# Presentation: 534970

## Measuring What Counts

**- AND -   **
**Making it Count for Quality**

**Constance Horgan**
**Brandeis University**
**Panel on Quality and Financing of Co-Occurring Services**
**Complexities of Co-Occurring Conditions Conference**
**Washington, DC**
**June 24, 2004**

## Overview of Presentation

- Background on quality and performance measurement
- Measuring performance
- Using performance measures: the role of stakeholders

## Historical Perspective

- 1930-1960
- Physicians defined quality
- 1970s
- Cost containment focus
- 1980s
- Rise of managed care
- 1990s
- Debate over legislating standards for managed care organizations
- Emergence of organizations focused on quality – NCQA, FAaCt
- Standardized measurement approaches

## Historical Perspective (continued)

- 2000 +
- Influential Institute of Medicine Report:  Crossing the Quality Chasm:  A New Health System for the 21st Century (2001)
- National Initiatives (e.g. National Quality Forum , National Quality Measures Clearinghouse)
- Continued development of quality report cards nationally (e.g. NCQA) and at state level (e.g. New York State Health Accountability Foundation)
- New approaches to quality measurement with multiple data sources and at provider or provider group level
- Use of incentives to providers to improve quality

## What is Performance Measurement?

- Health care performance measurement is the process of using a tool based on research (performance measure) to evaluate a managed care plan, health plan or program, hospital, or health care practitioner
- Performance implies that the responsible health care providing entity can be identified, held accountable, has control over the aspect of care being evaluated.

- Source: Understanding Performance Measurement www/ahcpr.gov/chtoolbx

## Classic Framework for Quality Measures

- Structure
- Access
- Process
- Outcomes
- Patient Experience

## Data Sources

- Claims/Encounter Data
- 2.  Patient Surveys
- 3.  Medical Record

## So How Are We Doing?

- Percentage of Recommended Care Received
-   Alcohol Dependence                    10.5 %
-    (5 indicators)
- Depression                                      57.7%
-    (14 indicators)
- Total – all conditions                      54.9%
- Source: McGlynn et el, NEJM (2003)

## Selected Behavioral Health Initiatives

-  New IOM study – Crossing the Quality Chasm –
-   An Adaptation to Mental Health and Addictive
-   Disorders
-  Join Together – National Policy Panel –
-   Rewarding Results
-  SAMHSA e.g. National Registry of Effective
-   Programs (NREP), Performance Partnerships
-  The Forum on Performance Measurement
-  Washington Circle

## Measuring Performance – The Case of      

**                ****Washington Circle**

- Develop a core set of performance measures for substance abuse treatment for public and private-sector health plans
- Collaborate with a broad range of stakeholders to ensure widespread adoption of substance abuse  performance measures by private employers, public payers and accrediting organizations

## Washington Circle Performance Measures

| Domain | Measure |
| --- | --- |
|  |  |
| Education | Educating Patients about AOD Disorders |
|  |  |
| Recognition | Identification |
|  |  |
| Treatment | Initiation |
|  | Engagement |
|  | Linkage of Detoxification and AOD Plan Services |
|  | Interventions for Family Members/Significant Others of AOD Clients in Treatment |
|  |  |
| Maintenance | Maintenance of Treatment Effects |

- (see www.washingtoncircle.org)

**Notes:**
This slide shows the full framework of measures.  We believe that a performance system that is focused on only one domain can lead to perverse incentives for managed care plans or treatment programs to focus only on that domain to the possible detriment of the others.  

Our initial efforts, and the one’s I’ll be describing today, are focused on the three measures highlighted in yellow  -- identification, initiation, and engagement.

## Three Administrative Measures 

**Identification Rates**** -- **Percent of adult enrollees with an AOD claim, defined as containing a diagnosis of AOD abuse or dependence or a specific AOD-related service, on an annual basis.
**Initiation of Plan-Provided Substance Abuse Services**** -- **Percent of adults with an inpatient AOD admission or with an outpatient claim for AOD abuse or dependence and any additional AOD services within 14 days.
**Treatment Engagement** -- Percent of adults diagnosed with AOD disorders that receive two additional AOD services within 30 days of the initiation of care.

## Washington Circle Testing Results

- Identification is extremely low (0.46%-1.45%)
- Drop off is high
- Initiation (26%-46%)
- Engagement (14%-19%)

- Source: Garnick et al (2002)

## Distribution of Adult SA/MH Claimants by Type of Diagnoses

**4,183**
- (**2.7%)**

**147,620**
**(95.0%)**

**3,550**
**(2.3%)**

**Alcohol and Other Drugs**

**Mental Health**

**Note – Percents are of all 155,353 claimants with any behavioral health services. **
- Source: Medstat. 2001 MarketScan

## Adult Enrollees with SA or MH diagnoses receive services from both specialty and medical providers. 

|  | Alcohol and Other Drug Diagnoses Only   (N=4,183) | Mental Health Diagnoses Only (N=147,620) | Both SA and MH Diagnoses (N=3,550) |
| --- | --- | --- | --- |
| Specialty providers only | 36.9% | 56.5% | 31.6% |
| Medical providers only | 50.5% | 32.2% | 11.8% |
| Both | 12.6% | 11.3% | 56.7% |

- Source: Medstat, 2001 MarketScan

## Challenges to Performance Measures for Co-Occurring Conditions 

-  Co-occurring represents a substantial proportion
-   of substance abuse claimants
-  Substantial proportion of co-occurring claimants
-   use both medical and specialty setting
-  If specialty, is it mental health or substance abuse
-   setting?

## Making Performance Measures Count: the role of stakeholders

- Purchasers
- Health Plans
- Clinicians/Provider Group
- Consumers
- Policy Makers
- Researchers

**Notes:**
As the measures become more well known and used in the next year, this list begins the set of possible users and they ways that they can  use the Washington Circle measures to improve quality.  And, the examples of actions in the next few slides are only a beginning of the larger set of activities.

## Call for Action

-  Recommendation 10 – Crossing the Quality Chasm
*“**Private and public purchasers should examine their current payment methods... to build in stronger incentives for quality enhancements.”*

## Purchasers

- Use performance measures in contracting requirements
- Work with health plans to improve performance measure scores
- Seek plans that have higher adherence to performance measures
- Pay physician groups for achieving certain goals

## Conclusion

- Measure what counts, BUT having a measure is _not_ sufficient
- How measures are used is key, SO seek solutions from multiple stakeholders

**Notes:**
In summary, the road behind us in developing the Washington Circle performance measures has been relatively short and has been traveled by a relatively small group of deeply committed individuals. The road that lies ahead is longer, has a larger number of diverging paths (although all pointed in the same general direction), and will include a much broader set of people.