1. U s in g Q u a lit y www.CenterForUrbanHealth.org
Me a s ure me nt a nd
R 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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
Insurance
N u m b e r s in s id e b a r s r e p r e s e n t
M 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.

10. 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?

11. 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

12. 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.org
Source: Minnesota State Demographic Center, August 2006

13. C h a n g e in M N y o u t h
p o p u la t io n : www.CenterForUrbanHealth.org
Source: Minnesota State Demographic Center, August 2006

14. 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.org
Source: Minnesota State Demographic Center, August 2006

15. 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

16. 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

17. 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

18. 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

19. 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 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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.org
O utc o m
e R e w a rd B a s e d on
me a s ur A c h ie v in g
e is : Absolute target Improvement
High resource providers Low resource providers
Unadjusted High resource patients High resource patients
Adjusted or High resource providers Low resource providers
stratified: Any kind of patient Any kind of patient
Observed to High resource providers Low resource providers
Expected Low resource patients Low resource patients

29. D e c is io n s n o w f a v o r :
www.CenterForUrbanHealth.org
O utc o m
e R e w a rd B a s e d on
me a s ur A c h ie v in g
e is : Absolute target Improvement
High resource providers Low resource providers
Unadjusted High resource patients High resource patients
Adjusted or High resource providers Low resource providers
stratified: Any kind of patient Any kind of patient
Observed to High resource providers Low resource providers
Expected Low resource patients Low resource patients

30. D e c is io n s c o u ld f a v o r :
www.CenterForUrbanHealth.org
O utc o m
e R e w a rd B a s e d on
me a s ur A c h ie v in g
e is : Absolute target Improvement
High resource providers Low resource providers
Unadjusted High resource patients High resource patients
Adjusted or High resource providers Low resource providers
stratified: Any kind of patient Any kind of patient
Observed to High resource providers Low resource providers
Expected Low resource patients Low resource patients

31. 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

32. 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 implications
Do existing measures
Develop & use new measures
assess equity or No
relevant to disparities.
equality in quality?
Stratify reports by SES
Does patient race & Very likely. Known
Use SES to risk-adjust or
SES affect MNCM that low SES 
outcomes measures? worse outcomes calculate observed-to-
expected outcomes
Which non-medical Family, patient, Reimbursement higher when
agents affect MNCM community, public contributions from non-
outcome measures? policies medical agents are low

33. 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

34. 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

35. www.CenterForUrbanHealth.org
T h is p r o b le m is
s o lv a b le !
L e t’ s s ta rt.

36. E x t r a s lid e s

37. C h r o n ic C a r e M o d e l
www.CenterForUrbanHealth.org
from E.H. Wagner 1998. What will it take to improve care for chronic
illness? Effective Clinical Practice. 1(1):2-4

38. 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)

39. 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.

40. M N H e a lt h S t r e n g t h s b y
Rac e* www.CenterForUrbanHealth.org
c 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 .

41. 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

42. C h a n g e s in M N
d e mo g ra p hy b y c o u nty
www.CenterForUrbanHealth.org

43. 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.