America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost.The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances.About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

Background
Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine. However, the overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial vs. repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing.

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The landscape of inappropriate laboratory testing: a 15-year meta-analysis.

Background Health care transitions in the last months of life can be burdensome and potentially of limited clinical benefit for patients with advanced cognitive and functional impairment. Methods To examine health care transitions among Medicare decedents with advanced cognitive and functional impairment who were nursing home residents 120 days before death, we linked nationwide data from the Medicare Minimum Data Set and claims files from 2000 through 2007. We defined patterns of transition as burdensome if they occurred in the last 3 days of life, if there was a lack of continuity in nursing homes after hospitalization in the last 90 days of life, or if there were multiple hospitalizations in the last 90 days of life. We also considered various factors explaining variation in these rates of burdensome transition. We examined whether there was an association between regional rates of burdensome transition and the likelihood of feeding-tube insertion, hospitalization in an intensive care unit (ICU) in the...

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End-of-life transitions among nursing home residents with cognitive issues.

Many commentators view the conversion of small, independent primary care practices into patient-centered medical homes as a vital step in creating a better-performing health care system. The country's first national medical home demonstration, which ran from June 1, 2006, to May 31, 2008, and involved thirty-six practices, showed that this transformation can be lengthy and complex. Among other features, the transformation process requires an internal capability for organizational learning and development; changes in the way primary care clinicians think about themselves and their relationships with patients as well as other clinicians on the care team; and awareness on the part of primary care clinicians that they will need to make long-term commitments to change that may require three to five years of external assistance. Additionally, transforming primary care requires synchronizing practice redesign with development of the health care "neighborhood," which is made up of a broad range of health and health care resources available to patients. It also requires payment reform that supports practice development and a policy environment that sets reasonable expectations and time frames for the adoption of appropriate innovations.

https://www.commed.vcu.edu/IntroPH/Primary_Care/2011/aafomedhomeproj.pdf

Transforming Physician Practices To Patient-Centered Medical Homes: Lessons

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Transforming Physician Practices To Patient-Centered Medical Homes: Lessons From The National Demonstration Project

The concept of accountable care organizations (ACOs) has been set forth in recently enacted national health reform legislation as a strategy to address current shortcomings in the U.S. health care system. This paper focuses on implementation issues related to these organizations, building on some initial examples. We seek to clarify definitions and key principles, provide an update on implementation in the context of other reforms, and address emerging issues that will affect the organizations' success. Finally, building on the initial experience of several organizations that are implementing accountable care and complementary reforms, we propose a national strategy to identify and expand successful approaches to accountable care implementation.

A National Strategy To Put Accountable Care Into Practice

Measuring physician performance is becoming commonplace as health plans and purchasers look for ways to drive quality improvement and to increase physicians' accountability and rewards for achieving quality goals. A recent study1 reported that, among 89% of health maintenance organization plans using physician-oriented pay-for-performance programs, more than one-third measured and rewarded quality at the individual physician level. In addition, public and private purchasers are demanding more information about America's physicians and hospitals to aid in value-based purchasing and selection of health plans and providers.2

However, concerns remain regarding the validity and reliability of such physician performance profiles. Several factors are needed to support fair and accurate comparisons among physicians. These include evidence-based quality measures, complete and accurate data sources, and standardized methods of data collection. Physician-level reliability of a quality measure is another key consideration in this measurement. Physician-level reliability refers to the ability of a quality measure to distinguish an individual physician's performance from the performance of physicians overall. Good physician-level reliability requires the following 2 factors: (1) a sufficient number of patients eligible for a given quality measure and (2) performance variation across physicians on that quality measure.3-5 The greater the number of a physician's patients who are eligible for a quality measure, the more precise the estimate of the physician's performance. When performance variation for a given quality measure across physicians is limited, the likelihood that a physician's performance is statistically significantly different from that of his or her peers is also decreased. Hofer and colleagues6 showed that not controlling for a quality measure's physician-level reliability significantly misrepresented performance differences across physicians. However, adjusting performance profiles in such a manner is not commonplace across the healthcare industry.

Ensuring that measurement results are valid and reliable is important when purchasers and plans (and potentially consumers) use the data to make decisions about which physicians get financial rewards or other benefits. The stakes are particularly high when profiling results are used for public reporting or eligibility for participation in a health plan network. Paying attention to the validity and reliability of data will help to ensure that these decisions are based on real differences in performance among physicians rather than any shortcomings of the measurement.

Although performance results based on limited sample sizes could be adjusted for the reliability of individual measures,7-9 the creation of composite scores may also be a useful way to increase the reliability of physicians' performance scores.10 Little is known about the extent to which constructing composite scores mitigates the limitations of sample size and reliability, while continuing to provide useful and understandable information.11

To date, there have been few reports regarding the reliability of physician-level performance scores associated with commonly used practices and methods in the healthcare industry. To begin to address this deficiency, this study relied on a large data set that combined patient-level administrative data from 9 large health plans to compute performance for primary care physicians (PCPs) using 27 commonly measured quality indicators. This data set is typical of data sources often used by individual health plans to profile physician performance. Specifically, we examined for each quality measure and composite score the proportion of PCPs who could be evaluated given different minimum sample size criteria and the physician-level reliability under those minimum sample size criteria. Our primary research questions were the following: (1) What is the physician-level reliability of commonly used performance measures calculated exclusively based on administrative data? (2) Can more physicians be reliably evaluated using a composite score?

Benchmarking Physician Performance: Reliability of Individual and Composite Measures

Measurement of physician quality performance is increasingly used by health plans as the basis for quality improvement, network design, and financial incentives.1 Still, efforts to measure physician performance face a number of challenges, in particular the need for sufficient sample size to support reliable measurement and the lack of consensus on methods for attributing patient measures to clinicians.2,3

Researchers have noted that measurement and comparison of physician quality can be hampered by sample size.4 A minimum threshold of 30 patients is a common guideline for supporting comparisons for an individual measure,5 and evidence suggests that at least 35 to 45 observations are needed to make valid comparisons.6,7 One challenge in obtaining sufficient sample size relates to the measure itself. Many quality measures describe a select group of patients and, by definition, will yield a small number of patients for any physician. Other measures apply to larger proportions of patients, but the ability to capture information on a physician's entire panel of patients is limited (as when performance measurement relies on data from a single health plan).

A related issue in quality measurement is attribution. Which physicians should be responsible for a quality measure? Given the current focus on team-based chronic disease care and the reality that most patients receive care from multiple clinicians,8 some authors argue that the most appropriate level of accountability is not the individual physician but rather a formal or informal group of physicians.9 Healthcare organizations often attribute patient quality measures based on utilization or a specific set of services, despite the challenges in identifying which physician should be held responsible for the fulfillment (or lack of fulfillment) of a quality measure.

Efforts are needed to understand how these issues may affect the meaningfulness and soundness of physician profiling efforts. In this study, we used a data set that is typical of the information used by health plans to characterize physician performance. Using 27 well-accepted measures that can be obtained from administrative data, we evaluated (1) how many quality events were available per physician and (2) how different attribution rules affect the number of quality events.

Availability of data for measuring physician quality performance.

Better data on the quality of health care being delivered in the United States are urgently needed if efforts to reform the nation's health care system are to succeed. This paper describes a "distributed data approach" to computing performance results while protecting patients' privacy. The strategy builds on the efforts of the Quality Alliance Steering Committee, a multistakeholder coalition focused on the implementation of performance measures. Instead of waiting for the government or the private sector to build large data warehouses, existing data from administrative sources, laboratories, clinical registries, and electronic health records could be put to greater use now, resulting in improved patient care and spurring further advances in performance measurement. In this article we introduce an overall framework for achieving these goals, and we describe a set of steps to accelerate and expand the availability of performance measures to improve care now.

Measuring health care performance now, not tomorrow: essential steps to support effective health reform.

OBJECTIVE To examine how resource use varies with care quality for managed care populations with diabetes. DESIGN AND METHODS Data from 31 commercial health plans (23 health maintenance organizations and 8 preferred provider organizations) were analyzed. Resource use was calculated using medical and pharmacy claims and enrollment data for members with diabetes. A standardized pricing methodology was applied for resource use associated with inpatient, pharmacy, evaluation and management, and procedural services. Quality of care results were calculated for 4 process quality indicators of the Healthcare Effectiveness Data and Information Set (HEDIS) comprehensive diabetes care measure set. RESULTS Resource use varied more between organizations than quality of care results. Pharmacy resource use was significantly associated with higher quality; inpatient, procedure and surgery, and ambulatory care visit resource use were not significantly associated. CONCLUSIONS Quality and resource use for managed care populations with diabetes may vary considerably and be largely independent factors in health care delivery. Health plans may be able to favorably impact both factors.

Joachim Roski

Papers

A National Strategy To Put Accountable Care Into Practice

Benchmarking Physician Performance: Reliability of Individual and Composite Measures

Availability of data for measuring physician quality performance.

Measuring health care performance now, not tomorrow: essential steps to support effective health reform.

Resource use and associated care effectiveness results for people with diabetes in managed care organizations.