Use of Outcome Measures in Payment Reform: Rationale (Text Version)

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On September 14, 2009, Patrick S. Romano made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (2.4 MB).

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Use of Outcome Measures in Payment Reform: Rationale

Patrick S. Romano, MD MPH
UC Davis Center for Healthcare Policy and Research

AHRQ Annual Conference
Bethesda, MD; September 14, 2009

 

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Overview

• Variation in quality and outcomes is substantial and is driven (at least somewhat) by provider behavior
• Suboptimal health care quality and outcomes contribute to excess costs
• Higher quality is not generally associated with higher overall costs, but improving quality often reduces provider revenue under current payment systems
• Questions and answers

 

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Variation in quality and outcomes is substantial and is driven (at least somewhat) by provider behavior

 

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Chronic disease proxy outcomes:
Managed care plan distribution, 2006

Percent of adults with diagnosed diabetes whose HbA1c level <9.0%

	Private	Medicare	Medicaid
Mean	70	73	49
90th %ile	81	88	68
10th %ile	60	56	30

Percent of adults with hypertension whose blood pressure <140/90 mmHg

	Private	Medicare	Medicaid
Mean	60	57	53
90th %ile	68	67	66
10th %ile	49	46	39

Note: Diabetes includes ages 18�75; hypertension includes ages 18�85.
Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Hospitals: Quality of care for heart attack, heart failure, and pneumonia

Percent of patients who received recom-mended care for all three conditions*

	2004	2006
Median	84	90
Best	99	100
90th %ile	91	96
10th %ile	75	78

Percent of patients who received recommended care for each condition*

	Heart Attack	Heart Failure	Pneumonia
Median	96	91	87
90th %ile	99	98	95
10th %ile	88	71	76

* Composite for heart attack care consists of 5 indicators; heart failure care, 2 indicators; and pneumonia care, 3 indicators.
Overall composite consists of all 10 clinical indicators. See report Appendix B for description of clinical indicators.
Data: A. Jha and A. Epstein, Harvard School of Public Health analysis of data from CMS Hospital Compare.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Hospital-Standardized Mortality Ratios

Standardized ratios compare actual to expected deaths, risk-adjusted for patient mix and community factors.
* Medicare national average for 2000=100

	U.S.	1	2	3	4	5	6	7	8	9	10
2000-2002	101	85	93	94	97	100	103	106	106	112	117
2004-2006	82	74	78	78	79	81	83	83	85	86	89

Decile of hospitals ranked by actual to expected deaths ratios

* See report Appendix B for methodology.
Data: B. Jarman analysis of Medicare discharges from 2000 to 2002 and from 2004 to 2006 for conditions leading to 80 percent of all hospital deaths.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Nosocomial infections in intensive care unit patients, 2006

Central line-associated bloodstream infection rate, per 1,000 days use		Percentile
Type of ICU	No. of units	10%	25%	50%	75%	90%
Medical	73	0.0	0.0	2.2	4.2	6.2
Med-surg major teaching	63	0.0	0.6	1.9	3.1	5.5
Med-surg all others	102	0.0	0.0	1.0	2.3	4.5
Surgical	72	0.0	0.9	2.0	4.4	7.4
Neonatal�Level III (infants weighing 750 grams or less)	42	0.0	2.5	5.2	11.0	15.6

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Nosocomial infections in intensive care unit patients, 2006

Ventilator-associated pneumonia rate, per 1,000 days use		Percentile
Type of ICU	No. of units	10%	25%	50%	75%	90%
Medical	64	0.0	0.9	2.8	4.6	7.2
Med-surg major teaching	58	0.0	1.3	2.5	5.1	7.3
Med-surg all others	99	0.0	0.0	1.6	3.8	6.2
Surgical	61	0.0	1.8	4.1	6.4	10.0
Neonatal (NICU)(infants weighing 750 grams or less)	36	0.0	0.0	1.7	4.1	9.5

Data: Reported by 211 hospitals participating in the National Healthcare Safety Network (Edwards et al. 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Potentially preventable adverse events and complications of care in hospitals among Medicare beneficiaries across states, 2005-2006

	Postoperative complications composite*	Adverse drug events composite**	Pressure sores
US Average	2.4	9.8	4.6
Top 10% States	1.9	8.8	3.6
Bottom 10% States	3.6	10.6	6.0

*Surgical patients with postoperative pneumonia, urinary tract infection (2005 only), or venous thromboembolic event
** Patients with serious bleeding associated with intravenous heparin, low molecular weight heparin, or warfarin, or hypoglycemia associated with insulin or oral hypoglycemics.
Data: M. Pineau, Qualidigm analysis of Medicare Patient Safety Monitoring System.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Suboptimal health care quality and outcomes contribute to excess costs

 

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"Business case": Impact of preventing PSI on mortality, LOS, charges
NIS 2000 analysis by Zhan & Miller, JAMA 2003;290:1868-74

Indicator	Mort (%)	LOS (d)	Charge ($)
Postoperative septicemia	21.9	10.9	$57,700
Selected infections due to medical care	4.3	9.6	38,700
Postop abd/pelvic wound dehiscence	9.6	9.4	40,300
Postoperative respiratory failure	21.8	9.1	53,500
Postoperative physiologic or metabolic derangement	19.8	8.9	54,800
Postoperative thromboembolism	6.6	5.4	21,700
Postoperative hip fracture	4.5	5.2	13,400
Iatrogenic pneumothorax	7.0	4.4	17,300
Decubitus ulcer	7.2	4.0	10,800
Postoperative hemorrhage/hematoma	3.0	3.9	21,400
Accidental puncture or laceration	2.2	1.3	8,300

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

 

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"Business case":
Impact of preventing PSI on mortality, LOS, VA cost
VA PTF 2001 analysis by Rivard et al., Med Care Res Rev; 65(1):67-87

Indicator	Mort (%)	LOS (d)	Charge ($)
Postoperative septicemia	30.2	18.8	$31,264
Selected infections due to medical care	2.7	9.5	13,816
Postop abd/pelvic wound dehiscence	11.7	11.7	18,905
Postoperative respiratory failure	24.2	8.6	39,745
Postoperative physiologic or metabolic derangement
Postoperative thromboembolism	6.1	5.5	7,205
Postoperative hip fracture
Iatrogenic pneumothorax	2.7	3.9	5,633
Decubitus ulcer	6.8	5.2	6,713
Postoperative hemorrhage/hematoma	5.1	3.9	7,863
Accidental puncture or laceration	3.2	1.4	3,359

Excess mortality, LOS, and charges computed from mean values for PSI cases and matched controls.

 

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Uncertain "business case" for some PSIs
Zhan & Miller, JAMA 2003;290:1868-74
Rosen et al., Med Care 2005;43:873-84

Indicator	Mort (%)	LOS (d)	Charge ($)
Birth trauma	-0.1 (NS)	-0.1 (NS)	300 (NS)
Obstetric trauma �cesarean	-0.0 (NS)	0.4	2,700
Obstetric trauma - vaginal w/out instrumentation	0.0 (NS)	0.05	-100 (NS)
Obstetric trauma - vaginal w instrumentation	0.0 (NS)	0.07	220
Complications of anesthesia*	0.2 (NS)	0.2 (NS)	1,600
Transfusion reaction*	-1.0 (NS)	3.4 (NS)	18,900 (NS)
Foreign body left during procedure†	2.1	2.1	13,300

* All differences NS for transfusion reaction and complications of anesthesia in VA/PTF.
† Mortality difference NS for foreign body in VA/PTF.

 

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Thomson Reuters analysis of PSI business case
Foster et al., AcademyHealth 2009

• AHRQ Patient Safety Indicators (PSIs) were used to identify selected medical and surgical injuries
• Thomson Reuters Projected Inpatient Data Base for federal FY 2007 (based on 21.5 million discharge abstracts from 2,620 acute hospitals)
• Regression models were used to adjust for age, sex, clinical category, and comorbid conditions
• Model coefficients were used to estimate annual impact attributable to PSI events
• Total impact:
  • almost 30,000 excess deaths
  • 3.4 million excess hospital days
  • $9 billion in excess hospital costs

 

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International evidence of "business case" from case control analysis of PSIs in NHS England

Admissions, England, 2005-6 Indicator	Excess LOS (days)	Excess Mortality (percent)
Pressure ulcer	9.1	13.4
Accidental puncture of lung	4.3	10.6
Central line and device related infections	11.4	5.7
Postoperative hip fracture	17.1	18.2
Postoperative sepsis	15.9	27.1
Obstetric trauma � vaginal with instrument	0.6	* (NS)
Obstetric trauma � vaginal without instrument	0.5	0.01 (NS)
Obstetric trauma � caesarean	0.2 (NS)	* (NS)

All differences were statistically significant at p<0.001 except as noted.
Raleigh VS, Cooper J, Bremner SA, Scobie S, Patient safety indicators for England from hospital administrative data, BMJ 2008, 337; a1702.

 

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Quality is not generally associated with overall costs, but improving quality often reduces provider revenue given current payment systems

 

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Total Medicare payments vary widely across Hospital Referral Regions

Map of the United States showing the total rates of reimbursement for noncapitated Medicare per enrollee (by Hospital Referral Region, 2006).

 

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Quality and costs of care for Medicare patients hospital-ized for heart attacks, hip fractures, or colon cancer, by Hospital Referral Regions, 2004

Chart showing the median relative resource use being $27,499.
Quality of Care* (1-Year Survival Index, Median=70%)

* Indexed to risk-adjusted 1-year survival rate (median=0.70).
** Risk-adjusted spending on hospital and physician services using standardized national prices.
Data: E. Fisher, J. Sutherland, and D. Radley, Dartmouth Medical School analysis of data from a 20% national sample of Medicare beneficiaries.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Quality of Care according to Level of Medicare Spending in Hospital Referral Region of Residence*

Variable	Quintile of EOL-EI					Test for Trend �
	1 (Lowest)	2	3	4	5 (Highest)
	<	-----------------------	%	-----------------------	>
Acute MI cohort �
Received reperfusion within 12 hours	55.8	55.3	52.3	53.3	49.8	v
Received aspirin in the hospital	87.7	87.0	84.8	85.3	83.9	v
Received aspirin at discharge	83.5	82.5	79.8	78.5	74.8	v
Received ACE inhibitors at discharge	62.7	60.0	56.6	58.3	58.5	v
Received ß-blockers in the hospital	61.5	61.0	54.3	61.5	63.9	^
Received ß-blockers at discharge	52.7	53.2	47.1	53.5	53.7	>0.05
MCBS cohort
Preventive services
Received influenza vaccine	60.3	56.3	54.3	50.0	48.1	v
Received pneumonia vaccine	29.4	28.7	27.2	25.3	19.7	v
Received Papanicolaou smear (among women without hysterectomy)	40.8	36.9	39.6	39.8	33.6	v
Received mammography (among women age 65-69 y)	48.7	46.9	46.2	47.5	47.6	>0.05

* ACE = angiotensin-converting enzyme; EOL-EI = End-of-Life Expenditure Index; MCBS = Medicare Current Beneficiary Survey; MI = myocardial infarction.
Arrows show the direction of any statistically significant association (P<0.05) between the percentage of patients receiving a specified service and regional EOL-EI differences. An arrow pointing upward indicates that as spending increases across regions, the percentage of patients receiving a specified service increases. A P value greater that 0.05 was considered not significant.
Values are for patients who were ideal candidates for the specific treatment, defined as having no absolute or relative contraindication.

 

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Estimated excess 90-day payments due to AHRQ PSIs, 2001-2 MarketScan Commmercial Claims Database (5.6 m enrollees)

Patient safety event class	Total	Index hospital	Readmits	Outpatient	Drugs
Technical problems	$646	$1,407	-$616	-$97	-$48
Infections	19,480	15,674	2,594	1,047	165
Pulmonary/vascular	7,838	6,533	659	373	273
Acute respiratory failure	28,218	25,828	1,702	631	57
Metabolic problems	11,797	11,536	288	-117	90
Wound problems	1,426	1,285	109	54	-22
Nursing-sensitive events	12,196	11,657	484	40	15

All differences in total excess payments were statistically significant at p<0.001 except for Technical Problems and Wound Problems, after adjusting for propensity based on 92 collapsed DRGs, 20 comorbidities, and 12 other patient characteristics.
Encinosa and Hellinger, HSR 2008;43:2067-85.

 

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Ambulatory care-sensitive hospitalizations (AHRQ PQI) for select conditions across states

Adjusted rate per 100,000 population

2002/2003^ 2004 U.S. Average 498 476 Top 10% states 258 246 Bottom 10% states 631 634	2002/2003^ 2004 U.S. Average 241 240 Top 10% states 137 126 Bottom 10% states 299 293	2002/2003^ 2004 U.S. Average 178 156 Top 10% states 62 49 Bottom 10% states 242 230
Heart failure	Diabetes*	Pediatric asthma

^ 2002 data for heart failure and diabetes; 2003 data for pediatric asthma. *Combines four diabetes admission measures: uncontrolled, short-term complications, long-term complications, and lower extremity amputations.
Data: National average�Healthcare Cost and Utilization Project, Nationwide Inpatient Sample; State distribution�State Inpatient Databases; not all states participate in HCUP (AHRQ 2005, 2007a).

 

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Medicare admissions for AHRQ PQIs, rates and associated costs, by Hospital Referral Regions

Rate of ACS admissions per 10,000 beneficiaries

	2003	2005
National mean	771	700
10th	499	465
25th	610	558
75th	887	816
90th	1043	926

Percentiles

Costs of ACS admissions as percent of all discharge costs

	2003	2005
National mean	13.4	12.6
10th	10.0	9.8
25th	11.8	11.1
75th	14.7	13.6
90th	16.3	15.2

Percentiles

See report Appendix B for complete list of ambulatory care-sensitive conditions used in the analysis.
Data: G. Anderson and R. Herbert, Johns Hopkins University analysis of Medicare Standard Analytical Files (SAF) 5% Inpatient Data.

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Planned AHRQ QI enhancements to support payment reform

• Extend Prevention Quality Indicators (PQIs) to EDs
  • Modify and test existing PQIs using State Emergency Department Databases (SEDD)
  • Feed "enhanced PQIs" into the Preventable Hospitalization Costs Mapping Tool
• Develop AHRQ ED Patient Safety Indicators (EDPSIs)
• Pilot AHRQ Efficiency and Resource Use Indicators
• Fully incorporate "Present on Admission" logic into the AHRQ PSIs
  • Current algorithms grafted POA onto previous algorithms, resulting in enhanced PPV/specificity but no gain in sensitivity
  • Reconsider necessity and value of PSI denominator exclusions (i.e., nursing home transfers for Pressure Ulcer) and numerator restrictions (i.e., procedures)

 

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Questions and Discussion

 

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Potentially inappropriate antibiotic prescribing, children with sore throat:
Managed care plan distribution, 2006

Percent of children prescribed antibiotics for throat infection without receiving a "strep" test*

National Average

Year	%
1997-2003	43
2004	35

Managed Care Plan Distribution, 2006

	Private	Medicaid
Mean	27	44
10th %ile	14	23
90th %ile	43	74

Note: National average includes ages 3�17 and plan distribution includes ages 2�18.
* A strep test means a rapid antigen test or throat culture for group A streptococcus.
Data: National average�J. Linder, Brigham and Women's Hospital analysis of National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey; Plan distribution�Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Managed care health plans:
Potentially inappropriate imaging studies for low back pain, by plan type

Percent of health plan members (ages 18�50) who received an imaging study within 28 days following an episode of acute low back pain with no risk factors

	Private	Medicaid
Mean	26	22
10th %ile	19	15
90th %ile	35	29

Managed care plans (2006)

	2004*	2005	2006
Private	25	25	26
Medicaid	22	21	22

Annual averages
 

* Denotes baseline year.
Data: Healthcare Effectiveness Data and Information Set (NCQA 2007).

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

 

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Unexplained Variation in Care at End of Life

Among chronically ill Medicare beneficiaries who received the majority of their care during 1999-2000 at 77 hospitals ranked as the best in America, there was striking variation in use of resources in the last six months of life, suggesting that where one receives care - more than the nature of one's illness - determines the amount of care that is provided.

Use of services during the last six months of life among Medicare fee-for-service beneficiaries with cancer, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) at 77 U.S. hospitals, 1999-2000

	Cancer	COPD	CHF
Hospital with the lowest rate	8.5	10.1	8.9
Hospital with the median rate	12.3	14.9	15.1
Hospital with the highest rate	23.0	29.6	32.3

Hospital days per decedent

	Cancer	COPD	CHF
Hospital with the lowest rate	0.6	1.8	2.1
Hospital with the median rate	1.4	4.4	4.3
Hospital with the highest rate	8.1	13.1	13.4

ICU days per decedent

	Cancer	COPD	CHF
Hospital with the lowest rate	13.0	15.4	15.2
Hospital with the median rate	26.2	35.2	33.9
Hospital with the highest rate	64.6	87.4	99.3

Physician visits per decedent

Source: Medicare administrative data (Wennberg et al. 2004b). Rates were case-mix adjusted to control for differences in patient's age, sex, race, and desease comorbidities. ICU - intensive care unit.