Question

Using the Hospital Compare Tool, choose two hospitals and evaluate data on three different medical conditions (select 1-2 quality measures for each medical condition). How do the hospitals compare using these measures and how do you explain the differences?

comparison between kaiser and providence

Answer 1

There are several reasons that we should care about healthcare quality. One is that healthcare is more vital to people than most other goods or services, and we have a strong collective interest in assuring that the healthcare system works as well as it can. The consequences of poor quality can be dire. Another reason is that we, individually and collectively, spend a lot on healthcare (and health insurance to mitigate the cost uncertainty), and these costs have risen much more rapidly over time than those of other sectors of the economy. Financing the rising cost of healthcare is challenging, requiring difficult tradeoffs for families and governments, and those paying the bills quite legitimately want to know if they are getting good value for their money. Healthcare also is extremely complex and specialized, so most of us do not know what to expect when we need healthcare or whether we were treated appropriately or optimally. Objective metrics about healthcare performance can assist individuals with their own healthcare decisions, provide context for state and national policy discussions about healthcare programs and investments, and point to where and how the system can be improved.

Vertical Integration in Kaiser:

Vertical integration = consolidates under one organizational roof and common ownership:
1. All levels of care - 1⁰, 2⁰, 3⁰
2. Facilities (hospitals and clinics) and staff (nurses and other personnel) necessary to provide a full spectrum of care

A recent Kaiser Family Foundation/Commonwealth Fund survey found that half of the primary care physicians say the proliferation of quality measures to assess their performance has had a negative effect on quality of care.

The focused indicators that have been developed to assess the treatment of specific diseases or conditions are useful for encouraging the improvement of practice at the provider level. But, each is too narrow to tell us very much about how the health system overall influences the level of health in the population, even assuming that they were consistently reported and available to be analyzed (which they are not). Measures now used by payers – which often focus on health delivery processes believed to influence health and are typically used to compare quality across providers – may change over time as new quality improvement ideas come into vogue or older ideas get implemented by the vast majority of providers, which complicates their use as metrics for trends in quality over time.

Developing meaningful measures of overall health system quality, and how it is changing, requires a combination of indicators that can reliably show how the system – which in our view includes providers, payers, and public health – is influencing the health of the population. Given the scale of the healthcare sector, and the numerous different quality measures from numerous different sources, settling on a set of metrics that can credibly represent health system quality – and can be measured through existing records or reasonable data collection efforts.

*In addition to looking at health outcomes, another way to measure healthcare system quality is to focus on what happens in clinical settings: Are patients getting the right care when they need it? By using such process measures, we can better understand the extent to which clinical care is following best practices believed to influence health outcomes. Process measures are also more actionable than outcomes measures in that they allow for a more direct assessment of adherence to clinical guidelines. However, it is often difficult to know whether a given process measure is accurately representing general improvements or declines in clinical practices. Additionally, the key data sources for knowing what services patients receive and their health outcomes following this care (i.e., medical records), are not captured in a standardized way and are not consistently available across providers or payers.

*Some issues arise when using this data to assess healthcare quality. One is that these data are heavily influenced by socioeconomic and other factors outside of the health system itself. Additionally, there is a significant lag time between making an improvement in medical care and seeing a measurable change in death rates. This makes drawing connections between specific health programs and their outcomes challenging.

Although there is no established framework for evaluating the healthcare system, a number of different metrics are used to look at health outcomes, quality of care, and access to services. Inconsistent or unavailable data and imperfect metrics make it difficult to firmly judge system-wide health quality in the U.S., but a review of the data we do have suggests that the system is improving across each of these dimensions, though it continues to lag behind comparably wealthy and sizable countries in many respects.

*Population Health

Measures of health outcomes can give us the most concrete sense of whether health and general well-being are improving, which could be due in part to improvements in the performance of the health system, but also to advancements in science or improvements in socioeconomic determinants of health. Outcomes measures can generally be grouped into those that assess longevity and those that assess the quality of life lived.

*Relative to comparable countries, the U.S. has better short-term outcomes following treatment for certain conditions, like 30-day mortality post-heart attack and post-ischemic stroke. And five-year survival rates for specific cancers (like breast and colon cancer) are higher in the U.S. Survival rate is a controversial measure, however, as it can vary due to the timing of diagnosis, and not necessarily due to longevity. Survival rates for cervical cancer are lower in the U.S. than in comparable countries, on average.

The U.S. generally lags behind comparable countries in prevention and other measures of quality. The U.S. has relatively higher hospital admission rates for many preventable conditions, including congestive heart failure, asthma, and diabetes complications. And the U.S. has higher rates of medical, medication, and lab errors than comparable countries.

U.S. performance notably lags on a range of surgical process quality measures — on average, more surgical items are retained or un-retrieved in the U.S., postoperative outcomes such as blood clots are more common, and obstetric trauma during vaginal delivery is also higher.

*Reviewing current measures of healthcare system quality suggests that the quality of healthcare in the U.S. is improving in many areas, though it still lags behind comparable countries on a number of key measures, and the gap in health outcomes seems to be growing.

*Existing outcomes, process, and access measures, many of which are compiled in AHRQ’s National Quality Report, can tell us a lot about the quality of the healthcare system in the U.S. With additional resources and more participation from outside stakeholders, this effort could no doubt be improved. However, there are reasons to believe that many of the current quality measures are too flawed to form the basis of a set of national quality indicators. In particular, consistent and compatible information about what happens in clinical settings is poor, limiting the ability to measure the extent to which care is evidence-based.

*Establishing a new set of national healthcare system quality measures that can be presented in a consistent manner over time would permit more definitive assessments about the status and trends in healthcare system quality and could be used to bring healthcare quality to the forefront of policy discussions and decisions. The better and more systematic quality measurement could help to identify those areas where investments of resources could yield the greatest improvements in health. This may be particularly important amid growing interest in tying payments for services to quality and outcomes.

Envisioning a new, national set of health system quality measures requires being clear about the purpose, which has implications for the breadth of information that needs to be collected.

*On the one hand, if the primary goal is to focus the attention of the public and policymakers on key health care quality issues and trends, a smaller set of focused indicators may be sufficient to meet that need. A small set of core indicators may be easier for policymakers and the public to understand and could help motivate change by focusing attention on aspects of the system that are most important.

*A larger set of national indicators, on the other hand, would support more granular analysis of where and how the system can be improved, and in that sense would be more actionable. In particular, a larger set of measures allows one to better match investment (costs) with return (quality) within specific parts of the health care system.

It may be that the right balance is a broader set of indicators to diagnose where quality is deficient and motivate efforts to improve care, with a focused set of metrics to communicate more broadly to the public and policymakers how the healthcare system is doing overall. This would require constant vigilance, however, to ensure that the reporting burden on providers does not grow too large.

*There are many organizations, public and private, with a role in designing, reviewing, or collecting quality measures, and many other stakeholders who contribute to or use them. These current stakeholders would need to be heavily involved with the selection and implementation of a set of national measures for both practical purposes and provide legitimacy to the effort.

*What is less clear is whether the process would need to be led by a government agency or whether it could be largely private. The recent IOM report recommended that the Secretary of Health and Human Services play a lead role in shepherding the process to create core measures, in part because the Secretary oversees large public programs and incorporating the core measures into them could jump-start the process. Other reasons to give a prominent role to a government agency include the added visibility and potential legitimacy that attach to “official” measures, as well as the potential for meaningful and stable funding. A government agency, if legally authorized, also could compel providers, plans and others to provide information in prescribed ways, which could lead to better standardization and ability to make international comparisons.

*There are reasons to be concerned about placing too much authority over the process in a government agency, however. One is that official processes are less flexible than private ones. The products of government agencies also are more exposed to the political process (through appropriations and otherwise), leaving more opportunities for decisions to be re-litigated or delayed. Some stakeholders also may be concerned about placing too much authority to collect information into the hands of the government, which currently has very little access to information associated with privately financed care.

*Regardless of the approach taken, presenting results from national indicators will be challenging. There is likely to be an improvement in some areas and but worsening in others, and the pace of change will likely vary across different indicators. It is relatively straightforward to report each year how much health care spending is growing.