Intergrating Quality into Utah's Health System Reform

Quality Initiatives within Other State Health System Reforms

Almost all current state health system reform initiatives include an emphasis on quality improvement and measurement.  The growing interest in quality is motivated by the desire to obtain the best value for the state’s and employers’ investment and by the recognition that so much current health care spending is for care that has no measurable clinical benefit.  Thus robust state quality initiatives generally recognize that the best way to contain costs is to improve outcomes.

Strategies to improve quality of care generally fall into two related categories. 

• Alignment of treatment and financing decisions with evidence-based medicine:                                                           

• Evidence-Based Practice Centers (EPCs) or Commissions.  Comprised of medical experts, EPCs review the scientific literature on assigned or prioritized topics or conditions and produce reports, technology assessments, and treatment protocols.  Some provide technical assistance to providers. 
  
  
• Pay for Performance or Value-Based or Quality-Based Purchasing. These often take the form of incentives for providers (like higher reimbursement rates or reputational incentives) to offer care in accordance with established clinical standards.  Evidence shows that such approaches can work, although debates continue over strategy selection (AHRQ, 2004).  More sophisticated forms of value-based purchasing include bundled payments for episodes of care, redesigning benefit structures to encourage consumers to use higher quality providers, and redesigning payment systems to promote alignment with quality goals.
  
  
• Information Technology and Electronic Medical Data Exchange: These activities work to eliminate duplicative care, reduce medical errors, and increase efficiency by automating key steps in complex processes that fail when left to human memory.  By facilitating rapid exchange of comprehensive medical data (like medical records), providers are better able to manage treatment of chronic diseases.  Good information technology (IT) also provides ready access to a wealth of data gleaned from up-to-the-minute clinical science, thus reducing variations in practice.

2. Improved patient care with an emphasis on prevention, wellness, and cultural sensitivity

• Prevention and Wellness Benefits and Incentives and disease or care management.
• Assignment to primary care provider (medical home).  A medical home replaces sporadic, crisis-driven care with regular, pro-active, patient-centered care which is more cost effective over the long-term. 
• Smoking cessation and weight loss programs.
• Encouraging preventive care by eliminating or minimizing co-pays.
  
  
• Culturally and Linguistically Appropriate Services (CLAS): Racial and ethnic disparities in care are well documented. Some disparities are related to socioeconomic factors like access to affordable coverage—but not all.   Effective communication between providers and patients is therefore critical to addressing disparities.

The following table illustrates the use of these approaches by selected states.

State	Evidence-Based Medicine	Pay for Performance (P4P) or Value-Based Purchasing	Prevention, , care management, electronic medical records
CA	Integrated Healthcare Association is a statewide leadership group that promotes quality improvement, accountability, and affordability of health care.  http://www.iha.org/. Efforts include: Quality measurement, uniform interoperability standards, health information technology (HIT)		Rewards for healthy behaviors for Medicaid, state employee plan, Healthy Families (CHIP).  Medical homes for children.
LA	Health Care Redesign Collaborative created after Hurricane Katrina to rebuild health care system to emphasize quality and evidence-based standards, and electronic data exchange. Overseen by LA Health Quality Forum.  http://www.dhh.louisiana.gov/offices/?ID=288	To participate in medical home network, physicians must report on quality measures. Uses a ‘medical home’ model: Everyone is assigned a primary care provider who coordinates care.
MA*	Health reforms establish Health Care Cost & Quality Council. Goals: 1) Reduce cost of care by avoiding preventable hospitalization & errors; 2) Ensure safety & effectiveness of care; 3) Improve screening for and management of chronic illnesses; 4) develop & implement useful measurements of quality; 5) reduce health disparities; 6) promote quality improvement through transparency initiatives.  http://www.mass.gov/?pageID=hqcchomepage&L=1&L0=Home&sid=Ihqcc.
ME*	Part of Dirigo Health agency, Maine Quality Forum develops measures to compare healthcare quality & produces annual reports, dissemination of information to providers on best medical practices and to consumers on overall health and health care.  Quality Forum makes recommendations on new technologies for the purposes of capital planning, and collaborates w/ Maine Health Data Organization on data exchange.   http://www.mainequalityforum.gov/		Efforts now underway to improve case management as a cost containment strategy.
MI	Connector-based plan w/ basic benefit package emphasizing preventive care.  http://www.mqic.org/     Michigan’s sophisticated Quality Improvement Collaborative appears to be unconnected to the broader reforms, however.		Healthy lifestyle initiatives will be built into Connector-based reform to contain costs.
MN*	Q-Care initially sets standards for care in four high-cost areas: diabetes, hospital stays, preventive care for adults & kids, cardiac care. Cost savings estimate: $153 million New Gov’s ‘Healthy Connections’ plan increases transparency to enable informed choices. http://www.health.state.mn.us/healthinfo/qcare.html	QCare (Quality Care & Rewarding Excellence) rewards top-performing providers.
MO	Missouri’s system redesign includes strengthening information technology (IT), starting with Medicaid.		Medicaid redesign (HealthNet) focuses on prevention & wellness: All enrollees will be assigned to medical homes & assessed for care needs. http://www.familiesusa.org/assets/pdfs/missouri-blunt-force.PDF
NC	Standards for care in Medicaid & state employee health plan decided by advisory group. Protocols to be shared with private market.		Medicaid Community Care Initiative  implements quality standards and ‘medical homes’  for Medicaid managed care plans. Savings estimated at $154-170 million for FY 2006.  http://www.communitycarenc.com/
OR*	Road Map for Health Care Reform (7-07) proposes to address quality, cost, and access; brings all care into alignment with evidence-based medicine through independent quality institute.  http://www.oregon.gov/DAS/OHPPR/HPC/OHPCReformRoadMapFINAL.pdf		Plan will establish primary care home for every Oregonian.
PA	Improves patient safety by eliminating hospital-acquired infections & medical errors. Health Care Cost Containment Council uses evidence-based resources like U.S. Preventive Services Task Force to conduct mandate benefit reviews. http://www.ohcr.state.pa.us/prescription-for-pennsylvania/PlainEnglishLegislation.pdf	Pay for Performance (P4P) to reward quality care.	Disease management for chronic conditions; improved access to preventive care by increasing supply of primary providers. Implements statewide smoking ban.
RI	Wellness Health Benefit Plan: Consumers commit to improve health by selecting a primary care provider and participating in wellness programs involving, for example, weight control and smoking cessation. http://www.commonwealthfund.org/usr_doc/silow-carroll_ritecare_598.pdf?section=4039
VT*	“Catamount” plan is basic benefit package for all uninsured. http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=471168		Controls cost of illness through reimbursement for phone consults, premium discounts for enrolling in health promotion & prevention programs & reduced cost-sharing for chronic illness management
WA*	May ’07 legislation created the Washington Quality Forum (WFQ) to address disparities and expand chronic care management.  Statewide Technology Assessment Program uses scientific evidence to guide coverage decisions.	WQF implements P4P	WQF uses an informed patient decision model that encourages prevention and establishes medical homes for children.

More time and experience is needed to know the merits or drawbacks of these and other diverse approaches.  However, given the specific challenges that Utah faces in improving health care quality and controlling costs, key “states to watch” include the following (marked in the table above with asterisks):

MA, ME, OR, VT, WA: These states’ initiatives are robust and well integrated into broader systemic health reforms.  They also go “the extra mile” in an effort to ensure that quality becomes integral to every phase of health care delivery.
 
MN: Minnesota’s quality efforts are directly linked to cost containment priorities, which makes them particularly instructive for penny-pinching states (like Utah) that frown upon increases in government spending.  It also bears noting that the United Health Foundation has ranked Minnesota—yet again—as the healthiest state in the nation.  Minnesota has been ranked #1 or #2 every single year since 1990.  For the final feather in its cap, Minnesota has consistently had the lowest uninsured rate in the nation (United Health Foundation, 2007).

How can we draw together the collective wisdom of these different state initiatives to craft a systematic, multi-year plan for quality improvement that meets Utah’s distinct needs?  The first step is to draw on our own local expertise, as outlined below.