Competing on Quality: 6 B

Competing on Quality: 6 B

to a Healthy Health Care 

to a Healthy Health Care 

Irene Fraser, Ph.D. Irene Fraser, Ph.D.

Director, Center for Delivery, Organiz

Director, Center for Delivery, Organiz

Markets Markets

FTC Roundtable on Competitive Signi

FTC Roundtable on Competitive Sign

of Healthcare Provider Quality Inform

of Healthcare Provider Quality Inform
Competition as a Path to 

Competition as a Path to 

Can Be a Bumpy Ro

Can Be a Bumpy Ro
The Bad The Bad News:It’s M

Difficult in Health C

Difficult in Health C

 Other Industries Other Industries  Health C

Health C
Competition on Quality: Thr

Competition on Quality: Thr

Similar (Not Identical) Hu

Similar (Not Identical) Hu

Three Paths: Three Paths:

 Consumers Consumers choose higher choose higher

-quality 

quality 

who then get more market share 

who then get more market share 

potentially higher rewards potentially higher rewards

 Payers choose higher choose higher

-quality prov

quality prov

then get more market share and p

then get more market share and p

higher rewards higher rewards

 Providers Providers compete among thems

compete among thems

intrinsic reasons, or because of p

intrinsic reasons, or because of p

Hurdles: Hurdles:

 Six Hurdles on Each Path, but Pla

Six Hurdles on Each Path, but Pla

differently for each differently for each
Hurdle #1: Awaren

Hurdle #1: Awaren

 Problem: Problem: Many 

consumers, and some consumers, and some payers, do not know that payers, do not know that quality differences exist quality differences exist

 Strategies: Strategies: IOM Report, IOM Report, 

well

-publicized horror publicized horror 

stories are beginning to stories are beginning to change that change that

 But most believe their But most believe their 

own provider is good provider is good
Hurdle #2: Measu

Hurdle #2: Measu

 Issue: For informed choice, need 

For informed choice, need 

uniform measures that are releva

uniform measures that are releva

credible to the consumer, payer, 

credible to the consumer, payer, 

 Barriers Barriers: too many measures, and 

: too many measures, and 

measures. Most are process or d

measures. Most are process or d

specific; different players value di

specific; different players value di

measures measures

 Progress: Progress: NQF focus, increased 

NQF focus, increased 

Medicare, Medicaid, states, privat

Medicare, Medicaid, states, privat

 Example Example: More than 50 Quality In

: More than 50 Quality In

from AHRQ accepted by NQF, in 

from AHRQ accepted by NQF, in 

use by states, CMS use by states, CMS
Example: AHRQ Qua

Example: AHRQ Qua

Indicators (QIs) Indicators (QIs)

 Use existing hospital discharge data, bas

Use existing hospital discharge data, bas

available data elements available data elements

 Growing use for reporting and P4P Growing use for reporting and P4P NQF endorsement for 50+ so far NQF endorsement for 50+ so far CMS using 9 under new Inpatient Payme

CMS using 9 under new Inpatient Payme

 12 states use AHRQ QIs for public report

12 states use AHRQ QIs for public report

Oregon

Utah

Texas

Colorado

Io
Hurdle #3: Data Hurdle #3: Dat

The challenge The challenge

 Measures without data ar Measures without data are useless to t

e useless to t

 Need market Need market

-level data level data BUT also need 

also need 

benchmarks. Why compete on mediocr

benchmarks. Why compete on mediocr

 Measures and data can improve with u

Measures and data can improve with u

measures and data can get better (thou

measures and data can get better (thou

–BUT–Even good measures with ba

Even good measures with b

create mischief create mischief

 Data must be good AND cheap Data must be good AND cheap There is no gold standard There is no gold standard

–Clinical, administrative, patient expe

Clinical, administrative, patient expe

data all have strengths, weaknesse

data all have strengths, weaknesse

– 

– EHR no data panacea EHR no data panacea
Hurdle #3: Data (co

Hurdle #3: Data (co

Some Progress Some Progress

 Moving toward hybrid Moving toward hybrid 

data for hospitals data for hospitals

– 

– Pine study shows adding Pine study shows adding 

POA and Laboratory POA and Laboratory Values approximates Values approximates accuracy of chart review accuracy of chart review

– 

– States building improved States building improved 

all-payer datasets payer datasets

 AQA, others working AQA, others working 

to improve physician to improve physician data

 NQF, others targeting NQF, others targeting 

episode data episode data
Administrative/Hybrid 

Administrative/Hybrid 

The Future The Future

 Improve Improve timeliness timeliness Provide on Provide on

-line all line all

-payer market

-level data level data on 

on 

efficiency, price. efficiency, price.

 Add clinical detail, data links for clinical detail, data links for accuracy, cred

accuracy, cred

 Expand outpatient outpatient reach (e.g. physician, episod

reach (e.g. physician, episod

 Pilot cross

-site data, new data data, new data links

 New tools for expanded data for expanded data  Additional Additional states, as feasible , as feasible Develop, validate, maintain, deploy Develop, validate, maintain, deploy measures i

measures i

 Expand data elements Expand data elements to align with levers of ch

to align with levers of ch

 Tools for change Tools for change
Good Data Not Enoug

Good Data Not Enoug

Customer Customer

-Friendly 

Friendly 
Hurdle #4: Understa

Hurdle #4: Understa

 The bad news: Most quality reports are 

The bad news: Most quality reports are 

–Don’t present information simply, ef

t present information simply, ef

ways the reader understands and c

ways the reader understands and c

 The good news: A growing evidence ba

The good news: A growing evidence ba

–Tested models in Tested models in AHRQ’sCAHPS, 

CAHPS, 

Indicator reports Indicator reports

–NQF Guidance for web NQF Guidance for web

-based com

based com

available soon available soon

 Links and aids: Links and aids: 

–www.talkingquality.gov www.talkingquality.gov, includes , includes–QI Model Report and Sponsor Guid

QI Model Report and Sponsor Guid

AHRQ website AHRQ website

 Source: Shoshanna Sofaer, Presentation to Charte

Source: Shoshanna Sofaer, Presentation to Charte

Exchanges, October 3, 2008 Exchanges, October 3, 2008
Hurdle # 5: Effective C

Hurdle # 5: Effective C

Barriers and 

Barriers and 

 Geograp

Geograp

hospital t

hospital t

 Insuranc

Insuranc

provider 

provider 

 Money a

Money a

insuranc

insuranc

 Time (no 

Time (no 

the ambu

the ambu
Hurdle #6: Other Ma

Hurdle #6: Other Ma

Realities Realities

Barriers: Barriers:

 Multiple markets Multiple markets 

– e.g. 

hospitals vs. physicians hospitals vs. physicians 

 Multiple Product Lines Multiple Product Lines 

–

Quality Scores Don Quality Scores Don’t 

Generalize Generalize

 Market segmentation by Market segmentation by 

payer source payer source 

Facilitating Progress Facilitating Progress

 Episode measures Episode measures Cross

-cutting measures cutting measures

 Payer Cooperation on Payer Cooperation on 

measures measures
The Challenge: Addressing 

The Challenge: Addressing 

Barriers at the Same T

Barriers at the Same T
irene.fraser@ahrq.hhs.

irene.fraser@ahrq.hhs.

Home Page Home Page

http://www.AHRQ.gov http://www.AHRQ.go