. Creating a High Performance Health Care System North Dakota Health Care Review, Inc. Quality Forum - October 9, 2007 Mary Wakefield, Ph.D., R.N. Associate Dean for Rural Health and Director, Center for Rural Health C H R Center for Rural Health Seven Core Areas of Focus 1. Rural Health Research 2. Rural Health Policy 3. Rural Health Workforce 4. Native American Health 5. Education, Training and Resource Awareness 6. Community Development and Technical Assistance 7. Program Evaluation 2 r:/director/presentations/nd qio 1
C H R 3 R C H Center for Rural Health Electronic Publications 4 r:/director/presentations/nd qio 2
C H R A product of the Department of Health and Human Services Rural Initiative. Established in December 2002 as a rural health and human services information portal. 5 R C H RAC Services Every State, DC, Puerto Rico & 10 Foreign Countries Customized Assistance 4,200 requests Phone: 1-800-270-1898 Fax: 1-800-270-1913 Email: info@raconline.org Website: http://www.raconline.org Web-Based Services (visits) TOTAL VISITS MORE THAN 1,346,652 RAC Health and Human Services Listserv J reaches more than 5,600 individuals 6 r:/director/presentations/nd qio 3
RAC Web Site http://www.raconline.org Funding opportunities Information guides on key topics News and Events Experts and Organizations Publications and Maps Success Stories State Resources 7 R Commission on a High Performance Health System The overarching mission of a high performance health system is to 8 r:/director/presentations/nd qio 4
help everyone, to the extent possible, lead long, healthy, and productive lives. 9 Scores: Dimensions of a High Performance Health System 0 100 Long, Healthy, & Productive Lives 69 Quality 71 Access 67 Efficiency 51 Equity 71 OVERALL SCORE 66 (Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) r:/director/presentations/nd qio 5
Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care Deaths per 100,000 population* 150 100 75 81 84 International Variation - 1998 88 88 88 92 97 97 99 115 115 106 107 109 109 129 130 132 State variation - 2002 134 119 110 103 90 84 50 0 France Japan Spain Sweden Italy Australia Canada Norway Netherlands Greece Germany Austria New Zealand Denmark United States Finland Ireland United Kingdom Portugal U.S. avg 10th 25th Median 75th Percentiles See Technical Appendix for list of conditions considered amenable to health care in the analysis. Data: International estimates World Health Organization, WHO mortality database (Nolte and McKee 2003); State estimates K. Hempstead, Rutgers University using Nolte and McKee methodology. 11 90th 11 C H R 110 83 84 LONG, HEALTHY & PRODUCTIVE LIVES Mortality Amenable to Health Care Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care. Deaths per 100,000 population* State Variation - 2002 90 103 119 134 U.S. average North Dakota 10th 25th Median 75th 90th Percentiles 12 r:/director/presentations/nd qio 6
EFFICIENCY 7000 6000 5000 4000 International Comparison of Spending on Health, 1980 2004 Average spending on health per capita ($US PPP) United States Germany Canada France Australia United Kingdom 16 14 12 10 Total expenditures on health as percent of GDP 3000 2000 1000 0 1980 1982 1984 Data: OECD Health Data 2005 and 2006. 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 8 6 4 2 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 United States Germany Canada France Australia United Kingdom 1998 2000 2002 (Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) 13 13 2004 Medicare Expenditures, 1970-2015 Dollars (in billions) $900 $799 $800 $700 $600 $553 $500 $400 $336 $300 $222 $184 $200 $72 $111 $100 $37 $8 $16 $0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 14 Note: Figures for 2010 and 2015 are projected (Source: 2007 Medicare Trustees Report) r:/director/presentations/nd qio 7
2000 2001 States Vary In Quality of Care WA ME VT NH MT ND MN QUALITY CA OR NV ID UT WY CO SD NE KS WI IA IL MO MI OH IN WV KY NY PA VA NJ MA RI CT DE MD DC TN NC AZ NM OK AR MS AL GA SC TX LA AK Note: State ranking based on 22 Medicare performance measures. FL Quartile Rank First Second Third Fourth (Source: S.F. Jencks, E.D. Huff, and T. Cuerdon, Change in the Quality of Care Delivered to Medicare Beneficiaries, 1998 1999 to 2000 2001, Journal of the 15 American Medical Association 289, no. 3 (Jan. 15, 2003): 305 312.) C H R QUALITY U.S. Adults Receive Half of Recommended Care; Quality Varies Significantly by Medical Condition 80 60 40 55 76 65 Percent of recommended care received 54 45 39 23 20 0 Overall Breast Cancer Hypertension Asthma Diabetes Pneumonia Hip Fracture (Source: E. McGlynn et al. 2003. "The Quality of Health Care Delivered to Adults 16 in the United States, The New England Journal of Medicine 248(26): 2635 2645.) r:/director/presentations/nd qio 8
R C H 30 25 20 15 Medicare Hospital 30-Day Readmission Rates, by Regions, 2003 Rate of hospital readmission within 30 days 18 16 14 16 20 22 10 5 0 National Mean North Dakota 10th 25th 75th 90th Percentiles Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of 2003 Medicare Standard Analytical Files 5% Inpatient Data 17 (Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) C H R Medical, Medication, and Lab Errors Among Sicker Adults Patients Reporting Any Error by Number of Doctors Seen in Past Two Years 34 30 22 23 25 27 30 75 1 doctor 4 or more doctors 50 25 12 37 40 35 31 15 14 14 12 28 22 48 0 UK GER NZ AUS CAN US 0 AUS CAN GER NZ UK US UK = United Kingdom; GER = Germany; NZ = New Zealand; AUS = Australia; CAN = Canada; US = United States. International Health Policy Survey of Sicker Adults; Schoen et al. 2005a. 2005 Commonwealth Fund International Health Policy Survey 18 r:/director/presentations/nd qio 9
CMS Hospital Compare CAHs as a group are performing: As well or better than urban hospitals on half of the pneumonia measures and surgical infection prevention measures Not as well as urban hospitals on all of the quality measures for AMI and CHF (Source: University of Minnesota analysis of Hospital Compare Data for 2005) 19 Medicare/Premier Hospital Quality P4P Demonstration First year results = significant improvement; composite score increased AMI: 87% to 91% Heart Failure: 65% to 74% Pneumonia: 69% to 79% Patients receiving better care showed lower mortality (AMI, CHF) Cost savings for hospitals (AMI, Pneumonia, CABG) and Medicare (Source: Premier, Centers for Medicare and Medicaid Services/Premier Hospital Quality Incentive Demonstration Project: Project Overview and Findings from year One, April 2006; and Premier, Exploring the Nexus of Quality and Cost: Methodology and Preliminary Findings, August 2006.) 20 r:/director/presentations/nd qio 10
Goals of CMS Value-Based Purchasing Program Improve clinical quality. Reduce adverse events. Encourage patient centered care. Avoid unnecessary costs. Stimulate investments in improving quality and/or efficiency. Make performance results transparent and comprehensible, empowering consumers. (North Carolina Hospital Association) 21 CR H CMS Value-Based Purchasing Plan Beginning FY 2007, hospitals report 21 measures or lose 2% in Medicare PPS reimbursement. Value-based payments beginning FY 2009. No payment increase allowed for patients with hospital-acquired infections. 22 r:/director/presentations/nd qio 11
R C H VBP Program Details Budget neutral. In-line with IOM and MedPAC. Build on existing CMS measures. Three domains: 1) Clinical quality 2) Patient centered care 3) Efficiency Performance measures and payments for outpatient care. 23 Outpatient PPS CY09 2.0% reduction for hospitals not reporting outpatient quality measures Proposed FY09: 10 new outpatient measures 5 Emergency Department AMI Transfer Measures 2 Surgical Care Improvement Measures 1 measure each for Heart Failure, Community- Acquired Pneumonia, and Diabetes CMS seeking comment on 30 additional measures 24 r:/director/presentations/nd qio 12
Electronic Medical Records and Information Systems Reduce duplicate tests Provide decision support for physicians and patients Facilitate referrals, Reduce medical errors Promote better management of chronic conditions and care coordination Registries Performance information 25 Where are We on IT? Only 28% of U.S. Primary Care Physicians Have Electronic Medical Records; Only 19% Have Advanced IT Capacity Percent reporting EMR Percent reporting 7 or more out of 14 functions* 100 75 98 92 89 79 100 75 87 83 72 59 50 25 42 28 23 50 25 32 19 8 0 0 NET NZ UK AUS GER US CAN NZ UK AUS NET GER US CAN *Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, 26 medications, patients due for care. Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians r:/director/presentations/nd qio 13
ACCESS: UNIVERSAL PARTICIPATION Number of States with High Proportion of Adults Ages 18 64 Is Growing Uninsured 1999 2000 2004 2005 WA OR NV CA ID UT AZ MT WY CO NM NH ME VT ND MN WI NY MA SD MI RI PA CT IA NJ NE OH IN DE IL WV MD VA DC KS MO KY NC TN OK AR SC MS AL GA TX LA WA OR NV CA ID UT AZ MT WY CO NM VT NH ME ND MN WI NY MA SD MI RI PA CT IA NJ NE OH IN DE IL WV MD VA DC KS MO KY NC TN OK AR SC MS AL GA TX LA AK FL AK FL HI 23% or more 19% 22.9% HI 14% 18.9% Less than 14% Data: Two-year averages 1999 2000 and 2004 2005 from the Census Bureau s March 2000, 2001 and 2005, 2006 Current Population Surveys. Estimates by the Employee Benefit Research Institute. 27 (Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) R C H Access to Care Uninsured in North Dakota 8.2% of North Dakotans are uninsured 51,920 people Similar to the population of Bismarck Over 11,000 are children Rural more likely to be uninsured % of population uninsured 50 45 40 35 30 25 20 15 10 5 0 8.2 North Dakota 15.2 U.S. 28 r:/director/presentations/nd qio 14
Receipt of All Three Recommended Services for Diabetics, by Race/Ethnicity, Family Income, Insurance, and Residence, 2002 Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year Total 53 Private Uninsured * 24 54 Urban ** 55 Rural 45 0 40 80 * Insurance for people ages 18 64. ** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants. Data: Medical Expenditure Panel Survey (AHRQ 2005a). 29 (Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006) 30 r:/director/presentations/nd qio 15
Gains if North Dakota Achieved Top State Performance More Getting the Right Care 1,200 diabetics would receive recommended care 910 children immunized More Getting Primary Care 64,174 adults and 27,871 children with primary care Less Avoidable Hospital Utilization More than 2,250 fewer Medicare hospital admissions and readmissions per year (Savings of $8.4 million + per year) 31 Key Findings Wide variation among states, huge potential to improve Two to three-fold differences in many indicators Leaders offer benchmarks Leading states consistently out-perform lagging states Suggests policies and systems linked to better performance Distinct regional patterns, but also exceptions Significant opportunities to address cost, quality, access Quality not associated with higher cost across states All states have room to improve Even best states perform poorly on some indicators. 32 r:/director/presentations/nd qio 16
The Dialogue Has Changed FROM: Americans have the best health care system in the world TO: We need to do better We spend more on health care than any other country We need more value for what we are spending 33 The American Health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will. (IOM, 2001) 34 r:/director/presentations/nd qio 17
What do we need to Focus on to be the Best? A high performance health system is designed to achieve four core goals: 1. high quality, safe care 2. access to care for all people 3. efficient, high value 4. system capacity to improve HIGH QUALITY, SAFE, COMPASSIONATE, COORDINATED CARE EFFICIENCY ACCESS AND EQUITY FOR ALL LONG, HEALTHY, AND PRODUCTIVE LIVES CAPACITY FOR SYSTEM AND WORKFORCE INNOVATION AND IMPROVEMENT 35 Keys to Transforming the U.S. and North Dakota Health Care System 1. Extend health insurance coverage 2. Safe, effective, and efficient care 3. Ensure coordinated and accessible care for all 4. Increase transparency, reward quality and efficiency 5. Information technology and exchange 6. Workforce for patient-centered and primary care 7. Collaboration among public and private stakeholders 36 r:/director/presentations/nd qio 18
Efforts to Extend Health Insurance Coverage to All 1. Extend Health Insurance Coverage to All 37 What Are the Most Important Health Care Issues for Presidential and Congressional Action? Percent listing issue as first or second priority: Total Less than $50,000 $50,000 $74,999 $75,000 or more Ensure that all Americans have adequate, reliable health insurance 52 56 52 50 Control the rising cost of medical care 37 35 42 39 Lower the cost of prescription drugs 31 31 27 33 Ensure that Medicare remains financially sound in the longterm 29 29 32 30 Improve the quality of nursing homes and long-term care 14 16 15 13 Reform the medical malpractice system 14 10 12 18 Reduce the complexity of insurance 12 12 10 10 (Source: C. Schoen, S.K. How, I. Weinbaum, J.E. Craig, Jr., and K. Davis, Public Views 38 on Shaping the Future of the U.S. Health System, The Commonwealth Fund, August 2006.) r:/director/presentations/nd qio 19
State Initiatives MA Strategy for Health Care Everyone does their part Illinois All-Kids Utah s Primary Care Network Section 1115 Medicaid Waiver Vermont Health Care Affordability Act Enacted May 2006 California Governor s Health Care Proposal Retaining/Expanding Employer Participation: Maine s Dirigo Health Minnesota Smart-Buy Alliance Rhode Island: Five- Point Strategy New Jersey Raises Age of Dependent Status for Health Insurance 39 Pursue Excellence in Provision of Safe, Effective, and Efficient Care 1. Extend Health Insurance Coverage to All 2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care 40 r:/director/presentations/nd qio 20
Perfect Care When is performance good enough? For you; for your family Near-perfection is attainable even in health care The question we all should be asking: How soon can we achieve perfect care? Within our organization Across the entire health care system 42 r:/director/presentations/nd qio 21
H.R.1651 Title: To provide for the establishment of the Rural Health Quality Advisory Commission Organize the Care System to Ensure Coordinated and Accessible Care for All 1. Extend Health Insurance Coverage to All 2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 44 r:/director/presentations/nd qio 22
Public Views about Effective Actions to Improve Care Quality 140 120 100 92 90 88 81 22 27 26 34 80 60 40 20 0 Computerized medical records somewhat effective very effective (Commonwealth Fund, 2006) Doctors and nurses working as a team/expanded role for nurses Receiving reminders for preventive care Doctors practicing in groups rather than on their own 45 Increase Transparency and Reward Quality and Efficiency 1. Extend Health Insurance Coverage to All 4. Increase Transparency and Reward Quality and Efficiency 2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 46 r:/director/presentations/nd qio 23
(North Carolina Hospital Association) 47 R C H Wisconsin Wisconsin Collaborative for Healthcare Quality Voluntary consortium formed in 2003 -- physician groups, hospitals, health plans, employers & labor Develops & publicly reports comparative performance information on physician practices, hospitals & health plans Includes measures assessing ambulatory care, IT capacity, patient satisfaction & access Wisconsin Health Information Organization Coalition formed in 2005 to create a centralized health data repository based on voluntary sharing of private health insurance claims, including pharmacy & laboratory data Wisconsin Dept of Health & Family Services and Dept of Employee Trust Funds will add data on costs of publicly paid health care through Medicaid 48 r:/director/presentations/nd qio 24
Expand the Use of Information Technology and Exchange 1. Extend Health Insurance Coverage to All 2. Pursue Excellence in Provision of Safe, 5. Expand the Use of Information Technology and Exchange 4. Increase Transparency and Reward Quality and Efficiency Effective, and Efficient Care 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 49 Rural Health Information Technology New USDA Initiative on Electronic Medical Records Combines grant and loan funding (20:80) @ 5% Can apply up to one month before end of FY $50K up to $1 million Continuing annual grants and loans for distance learning and telemedicine http://www.usda.gov/rus/telecom/dlt/dlt.htm 50 r:/director/presentations/nd qio 25
Using Telemedicine to Improve Access in Rural Communities The use of electronic information and telecommunications technologies to support long-distance clinical care Improves communication with providers Provides better health monitoring Saves long distance travel Mental health has proven to be a good model High approval ratings from rural patients 51 23 Barriers to Use of Telemedicine in Rural Areas Provider acceptance Health insurance coverage restrictions Licensing restrictions Lack of local infrastructure 52 24 r:/director/presentations/nd qio 26
North Dakota Telepharmacy Project Licensed pharmacists provide traditional services to registered pharmacy technicians at remote sites via audio and video computer links 57 pharmacies involved in project: 21 central pharmacy sites and 36 remote telepharmacy sites 33 counties (62%) in North Dakota and two in Minnesota Served 40,000 rural citizens since its inception in 2002 53 26 Develop the Workforce to Foster Patient/ Population Centered and Primary Care 1. Extend Health Insurance Coverage to All 5. Expand the Use of Information Technology 4. Increase Transparency and Reward Quality and Efficiency 2. Pursue Excellence in Provision of Safe, Effective, and Exchange and Efficient Care 6. Develop the Workforce to Foster Patient-Centered and Primary Care 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 54 r:/director/presentations/nd qio 27
Ratio of Rates of Inpatient & Part B Spending During the Last Two Years of Life to the U.S. Average (Deaths Occurring 2000-03) 1.15 to 1.37 (5) 1.00 to < 1.15 (6) 0.85 to < 1.00 (32) 0.81 to < 0.85 (8) (Dartmouth) 55 Standardized FTE Physician Labor Inputs per 1,000 Decedents During the Last Two Years of Life (Deaths Occurring 2000-03) 24 or More (5) 21 to < 24 (10) 18 to < 21 (27) Fewer than 18 (9) (Dartmouth) 56 r:/director/presentations/nd qio 28
The Relationship Between the Ratio of Primary Care to Medical Specialist Physician Labor Inputs and Days Spent in Intensive Care (Deaths Occurring 2000-03) ICU Days per Decedent During the Last Six Months of Life 6.0 5.0 4.0 3.0 2.0 1.0 0.0 ND R 2 = 0.48 0.0 0.5 1.0 1.5 2.0 Ratio of Primary Care to Medical Specialist FTE Labor Inputs During the Last Two Years of Life 57 (Dartmouth) The Relationship Between the Ratio of Primary Care to Medical Specialist Physician Labor Inputs (Deaths Occurring 2000-03) and CMS hospital compare composite quality score 90.0 CMS Hospital Compare Composite Quality Score 85.0 80.0 75.0 ND 70.0 R 2 = 0.11 0.0 0.5 1.0 1.5 2.0 Ratio of Primary Care to Medical Specialist FTE 58 Labor Inputs During the Last Two Years of Life (Dartmouth) r:/director/presentations/nd qio 29
Primary Care Health is better in areas where there are more primary care services. People who receive primary care are healthier. Costs of care are lower in areas where there are more primary care services. (Starfield, et. al. 2005) 59 Encourage Leadership and Collaboration Among Public and Private Stakeholders 1. Extend Health Insurance Coverage to All 4. Increase Transparency and Reward Quality and Efficiency 2. Pursue Excellence in Provision of Safe, Effective, and 5. Expand the Use of Information Technology and Exchange Efficient Care 6. Develop the Workforce to Foster Patient-Centered and Primary Care 3. Organize the Care System to Ensure Coordinated and Accessible Care for All 7. Encourage Leadership and Collaboration Among Public and Private Stakeholders 60 r:/director/presentations/nd qio 30
By Engaging. Broad-based coalition of clinicians, hospitals, public health, health plans, purchasers, and government agencies For example, on a common quality agenda, including shared guidelines and tools, reporting quality measures and patient satisfaction measures 61 At the State Level What We Can Do: Promote: evidence-based health care effective chronic care management transitional care post-hospital discharge data transparency and reporting on performance practice value-based purchasing the use of health information technology wellness and healthy living access to primary care and preventive services simplify and streamline public program eligibility 62 r:/director/presentations/nd qio 31
Health Policy Forecast Cuts? 2008 Climate Map Level Funding Increases? Predictions notoriously difficult Early signs of clear skies (initial deliberations/ position statements) Chance of late storms 63 C H R 2006 Data (Center for Responsive Politics at www.opensecrets.org) 64 r:/director/presentations/nd qio 32
C H R For more information contact: Center for Rural Health University of North Dakota School of Medicine and Health Sciences Grand Forks, ND 58202-9037 Tel: (701) 777-3848 Fax: (701) 777-6779 http://medicine.nodak.edu/crh Email: mwake@medicine.nodak.edu 65 r:/director/presentations/nd qio 33