1999 CAS Seminar on
Health and Managed Care
Hilton Head Island, SC
October 18-19, 1999
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 1
Intro - Shevlin
Benchmarking Measures
and Quality Control
Hilton Head Island, SC
October 18-19, 1999
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 2
Overview on Healthcare Benchmarks
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What?
Why?
Examples
Sources
Classifications
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
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Planning
Limitations
Analysis
Application
Discussion
October 18-19, 1999
page 3
Healthcare Benchmarks
- What are they? • “Gold standards”; target results
• Easily and reproducibly measured
• Pertaining to Financial or Clinical
Outcomes
• Typically involve ratios
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 4
Healthcare Benchmarks
- Why Do We Need Them? -
• Used for Comparison and Quality
Improvement
• “If you cannot measure, you
cannot improve”
• To provide objective measures that
will drive performance to a new
level of excellence
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 5
Healthcare Benchmarks
- Why Do We Need Them Today? -
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History of Efforts in Healthcare Quality
Early years - physician esteem/ethics/peers
1980s - Utilization Management (UM)
1990s - Case/Care Management
Now - Disease/Health Management
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 6
Healthcare Benchmarks
- Why Do We Need Them? •
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Apply evidence-based medicine
Establish “Best Practice”
Monitoring results: “Report Cards”
Target “Intervention Strategies”
Establish Value
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 7
Healthcare Benchmarks
- Why Do We Need Them? Improving healthcare:
• Services
• Process
• Outcomes
• Resources
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 8
Healthcare Benchmarks
- Clinical Examples Mortality - Unequivocal?
- Clinical v.s. cost implication
- Certain diseases and surgeries
- Must be severity risk adjusted
Morbidity - Tests (lab)
- Vitals signs
- Physical findings (disease classes)
- Trends
- Manual records extraction is expensive
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 9
Healthcare Benchmarks
- Clinical Examples Prevention
• Primary
- Screenings/Immunizations
• Secondary
- Drugs/Services
Clinical Guidelines
- Diagnostics/Therapeutics
- Inappropriate
Complications
- Medical/Surgical
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 10
Healthcare Benchmarks
- Other Examples Financials - Dollars
- Resources
Perception / Satisfaction / Patient Self-Assessment
- Functional status
- Access to care
- Waiting times, time to return calls
- Quality of life
- In areas of concern to the patient
Proxy Measures - Length of stay
- Number of visits/services/readmissions
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 11
Intro - Shevlin
Asthma
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 12
Healthcare Benchmarks
- Sources: for Data •
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Medical & pharmacy claims data
Laboratory data
Electronic medical records
Hospital information systems
Utilization review & incident reports
Surveys & direct observation
Proxy Measures: LOS, visits (billing)
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 13
Healthcare Benchmarks
- Sources: Market Characteristics 100
80
60
40
20
0
0%
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
25%
50%
75%
100%
October 18-19, 1999
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Healthcare Benchmarks
- Sources: Accreditation/Measurements Drivers
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Purchasers
Comparatives among suppliers
Financial and quality objectives
Lacking knowledge and/or resource
for measures and outcomes
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 15
Healthcare Benchmarks
- Sources: The Accreditation Industry Organizations
•The “Joint Commission” on Accreditation of
Healthcare Organizations (JCAHO)
•National Committee for Quality Assurance
(NCQA)
•Accreditation Association for Ambulatory Health
Care (AAAHC)
•Utilization Review Accreditation Commission
(URAC)
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 16
Healthcare Benchmarks
- Sources: The Measurement Industry •
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Organizations
Foundation for Accountability
(FACCT)
University of Wisconsin
University of California
Association for Healthcare and
Policy Research (AHCPR)
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 17
Healthcare Benchmarks
- Sources Review
– Customers care about “value”
– Suppliers care about customers
– Third parties make it happen
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 18
Healthcare Benchmarks
- Classifications -
• Codes
– ICD
– CPT
– DRG
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
• Groupers
– MDCs
– ACGs
– DCGs
October 18-19, 1999
page 19
Healthcare Benchmarks
- Planning: Choosing the Right Ones •
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Relevant Outcomes (desirable or not)
Measurable (reproducibly)
Impact Sensitive
Achievable
Return on Investment
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 20
Healthcare Benchmarks
- Planning: Achievability •
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Time Requirements
Volume Requirements
Scope Management
Buy-In
Realistic, Incremental Goals
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 21
Healthcare Benchmarks
- Planning: Controls • General
– Case matched
– Temporal issues
• Internal
– Most similar
– Randomized
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
• External
– Availability/Quality
– Industry ‘Best Practice’
– Improvement priorities
– Historical perspective
October 18-19, 1999
page 22
Intro - Shevlin
Don’t Forget to Plan
Don’t Forget to Update
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 23
Healthcare Benchmarks
- Planning: Reevaluation • Regularly (annually)
• New measurement or coding procedures
• New technology or diagnostics
• New therapeutic modalities or interventions
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 24
Healthcare Benchmarks
- Data Limitations •
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Population drift/differences
Environmental issues
Collection process/irregularity
Storage process/irregularity
Integrity indicators
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 25
Healthcare Benchmarks
- Analysis • Data limitations
• Barriers
• Be suspicious
– Skewed or broken axes
– Missing data
– Sub-populations
– Undisclosed methods
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 26
Healthcare Benchmarks
- Application: How to make it work •
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Physicians do not need more medical school
Practice Guidelines and Outcomes Data
Benchmarks and Peer Profiling
Physicians do not like to be outliers
Physicians are uncomfortable with change
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 27
Intro - Shevlin
“If You Can Not Measure,
You Can Not Improve”
CAS Seminar on Health and Managed Care
Benchmarking Measures and Quality Control
October 18-19, 1999
page 28