Intergrating Quality into Utah's Health System Reform

Integrating Quality into Utah’s Health Reforms: Recommendations

Quality maximizes value, and quality contains costs.  These are the fundamental principles motivating the diverse quality-based reforms we propose.  Utah policymakers and business leaders are already convinced of the importance of maximizing value and containing cost in health care systems, but they need more systematic integration of quality improvement into proposals for health system reforms (United Way of Salt Lake, 2007).

Over the years Utah has pursued many different quality and patient safety initiatives, with varying results.  Recent efforts have included:

• Working together, the state and key providers developed and implemented a sentinel event reporting system for hospitals and ambulatory surgery centers.
  
  
• Utah also implemented a state rule that requires all hospitals to have active programs in place to prevent adverse drug events (ADEs) and audits these programs every three years.
  
  
• Working with the Centers for Medicare and Medicaid Services (CMS), a division of the Federal Department of Health and Human Services, Utah has implemented a demonstration project aimed at encouraging adult primary care doctors to use electronic medical records (EMRs) to better manage chronic disease and preventive services.  Under this program, physicians receive substantial financial incentives to adopt and use EMRs in their practices and to show improvement on standard evidence-based quality measures.
  
  
• Utah recently initiated a series of transparency efforts to report data comparing quality and cost across different hospital facilities, using two web-based tools, UT CheckPoint (using the CMS core measure set) and UT PricePoint. 
  
  
• The state has recently begun a parallel effort to provide more data about hospital level performance, using an all-payer hospital database and selected measures from the AHRQ Quality and Patient Safety Indicator set.  This initiative was encouraged by state legislation.

 

Though worthy, these last two transparency initiatives illustrate the limitations of Utah’s current statewide quality programs.  The basic idea behind consumer-oriented transparency is that patients and their families could use these tools to shop for value for their health care dollar, and facilities would in turn increasingly compete for these dollars by providing better value.  While this kind of transparency inherently adds some value because it can help to keep more of hospital leaders’ attention and resources focused on quality and consistency, these tools alone are unlikely to change patient choices in the current system.  In fact, health care systems are inherently at odds with the basic assumptions that drive consumerism in other markets.  First, consumers do not have much control over where they get care.  Nor do they have enough medical knowledge or access to sufficient information to make choices about what constitutes a “better value” for different health care needs. 

Furthermore, research shows that consumers do not turn to “objective ratings” for guidance in their health care decisions in today’s market.  A recent study by the Harvard School of Public Health and Robert Wood Johnson Foundation found that individuals are more likely to base health care decisions on the advice of family and friends than on expert ratings (Robert Wood Johnson Foundation, 2007).   Finally, thus far transparency efforts in Utah have been isolated mostly to hospital care; they have yet to provide any information about physician performance or to encourage better coordination and collaboration across settings of health care delivery.

These transparency efforts are well-intentioned and represent a good start.  But they fall well short of their goal, because they are not fully integrated and do not acknowledge the current environment or address fully the limitations of the system.  Instead of just limited, uncoordinated efforts, we need bold, systematic, programmatic initiatives for quality improvement. 

The following recommendations would place Utah at the forefront of statewide quality improvement:

Create a Health Benefits Commission to establish and continuously maintain an essential benefit package for all Utahns.

As proposed in the United Way Financial Stability Council’s conceptual framework for health reform in Utah, the Health Benefit Commission would have both rule-making and adjudicatory functions.  Members of the Commission would be appointed by the Governor submitted to the Utah Senate for final approval.  Commissioners would be responsible for initially identifying and then continually updating the list of medical services included in the basic benefit package.  Since their determinations would be based upon clinical effectiveness, the Commission must be supported in their efforts by a public-and private partnership of medical scientists which would serve as the primary resource for establishing evidence-based standards of care and guidelines for the essential benefit package.   This critical partnership between a strong, state-mandated Commission and evidence-driven medical expertise will enable Utah to address the massive quality-related waste embedded in the current insurance and health care delivery systems in our state.

Further duties of the clinical science partnership with the Health Benefit Commission could include:

• Centralized collection of quality information across the state, emphasizing episodes of care.
• Support for and facilitation of collaboration among quality efforts statewide;
• Helping providers to collect and use data for improvement;
• Disseminating quality data in transparent formats that are useful to a broad range of audiences.

 

Utah may not need to create new structures and institutions to perform these important tasks; what is needed, however, is a thoughtful, strategic integration of quality improvement efforts into the proposed health system reform framework.  The proposed Health Benefit Commission would build upon the nationally recognized quality improvement leadership of Intermountain Healthcare, HealthInsight, and others already present in our state.  It would be the task of the Health Benefit Commission to coordinate with and magnify the effectiveness of these groups already working together on transparency of cost and quality data and on financial incentives for quality through the Utah Partnership for Value-Driven Health Care (UPV).  The UPV is the state’s applicant for AHRQ Chartered Value Exchange (CVE) status.  This effort already incorporates the work of HealthInsight, the Utah Health Data Committee, Utah Medicaid and key insurers, the Salt Lake Chamber of Commerce and key business interests, the Utah Medical Association, the Utah Hospital and Health Systems Association and their websites mentioned above, and the Utah Health Information Network, among others.

The AHRQ currently sponsors and supports similar community efforts around the country and serves as a clearinghouse for best practices through the CVE program.  Utah could potentially join the Robert Wood Johnson Foundation’s Network for Regional Healthcare Improvement to learn from and contribute to the six existing, more mature regional coalitions for health care improvement (NRHI, 2006).  The Utah partners listed above should also consider formal affiliation with one of the Aligning Forces sites also sponsored by the Robert Wood Johnson Foundation.  The purpose of the Aligning Forces for Quality: The Regional Market Project is to help communities across the country improve the quality of health care for patients with chronic conditions such as diabetes, asthma, depression and heart disease.

Among the various options for initial action available to the Health Benefit Commission, we would recommend attention to the following:

• Strengthen the statewide mandatory public health surveillance system for preventable hospital deaths and impairment (Utah Department of Health, 2003).  A preventable hospital death due to medical error is a sentinel event indicating immediate need for substantive change in patient care.  Just as public investigations of commercial airline crashes have exposed systemic, correctable problems in the air traffic system, timely investigation of preventable medical errors is necessary to assure patients that systemic problems in health care delivery are being addressed and eliminated.  However, self-reporting systems alone have limited utility and will never provide an accurate picture of performance or improvement over time.  As an initial investment in more active surveillance, Utah’s surveillance system for preventable injuries in hospitals should be expanded to include a random, trigger-based chart review of patient care in all Utah hospitals.  We cannot improve what we cannot measure effectively.
  
  
• Require basic, ongoing quality improvement training for the medical staff and employees of Utah hospitals, clinics, nursing homes, and home health agencies.  Provider quality improvement programs must be assessed regularly against recognized clinical standards, and the results of these assessments should be reported to the public.  Quality improvement cannot be achieved simply by administrative fiat.  It requires the continuous, coordinated, committed efforts by leaders and by all individuals with front-line health-care responsibilities.  Every health care worker should understand the fundamental importance of quality improvement and be empowered with the knowledge and skills to contribute to it.  
  
  
• Establish mandatory shared-decision making processes for patient care as the method for informed consent before medical intervention.  Improving quality means providing no less cared than the patient needs, but also no more care than the patient wants.  Patients are often more risk averse than are physicians, yet may not speak up about their concerns.  Studies have shown that, if given good information about the likely consequences of each possible option, the average patient would choose recommended surgical interventions 40% less often than their provider.  Shared decision tools can help to align treatment goals and patient wishes.  These tools are already available for use in clinical settings, but must be systematically incorporated into health system processes. 

Establish ‘medical homes’ within the context of proposed health system reforms, starting with Medicaid and CHIP; develop a medical home plan for the state.

A medical home is defined by the American Academy of Pediatrics and the American Academy of Family Practice as an approach to health care characterized by a partnership between patients and their care providers.  A medical home is the point of first contact between a family and the health care system that is always accessible, with continuous service over the long term, and where primary care is comprehensive, family-centered, coordinated, compassionate, and culturally effective (American Academy of Pediatrics, 2002).  The proposed “Essential Benefit Package” should support full access for all to a medical home so that Utah’s families receive the care they need at the appropriate time and place, avoiding overuse of emergency rooms. 

There may be some upfront cost associated with implementing ‘medical home’ access in states like Utah where there is a critical shortage of primary care providers.  But the initial expense will undoubtedly pay off later.  States with more family practitioners use more effective care and have lower spending, while those with more specialists have higher costs and lower quality of care (Baicker, 2004).  Patients with a medical home are more likely to receive appropriate preventive care, are less likely to be hospitalized for preventable conditions, and are more likely to be diagnosed early for chronic or disabling conditions.   Thus better coordination and continuity of medical homes will improve outcomes and cut costs over the long term. 

As the concept is defined by the national primary care specialty societies and leading business interests, medical homes can be a demanding undertaking.  To maximize value from health system change, Utah should invest the necessary resources to prepare physicians to meet the exacting requirements of the medical home concept.

Expand IT (Information Technology) capacity among all providers. 

In a 2003 survey of physicians, the Commonwealth Fund found that at the time of a patient’s appointment, his or her medical records, tests results, and other related information were unavailable 72% of the time (AHRQ, 2007).  HealthInsight estimates that 30-45% of Utah physicians currently use electronic medical records (Donnelly, 2007).  While this level of use is high when compared to other states, we have yet to reach the tipping point in EMR use that will drive system-wide change.  There is a wealth of data available just waiting to be used for quality improvement.  Information technology can help us tap that resource.   Improved IT can also serve as a powerful tool to help clinicians put evidence-based standards and up-to-the-minute scientific advances into immediate practice, improving quality and efficiency.  The state should expand upon current efforts to support adoption and use of EMRs by physicians and institutions.  We should also support efforts to create effective clinical Health Information Exchange (HIE) among providers across settings and along the full continuum of care.

 Develop statewide CLAS (Culturally and Linguistically Appropriate Services) standards and implement them through public-private partnerships. 

Cultural competence has been defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or amongst professions and enables that system, agency or those professions to work effectively in cross-cultural situations (Cross, 1989).”  Recognizing the need for a national consensus on cultural and linguistic standards for health care, the Federal Office of Minority Health released a set of standards for culturally and linguistically appropriate services (CLAS) in 2001.   The CLAS standards are designed to address health disparities by correcting inequities in health care delivery systems and ensuring that services are responsive to the needs of all consumers.  The standards are organized under three categories:

• Culturally competent care;
• Language access services;
• Organizational supports for cultural competence.
  

In historically homogeneous cultures like Utah the need for CLAS standards may be magnified. This somewhat counter-intuitive observation is based on the following related considerations:

• With a few notable exceptions, health care delivery systems have been designed to serve the state’s historically homogenous populations.
  
• The relative lack of critical mass has made it difficult for Utah’s ethnic communities to command the “market share” that might otherwise stimulate culturally and linguistically appropriate service delivery.

As the most ethnically diverse state in the nation, California has extensive experience using statewide cultural competency standards for its health plans.  Following are take-home messages from the California context to states considering statewide standards:

• Dedicate staff to cultural competence.  Plans that tried to add cultural competence activities to other staff responsibilities eventually recognized the need for at least a full-time cultural competence coordinator.

• Link cultural competence to quality improvement.  Cultural competence activities pursued in connection with quality improvement efforts were more likely to be integrated into health plans’ operations.
  
  
• Improve capacity to track racial, ethnic, and language data.  Plans were unable to achieve statewide standards without collection of member-specific data.
  
  
• Collaborate and get assistance where possible.  Many tasks, such as translating documents, were complicated and resource-intensive.  Cross-plan collaborations were found to be extremely helpful (Brach, 2006).