Straightforwardness in social insurance:.


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Straightforwardness in Social insurance Quality What you have to think about open reporting Elizabeth Mort, MD, MPH VP Quality and Security, MGH Partner Boss Restorative Officer, MGH Group Pioneer for Uniform Brilliant, Accomplices Medicinal services Inc. Straightforwardness in social insurance:
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Straightforwardness in Health Care Quality What you have to think about open reporting Elizabeth Mort, MD, MPH Vice President Quality & Safety, MGH Associate Chief Medical Officer, MGH Team Leader for Uniform High Quality, Partners HealthCare Inc.

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Transparency in social insurance Transparency includes being open about what you do, how you do it, and the outcomes that you get. In social insurance, straightforwardness incorporates Clinical quality and security Service and access Pricing and expense Purpose: Increase open responsibility Inform consumers’ choice making Rationalize asset utilization (costs) in human services Inspire suppliers to enhance

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Outline How could we have been able to we arrive? What data is out there? A short introduction on quality estimation, positioning, tiering Landmark suit Current activities in MA Discussion

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How could we have been able to we arrive? Increasing expense of medicinal services Longstanding issue, now in emergency Gaps in quality Striking variety in quality and administration conveyance Consumerism Consumer strengthening driving straightforwardness and responsibility Consumer coordinated wellbeing arrangements as another strategy to lessen costs

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RISING COSTS 5 Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2008 International Comparison of Spending on Health, 1980-2005 Average spending on wellbeing per capita ($US PPP*) Total consumptions on wellbeing as percent of GDP * PPP=Purchasing Power Parity. Information: OECD Health Data 2007, Version 10/2007. 5

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GAPS IN QUALITY 6 Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2008 Mortality Amenable to Health Care Deaths per 100,000 population* * Countries’ age-institutionalized passing rates before age 75; including ischemic coronary illness, diabetes, stroke, and bacterial diseases. See report Appendix B for rundown of all conditions considered agreeable to human services in the examination. Information: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine examination of World Health Organization mortality records (Nolte and McKee 2008).

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GAPS IN QUALITY 7 Source: Commonwealth Fund National Scorecard on U.S. Wellbeing System Performance, 2008 Recommended Screening & Preventive Care for Adults Percent of grown-ups (ages 18+) who got all suggested screening and preventive consideration inside of a particular time period given their age and sex* U.S. Normal U.S. Variety 2005 * Recommended consideration incorporates seven key screening and preventive administrations: circulatory strain, cholesterol, Pap, mammogram, fecal mysterious blood test or sigmoidoscopy/colonoscopy, and influenza shot. See report Appendix B for complete portrayal. Information: B. Mahato, Columbia University examination of Medical Expenditure Panel Survey.

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Emerging models of installment change: new mixes of old thoughts Incremental changes, for example, default for never occasions Primary consideration installment change, medicinal home, layered case-administration charges, capitation Episode-based installments, worldwide case rates Shared investment funds models, suppliers offer in reserve funds, quality observed Consumer coordinated arrangements Rosenthal MB, NEJM 359;12 Sept 18, 2008

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Consumer-coordinated wellbeing arrangements are rising Rationale: patients with additional out of pocket costs will drive more method of reasoning utilization of assets (ideally information driven) Several mixtures Higher co-installments and deductibles Health bank accounts Tax credits Tiering of doctors Tiering has been the strategy of decision in MA utilized by the Group Insurance Commission

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“ For Your Benefit ,” Group Insurance Commission Newsletter, Fall 2008

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So, what’s at issue? “The fitting approach to gauge physicians’ (quality and) proficiency is a matter of difference between those that pay for (utilization) human services and the individuals who give it.” Arnold Milstein, MD Thomas Lee, MD NEJM 357:26 December 27, 2007

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Providers stress about… Poorly composed execution reporting can prompt hazard avoidance The danger of misclassifying a doctor debilitates their notoriety and occupation There are more compelling approaches to address expense of consideration There are more precise methods for measuring quality

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Consumers and buyers Consumers need more data about the nature of consideration their doctor’s give Consumers need more data about the worth they are obtaining

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Our test Not measuring MD competency somehow is basically impossible Not controlling expenses somehow is just impossible Goal this evening: Review the present estimation activities Discuss what we can get behind as far as evaluating the nature of consideration of MDs

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What’s out there?

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Sources of MD-particular data Word of mouth BORIM doctor profiles Health grade profiles MHQP profiles Health arrangement items levels Angie’s list Vitals.com Consumers checkbook Rate MD Google

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BORIM

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DPH forte profiles: CABG

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DPH claim to fame profiles: CABG

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http://www.mhqp.org

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Healthgrades

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Vitals.com

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Benefits supervisor Husband and wife have quite recently moved to Boston and are utilized by the state and secured through the GIC They’re needing a wellbeing arrangement and need access to: Cardiology

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What is GIC?

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GIC individuals pick an arrangement

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A short introduction on quality estimation Measures of value and effectiveness Physician profiling Tiering philosophies

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Defining quality is a test Donabedian : structure, process, result IOM six points: protected, successful, patient-focused, opportune, productive, impartial FACCT spaces: staying sound, showing signs of improvement, living with ailment or incapacity, adapting to end of life Internal versus Outer crowd

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What we requirement for a decent framework Standardized execution measures speaking to every single significant space Access to pt level information Data confirmation and reviewing Comparative examinations and reporting Performance Measurement Accelerating Improvement IOM 2007

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Health care settings are not just as secured Hospitals - most develop Groups - to some degree created Provider-level - extremely spotty Systems – early Health arranges – NCQA drove the way States - spotty Community - underestimated

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Service line scope is spotty Confidential and Proprietary © March 2008 Sg2

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Steps toward straightforwardness: where are we on this lofty trip? Secret and Proprietary © March 2008 Sg2

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Meanwhile….on-line instruments are proliferating… Source: The Advisory Board Company. Drivers of Consumer Choice Implications from the 2007 Consumer

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Loose discuss precision Accuracy of estimation Reliability Validity Misclassification of doctors Reliability and legitimacy Cut-off focuses

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Reliability identifies with the consistency of a measure Internal consistency, (Cronbach’s Alpha) normally measured between 0-1.0) Test-retest Inter-rater Reliability is an essential for legitimacy!!!

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Validity Face legitimacy (sounds great) Content (are all measurements of the develop measured, accept this is conceivable) Construct (considered with that which is being measured can\'t be operationally characterized) Predictive (cholesterol and CAD hazard) Concurrent (high scores on security culture and low rates of SREs)

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Risk of mis-order Score Significantly underneath Significantly above 0.7 0.8 0.9 50 th percentile Risk of misclassification is low <2.5 % with test size of 45 and estimation dependability of 0.7 Dana Safran. et al; J Gen Intern Med 20-06; 21:13-21 = range of vulnerability

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Efficiency measures Currently, the lion\'s share of productivity measures depend on the MD as the unit of examination Data sources: experience and cases information Risk alteration depends on same source

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Efficiency measures Episode of treatment groupers (ETGs) Pooled cases information are utilized to infer the aggregate expense for a specific scene Care is then credited to a doctor Physicians normal expense is resolved for each ETG Cost per ETG is arrived at the midpoint of over all ETGs that identify with that doc Proprietary

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Commentary on ETG legitimacy We have motivation to be concerned Elizabeth McGlynn, PhD Associate Director, RAND Health; Distinguished Chair in Health Quality

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Measure cost proficiency through “ETG” technique Measure quality by means of HEDIS, and so on. Crush quality and expense scores from cases information Incent patient and doctor conduct by means of differentials in co-installments Implemented in 2006 Tiering

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GIC’s rules for 2008-2011 Must independently rate MD’s in six fortes Cardiology Endocrinology Orthopedics Gastroenterology Rheumatology OB-GYN Three levels for all arrangements foreordained Tier 1: 20% Tier 2: 65% Tier 3: 15% Must utilize GIC’s information Standardized reports to make the rankings interpretable for the doctors (grew cooperatively with MMS data)

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Tufts Navigator (GIC): Tiering Explanation

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Tufts Navigator (GIC): Tiering Explanation proceeded with

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Landmark prosecution

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NY Principles for MD Tiering Core standards of the settlement Accuracy Transparency of data Oversight of procedure Ratings analyst: a 501 c 3 association National standard setting association Regular answering to NY AG

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MMS sues GIC

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What Physicians Are Saying “I am obviously treating patients for epilepsy, as indicated by the GIC. Fairly strange for an ophthalmologist.” “Several patients recorded couldn\'t in any way, shape

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