Using Quality Measurement and Reporting to Confront Disparities Yiscah Bracha, M.S. Research Director Center for Urban Hea...
Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to add...
Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R  </li></ul><ul><li>Reason to use QM&R to ad...
Goal of Quality Measurement & Reporting <ul><li>Improve population health by </li></ul><ul><li>Improving the quality of me...
When does care most matter to health? <ul><li>Improved quality of medical care makes the most difference to health among t...
Who is most sick and at risk in Minnesota? <ul><li>Racial and ethnic minorities </li></ul><ul><li>Persons of low SES </li>...
Premature mortality in MN by race:
Child health indicators in MN by race *Source:  Minnesota Department of Health, Spring 2006
Indicators of SES by Minnesota race 46  14  23  12  6  16  11  8  39  4  n/a  6 Numbers inside bars represent Minnesota’s ...
Ways to improve MN’s overall health: <ul><li>Improve quality of medical care for majority population, which already is hea...
Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R   </li></ul><ul><li>Reason to use QM&R to a...
Growth in MN non-white population: Source:  Minnesota State Demographic Center, August 2006
Change in MN youth population: Source:  Minnesota State Demographic Center, August 2006
Projected changes in MN population: Source:  Minnesota State Demographic Center, August 2006
Conclusions: <ul><li>Our state is rapidly diversifying </li></ul><ul><li>Much more diversity expected in the future </li><...
Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to add...
How QM&R could address disparities: <ul><li>Help low-income patients use reports  </li></ul><ul><li>Develop disparities-re...
Helping ptts use reports (?) <ul><li>Empirical Q:  Do  patients switch providers on the basis of quality reports? Research...
How QM&R could address disparities: <ul><li>Help low-income patients better use reports   </li></ul><ul><li>Develop dispar...
Goal of Quality Measurement & Reporting <ul><li>Improve population health by </li></ul><ul><li>Improving the quality of me...
How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-re...
1.  Measures relevant to disparities <ul><li>Diversity measures: </li></ul><ul><ul><li>% patients served proportionate to ...
Other measures relevant to disparities: <ul><li>Patient-centeredness.  Develop indicators of good care specific to: </li><...
How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-re...
2a.  Stratify reports <ul><li>For all measures, show outcomes within strata such as: </li></ul><ul><ul><li>Race/ethnicity ...
How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-re...
2b. Structure of reports  <ul><li>All structure decisions favor some at the expense of others; thus choice of structure re...
Who is favored by what structure decision? Low resource providers Low resource patients High resource providers Low resour...
Decisions now favor: Low resource providers Low resource patients High resource providers Low resource patients Observed t...
Decisions  could  favor: Low resource providers Low resource patients High resource providers Low resource patients Observ...
Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to add...
Questions, answers & implications: Develop & use new measures relevant to disparities.  No Do existing measures assess equ...
The Bad News: <ul><li>Minnesota has a disparities problem </li></ul><ul><li>If not addressed, this problem will: </li></ul...
The good news: <ul><li>Quality measurement & reporting framework is state-of-the-art: </li></ul><ul><ul><li>Excellent coop...
This problem is solvable! Let’s start.
Extra slides
Chronic Care Model from  E.H. Wagner 1998.  What will it take to improve care for chronic illness?  Effective Clinical Pra...
Visioning a new reimbursement structure: <ul><li>Based on episodes of care </li></ul><ul><li>Fosters collaboration and mut...
How healthy is Minnesota? <ul><li>Minnesota has ranked as one of the top two healthiest states since1990* </li></ul><ul><l...
MN Health Strengths by Race* *Source:  Minnesota Department of Health, Spring 2006 .
MN population growth rates by race:
Changes in MN demography by county
Some answers to empirical Qs: <ul><li>Effect of patient characteristics on measures of diabetes quality: </li></ul><ul><ul...
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03. Quality Measurement and Report: Implications for Disparities

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Measuring and reporting quality is supposed to improve the quality of healthcare. This presentation discusses how the agenda may exacerbate disparities, and what can be done about that. Presented at Minnesota Community Measurement, February 07.

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  • February 7, 2007. Quality Measurement &amp; 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.
  • 03. Quality Measurement and Report: Implications for Disparities

    1. 1. Using Quality Measurement and Reporting to Confront Disparities Yiscah Bracha, M.S. Research Director Center for Urban Health at HCMC Minneapolis Medical Research Foundation
    2. 2. Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to address disparities </li></ul><ul><ul><li>Locus of Minnesota’s problems in population health </li></ul></ul><ul><ul><li>Demographic changes in the state </li></ul></ul><ul><li>Ways to use QM&R to address disparities </li></ul><ul><ul><li>Disparities-relevant measures </li></ul></ul><ul><ul><li>Disparities-relevant reports </li></ul></ul><ul><ul><ul><li>Stratified measures </li></ul></ul></ul><ul><ul><ul><li>Structure reports to favor providers who do most with least </li></ul></ul></ul><ul><li>Conclusions </li></ul>
    3. 3. Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to address disparities </li></ul><ul><ul><li>Locus of Minnesota’s problems in population health </li></ul></ul><ul><ul><li>Demographic changes in the state </li></ul></ul><ul><li>Ways to use QM&R to address disparities </li></ul><ul><ul><li>Disparities-relevant measures </li></ul></ul><ul><ul><li>Disparities-relevant reports </li></ul></ul><ul><ul><ul><li>Stratified measures </li></ul></ul></ul><ul><ul><ul><li>Structure reports to favor providers who do most with least </li></ul></ul></ul><ul><li>Conclusions </li></ul>
    4. 4. Goal of Quality Measurement & Reporting <ul><li>Improve population health by </li></ul><ul><li>Improving the quality of medical care delivered to the population </li></ul><ul><li>Assumed mechanisms: </li></ul><ul><ul><li>Individual patients choose providers of highest reported quality </li></ul></ul><ul><ul><li>Providers improve quality in order to earn: </li></ul></ul><ul><ul><ul><li>Increased market share </li></ul></ul></ul><ul><ul><ul><li>Improved public image </li></ul></ul></ul><ul><ul><ul><li>Bonus payments from health plans </li></ul></ul></ul>
    5. 5. When does care most matter to health? <ul><li>Improved quality of medical care makes the most difference to health among those: </li></ul><ul><ul><li>Who are acutely ill </li></ul></ul><ul><ul><li>With complex chronic disease </li></ul></ul><ul><ul><li>With lifestyles and exposures that place them at high risk for ill health </li></ul></ul>
    6. 6. Who is most sick and at risk in Minnesota? <ul><li>Racial and ethnic minorities </li></ul><ul><li>Persons of low SES </li></ul>
    7. 7. Premature mortality in MN by race:
    8. 8. Child health indicators in MN by race *Source: Minnesota Department of Health, Spring 2006
    9. 9. Indicators of SES by Minnesota race 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.
    10. 10. Ways to improve MN’s overall health: <ul><li>Improve quality of medical care for majority population, which already is healthiest in the nation? </li></ul><ul><li>-OR- </li></ul><ul><li>Improve quality of medical care for minority populations, which have some of the lowest health indicators in the nation? </li></ul>
    11. 11. Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to address disparities </li></ul><ul><ul><li>Locus of Minnesota’s quality problem </li></ul></ul><ul><ul><li>Demographic changes in the state </li></ul></ul><ul><li>Ways to use QM&R to address disparities </li></ul><ul><ul><li>Disparities-relevant measures </li></ul></ul><ul><ul><li>Disparities-relevant reports </li></ul></ul><ul><ul><ul><li>Stratified measures </li></ul></ul></ul><ul><ul><ul><li>Structure reports to favor providers who do most with least </li></ul></ul></ul><ul><li>Conclusions </li></ul>
    12. 12. Growth in MN non-white population: Source: Minnesota State Demographic Center, August 2006
    13. 13. Change in MN youth population: Source: Minnesota State Demographic Center, August 2006
    14. 14. Projected changes in MN population: Source: Minnesota State Demographic Center, August 2006
    15. 15. Conclusions: <ul><li>Our state is rapidly diversifying </li></ul><ul><li>Much more diversity expected in the future </li></ul><ul><li>Reasons to target resources to disparities: </li></ul><ul><ul><li>Justice: Gaps are indefensible </li></ul></ul><ul><ul><li>Efficiency: Direct resources to places where there is most room to improve </li></ul></ul><ul><ul><li>Sustainability: As the state grows more diverse, the minority in poor health may become the majority </li></ul></ul>
    16. 16. Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to address disparities </li></ul><ul><ul><li>Locus of Minnesota’s quality problem </li></ul></ul><ul><ul><li>Demographic changes in the state </li></ul></ul><ul><li>Ways to use QM&R to address disparities </li></ul><ul><ul><li>Disparities-relevant measures </li></ul></ul><ul><ul><li>Disparities-relevant reports </li></ul></ul><ul><ul><ul><li>Stratified measures </li></ul></ul></ul><ul><ul><ul><li>Structure reports to favor providers who do most with least </li></ul></ul></ul><ul><li>Conclusions </li></ul>
    17. 17. How QM&R could address disparities: <ul><li>Help low-income patients use reports </li></ul><ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-relevant reports </li></ul><ul><ul><li>Stratify reports to reveal disparities </li></ul></ul><ul><ul><li>Structure reports to reward providers who </li></ul></ul><ul><ul><ul><li>Do the best with the most challenging patients </li></ul></ul></ul><ul><ul><ul><li>Do the best with the most limited resources </li></ul></ul></ul>
    18. 18. Helping ptts use reports (?) <ul><li>Empirical Q: Do patients switch providers on the basis of quality reports? Research: </li></ul><ul><ul><li>Few patients consult reports. </li></ul></ul><ul><ul><li>Workers switch health plans on the basis of cost, not reported quality </li></ul></ul><ul><li>Normative Q: Should patients switch providers on the basis of quality reports? </li></ul><ul><ul><li>Many say no. Switching disrupts continuity, which is necessary for quality </li></ul></ul>
    19. 19. How QM&R could address disparities: <ul><li>Help low-income patients better use reports </li></ul><ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-relevant reports </li></ul><ul><ul><li>Stratify reports to reveal disparities </li></ul></ul><ul><ul><li>Structure reports to reward providers who </li></ul></ul><ul><ul><ul><li>Do the best with the most challenging patients </li></ul></ul></ul><ul><ul><ul><li>Do the best with the most limited resources </li></ul></ul></ul>
    20. 20. Goal of Quality Measurement & Reporting <ul><li>Improve population health by </li></ul><ul><li>Improving the quality of medical care delivered to the population </li></ul><ul><li>Assumed mechanism: </li></ul><ul><ul><li>Individual patients choose providers of highest reported quality </li></ul></ul><ul><ul><li>Providers improve quality in order to earn: </li></ul></ul><ul><ul><ul><li>Increased market share </li></ul></ul></ul><ul><ul><ul><li>Improved public image </li></ul></ul></ul><ul><ul><ul><li>Bonus payments from health plans </li></ul></ul></ul>
    21. 21. How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-relevant reports </li></ul><ul><ul><li>Stratify reports to reveal disparities </li></ul></ul><ul><ul><li>Structure reports to reward providers who </li></ul></ul><ul><ul><ul><li>Do the best with the most challenging patients </li></ul></ul></ul><ul><ul><ul><li>Do the best with the most limited resources </li></ul></ul></ul>
    22. 22. 1. Measures relevant to disparities <ul><li>Diversity measures: </li></ul><ul><ul><li>% patients served proportionate to demographics in community </li></ul></ul><ul><ul><li>% health care workers with demographics proportionate to those in community </li></ul></ul><ul><li>Access measures: </li></ul><ul><ul><li>Cancelled appointment rates </li></ul></ul><ul><ul><li>Availability of transportation and child care </li></ul></ul><ul><ul><li>% patients served who are uninsured or MA </li></ul></ul>
    23. 23. Other measures relevant to disparities: <ul><li>Patient-centeredness. Develop indicators of good care specific to: </li></ul><ul><ul><li>Multiple chronic conditions </li></ul></ul><ul><ul><li>Gender and age </li></ul></ul><ul><ul><li>Patient stated preferences for aggressive vs. conservative medical therapy </li></ul></ul>
    24. 24. How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-relevant reports </li></ul><ul><ul><li>Stratify reports to reveal disparities </li></ul></ul><ul><ul><li>Structure reports to reward providers who </li></ul></ul><ul><ul><ul><li>Do the best with the most challenging patients </li></ul></ul></ul><ul><ul><ul><li>Do the best with the most limited resources </li></ul></ul></ul>
    25. 25. 2a. Stratify reports <ul><li>For all measures, show outcomes within strata such as: </li></ul><ul><ul><li>Race/ethnicity </li></ul></ul><ul><ul><li>Estimate of SES (from census data) </li></ul></ul><ul><ul><li>Number of co-morbidities </li></ul></ul><ul><li>For all strata, show % patients served within stratum </li></ul>
    26. 26. How QM&R could address disparities: <ul><li>Develop disparities-relevant measures </li></ul><ul><li>Develop disparities-relevant reports </li></ul><ul><ul><li>Stratify reports to reveal disparities </li></ul></ul><ul><ul><li>Structure reports to reward providers who </li></ul></ul><ul><ul><ul><li>Do the best with the most challenging patients </li></ul></ul></ul><ul><ul><ul><li>Do the best with the most limited resources </li></ul></ul></ul>
    27. 27. 2b. Structure of reports <ul><li>All structure decisions favor some at the expense of others; thus choice of structure reflects normative values. </li></ul><ul><li>Two critical dimensions of structure: </li></ul><ul><ul><li>Use raw outcomes vs. outcomes adjusted by patient characteristics </li></ul></ul><ul><ul><li>Display attainment of absolute threshold vs. attainment of improvement </li></ul></ul>
    28. 28. Who is favored by what structure decision? Low resource providers Low resource patients High resource providers Low resource patients Observed to Expected Low resource providers Any kind of patient High resource providers Any kind of patient Adjusted or stratified: Low resource providers High resource patients High resource providers High resource patients Unadjusted Improvement Absolute target Reward Based on Achieving Outcome measure is:
    29. 29. Decisions now favor: Low resource providers Low resource patients High resource providers Low resource patients Observed to Expected Low resource providers Any kind of patient High resource providers Any kind of patient Adjusted or stratified: Low resource providers High resource patients High resource providers High resource patients Unadjusted Improvement Absolute target Reward Based on Achieving Outcome measure is:
    30. 30. Decisions could favor: Low resource providers Low resource patients High resource providers Low resource patients Observed to Expected Low resource providers Any kind of patient High resource providers Any kind of patient Adjusted or stratified: Low resource providers High resource patients High resource providers High resource patients Unadjusted Improvement Absolute target Reward Based on Achieving Outcome measure is:
    31. 31. Today’s presentation will discuss: <ul><li>Goals & presumed mechanisms of QM&R </li></ul><ul><li>Reason to use QM&R to address disparities </li></ul><ul><ul><li>Locus of Minnesota’s quality problem </li></ul></ul><ul><ul><li>Demographic changes in the state </li></ul></ul><ul><li>Ways to use QM&R to address disparities </li></ul><ul><ul><li>Disparities-relevant measures </li></ul></ul><ul><ul><li>Disparities-relevant reports </li></ul></ul><ul><ul><ul><li>Stratified measures </li></ul></ul></ul><ul><ul><ul><li>Structure reports to favor providers who do most with least </li></ul></ul></ul><ul><li>Conclusions </li></ul>
    32. 32. Questions, answers & implications: Develop & use new measures relevant to disparities. No Do existing measures assess equity or equality in quality? Reimbursement higher when contributions from non-medical agents are low Family, patient, community, public policies Which non-medical agents affect MNCM outcome measures? <ul><li>Stratify reports by SES </li></ul><ul><li>Use SES to risk-adjust or calculate observed-to-expected outcomes </li></ul>Very likely. Known that low SES  worse outcomes Does patient race & SES affect MNCM outcomes measures? Policy implications Answer Question
    33. 33. The Bad News: <ul><li>Minnesota has a disparities problem </li></ul><ul><li>If not addressed, this problem will: </li></ul><ul><ul><li>Challenge our commitment to equality </li></ul></ul><ul><ul><li>Waste health improvement resources by not directing them to the places they can do the most good </li></ul></ul><ul><ul><li>Undermine the future vitality of the state, as low-income, minority populations continue to grow </li></ul></ul><ul><li>Quality measurement & reporting methods </li></ul><ul><ul><li>Currently do not address the problem </li></ul></ul><ul><ul><li>May exacerbate it </li></ul></ul>
    34. 34. The good news: <ul><li>Quality measurement & reporting framework is state-of-the-art: </li></ul><ul><ul><li>Excellent cooperation among health plans </li></ul></ul><ul><ul><li>Strong support from business and state </li></ul></ul><ul><ul><li>Willingness to address the disparities issue </li></ul></ul><ul><li>We can utilize the existing framework to address disparities </li></ul>
    35. 35. This problem is solvable! Let’s start.
    36. 36. Extra slides
    37. 37. 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
    38. 38. Visioning a new reimbursement structure: <ul><li>Based on episodes of care </li></ul><ul><li>Fosters collaboration and mutual accountability among all responsible actors: </li></ul><ul><ul><li>Schools and community based social agencies </li></ul></ul><ul><ul><li>Municipalities & counties (e.g. public health impact of development decisions) </li></ul></ul><ul><ul><li>State (e.g. MA eligibility & reimbursement policies) </li></ul></ul>
    39. 39. How healthy is Minnesota? <ul><li>Minnesota has ranked as one of the top two healthiest states since1990* </li></ul><ul><li>According to United Health Foundation, our strengths include: </li></ul><ul><ul><li>Low uninsurance rate </li></ul></ul><ul><ul><li>Low CVD death rate </li></ul></ul><ul><ul><li>Low premature death rate </li></ul></ul><ul><ul><li>Low infant mortality rate </li></ul></ul>* Source: United Health Foundation’s America’s Health Rankings.
    40. 40. MN Health Strengths by Race* *Source: Minnesota Department of Health, Spring 2006 .
    41. 41. MN population growth rates by race:
    42. 42. Changes in MN demography by county
    43. 43. Some answers to empirical Qs: <ul><li>Effect of patient characteristics on measures of diabetes quality: </li></ul><ul><ul><li>Low SES patients have higher rates of smoking, higher BP, higher chol, higher HbA1c. </li></ul></ul><ul><ul><li>Reductions in HbA1c less likely in patients with multiple chronic conditions, have diabetes of longer duration, youngest & oldest, racial minorities, low SES. </li></ul></ul><ul><ul><li>Risk-adjusting provider report card by patient SES can eliminate apparent outliers </li></ul></ul><ul><li>Strength of this knowledge claim: Very good. </li></ul>
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