u s s : www.CenterForUrbanHealth.org• 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
  • G o a l o f Q u a lit y M e a s u r e m e n t & R e p o r t in g www.CenterForUrbanHealth.org • 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
  • Whe n d o e s c a re mo s t m a t t e r t o h e a lt h ? www.CenterForUrbanHealth.org• 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
  • W h o is m o s t s ic k a n d a t r is k in M in n e s o t a ? www.CenterForUrbanHealth.org • Racial and ethnic minorities • Persons of low SES
  • P r e m a t u r e m o r t a lit y in M N by ra c e : www.CenterForUrbanHealth.org
  • C h ild h e a lt h in d ic a t o r s in MN by ra c e www.CenterForUrbanHealth.org 18 16 14 White 12 Asian 10 Rates Hispanic 8 6 African American 4 Native American 2 0 Inadequate Low Infant prenatal birthweight mortality care babies rate*Source: Minnesota Department of Health, Spring 2006
  • In d ic a t o r s o f S E S b y M in n e s o t a r a c e www.CenterForUrbanHealth.org 80 70 Percent of Minnesotans 60 White 50 Black 40 Hispanic 30 Other 20 10 0 46 14 23 12 6 16 11 8 39 4 n/a 6 Poverty Employer Medicaid InsuranceN u m b e r s in s id e b a r s r e p r e s e n tM in n e s o t a ’ s r a n k a m o n g s t a t e s .Employer-sponsored insurance and Medicaid for non-elderly.
  • W a y s t o im p r o v e M N ’ s o v e r a ll h e a lt h : www.CenterForUrbanHealth.org• 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?
  • T o d a y ’ s p r e s e n t a t io n w ill d is c u s s : www.CenterForUrbanHealth.org• 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
  • G r o w t h in M N n o n -w h it e p o p u la t io n : www.CenterForUrbanHealth.orgSource: Minnesota State Demographic Center, August 2006
  • C h a n g e in M N y o u t h p o p u la t io n : www.CenterForUrbanHealth.orgSource: Minnesota State Demographic Center, August 2006
  • P r o je c t e d c h a n g e s in M N p o p u la t io n : www.CenterForUrbanHealth.orgSource: Minnesota State Demographic Center, August 2006
  • C o n c lu s io n s : www.CenterForUrbanHealth.org• 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
  • T o d a y ’ s p r e s e n t a t io n w ill d is c u s s : www.CenterForUrbanHealth.org• 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
  • H o w Q M & R c o u ld a d d r e s s d is p a r it ie s : www.CenterForUrbanHealth.org• Help low-income patients use reports• Develop disparities-relevant measures• Develop disparities-relevant reports a. Stratify reports to reveal disparities b. Structure reports to reward providers who i. Do the best with the most challenging patients ii. Do the best with the most limited resources
  • H e lp in g p t t s u s e r e p o r t s (? ) www.CenterForUrbanHealth.org• 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
  • H o w Q M & R c o u ld a d d r e s s d is p a r it ie s : www.CenterForUrbanHealth.orgHelp low-income patients better use reports• Develop disparities-relevant measures• Develop disparities-relevant reports a. Stratify reports to reveal disparities b. Structure reports to reward providers who i. Do the best with the most challenging patients ii. Do the best with the most limited resources
  • G o a l o f Q u a lit y M e a s u r e m e n t & R e p o r t in g www.CenterForUrbanHealth.org • 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
  • H o w Q M & R c o u ld a d d r e s s d is p a r it ie s : www.CenterForUrbanHealth.org• Develop disparities-relevant measures• Develop disparities-relevant reports a. Stratify reports to reveal disparities b. Structure reports to reward providers who i. Do the best with the most challenging patients ii. Do the best with the most limited resources
  • 1. M e a s u r e s r e l e v a n t t o d is p a r it ie s www.CenterForUrbanHealth.org• 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
  • O t h e r m e a s u r e s r e le v a n t t o d is p a r it ie s : www.CenterForUrbanHealth.org• Patient-centeredness. Develop indicators of good care specific to:  Multiple chronic conditions  Gender and age  Patient stated preferences for aggressive vs. conservative medical therapy
  • H o w Q M & R c o u ld a d d r e s s d is p a r it ie s : www.CenterForUrbanHealth.org• Develop disparities-relevant measures• Develop disparities-relevant reports  Stratify reports to reveal disparities  Structure reports to reward providers who i. Do the best with the most challenging patients ii. Do the best with the most limited resources
  • 2a. S t r a t if y r e p o r t s www.CenterForUrbanHealth.org• 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
  • H o w Q M & R c o u ld a d d r e s s d is p a r it ie s : www.CenterForUrbanHealth.org• Develop disparities-relevant measures• Develop disparities-relevant reports  Stratify reports to reveal disparities  Structure reports to reward providers who i. Do the best with the most challenging patients ii. Do the best with the most limited resources
  • 2 b . S tru c tu re o f re p o rts www.CenterForUrbanHealth.org• 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
  • W h o is f a v o r e d b y w h a t s t r u c t u r e d e c is io n ? www.CenterForUrbanHealth.orgO utc o me R e w a rd B a s e d onme a s ur A c h ie v in ge is : Absolute target Improvement High resource providers Low resource providersUnadjusted High resource patients High resource patientsAdjusted or High resource providers Low resource providersstratified: Any kind of patient Any kind of patientObserved to High resource providers Low resource providersExpected Low resource patients Low resource patients
  • D e c is io n s n o w f a v o r : www.CenterForUrbanHealth.orgO utc o me R e w a rd B a s e d onme a s ur A c h ie v in ge is : Absolute target Improvement High resource providers Low resource providersUnadjusted High resource patients High resource patientsAdjusted or High resource providers Low resource providersstratified: Any kind of patient Any kind of patientObserved to High resource providers Low resource providersExpected Low resource patients Low resource patients
  • D e c is io n s c o u ld f a v o r : www.CenterForUrbanHealth.orgO utc o me R e w a rd B a s e d onme a s ur A c h ie v in ge is : Absolute target Improvement High resource providers Low resource providersUnadjusted High resource patients High resource patientsAdjusted or High resource providers Low resource providersstratified: Any kind of patient Any kind of patientObserved to High resource providers Low resource providersExpected Low resource patients Low resource patients
  • T o d a y ’ s p r e s e n t a t io n w ill d is c u s s : www.CenterForUrbanHealth.org• 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
  • Q u e s t io n s , a n s w e r s & im p lic a t io n s : www.CenterForUrbanHealth.org Question Answer Policy implicationsDo existing measures Develop & use new measuresassess equity or No relevant to disparities.equality in quality? Stratify reports by SESDoes patient race & Very likely. Known Use SES to risk-adjust orSES affect MNCM that low SES outcomes measures? worse outcomes calculate observed-to- expected outcomesWhich non-medical Family, patient, Reimbursement higher whenagents affect MNCM community, public contributions from non-outcome measures? policies medical agents are low
  • Th e B a d N e w s : www.CenterForUrbanHealth.org• 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
  • Th e g o o d n e w s : www.CenterForUrbanHealth.org• 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.orgT h is p r o b le m is s o lv a b le ! L e t’ s s ta rt.
  • E x t r a s lid e s
  • C h r o n ic C a r e M o d e l www.CenterForUrbanHealth.orgfrom E.H. Wagner 1998. What will it take to improve care for chronicillness? Effective Clinical Practice. 1(1):2-4
  • V is io n in g a n e w r e im b u r s e m e n t s t r u c t u r e : www.CenterForUrbanHealth.org• 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)
  • H o w h e a lt h y is M in n e s o t a ? www.CenterForUrbanHealth.org • 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.
  • M N H e a lt h S t r e n g t h s b y Rac e* www.CenterForUrbanHealth.orgc e : M in n e s o t a D e p a r t m e n t o f H e a lt h , S p r in g 2 0 0 6 .
  • M N p o p u la t io n g r o w t h ra te s b y ra c e : www.CenterForUrbanHealth.org
  • C h a n g e s in M Nd e mo g ra p hy b y c o u nty www.CenterForUrbanHealth.org
  • S o m e a n s w e r s t o e m p ir ic a l Qs: www.CenterForUrbanHealth.org • 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.