Health Care System Performance
Managed Care and Quality for Medicaid Beneficiaries
This study used 11 quality indicators from the Healthcare Effectiveness Data and Information Set (applicable to the Medicaid population) to compare the quality of care within and between patient populations in three types of managed care plans: those serving predominantly Medicaid enrollees, those serving predominantly commercial enrollees, and those serving substantial numbers of both types of enrollees. It found Medicaid managed care enrollees receive lower-quality care than commercial managed care enrollees, with no differences in quality between Medicaid-only plans and commercial plans. B. E. Landon et al. (2007) Quality of Care in Medicaid Managed Care and Commercial Health Plans. Journal of the American Medical Association 298, 1674–1681.
Improving Quality and Efficiency at the State Level
New data on personal health spending, quality, and health system performance at the state level show that personal health spending is not related to mortality or quality, but Medicare spending is closely linked to preventable hospitalization. Thus, the authors conclude that state policy officials should focus on improving health care quality and efficiency in tandem with their efforts to increase health insurance coverage. K. Davis and C. Schoen (2007) State Health System Performance and State Health Reform. Health Affairs Web Exclusive 26, w664–w666.
Pediatric Care and Quality
Quality indicators were developed, using a RAND–UCLA modified Delphi method, to assess whether pediatric outpatients randomly selected from 12 metropolitan areas received recommended care. Children in the study, on average, received 46.5 percent of indicated care, with quality varying according to the clinical area. The authors conclude that strategies to reduce these deficits, which are similar in magnitude to those reported for adults, are needed. R. Mangione-Smith et al. (2007) The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 357, 1515–1523.
International Survey Supports "Medical Homes"
A new Commonwealth Fund study found that having a "medical home," or a regular source of care that is accessible and helps coordinate care, is associated with more positive patient experiences. The international survey, which included about 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, also identified wide differences among countries in terms of access to care, availability of after-hours care, and coordination, as well as areas of shared concern. C. Schoen et al. (2007) Toward Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007. Health Affairs Web Exclusive 26, w717–w734.
Healthy People 2010 and Disparities
At mid-decade, Healthy People 2010 objectives have most frequently led to improvements in the health of the total population, without any reduction in relative disparities among racial and ethnic groups. The authors conclude that, because strategies to maximize improvement in overall population health may have little or no impact on relative disparities—or may even cause them to increase—an independent commitment to eliminating disparities might be necessary. K. Keppel et al. (2007) Improving Population Health and Reducing Health Care Disparities. Health Affairs 26, 1281–1292.
Quality Reporting
Standardizing Quality
An increasing number of quality measures are being reported publicly, yet the measurement of quality in health care is neither standardized nor consistently accurate and reliable. The authors conclude that health care has much to learn from the reporting standards for financial data and pharmaceutical information, and that the time has come to create a stronger environment to help protect patients, clinicians, and payers from misinformation regarding quality of care and to help ensure public trust in the health care profession. P. J. Pronovost et al. (2007) The GAAP in Quality Measurement and Reporting. Journal of the American Medical Association 298, 1800–1802.
Evaluating Safety Scorecards
This commentary proposes a framework to help health care organizations more effectively and efficiently develop their safety scorecards, evaluate their validity, and understand measures that are appropriate to present as rates. The goal is to enable them to better address the question, "are patients safer?" P. J. Pronovost et al. (2007) A Framework for Health Care Organizations to Develop and Evaluate a Safety Scorecard. Journal of the American Medical Association 298, 2063–2065.
Tiering Hospitals
Four alternative tiering strategies that combine hospital quality and cost data to designate "preferred" hospitals (defined as those ranking in the top quartile) were compared in five markets (Boston, Miami, Phoenix, Seattle, and Syracuse). The authors found that these tiering strategies led to substantially different results, suggesting the need for clear prioritization by payers and the application of more rigorous methods to identify high-value hospitals. M. B. Rosenthal et al. (2007) Using Performance Data to Identify Preferred Hospitals. Health Services Research 42, 2109–2119.
Performance Profiling Systems
Three different methods of performance measurement, focused explicit (38 measures for six conditions/prevention), global explicit (372 measures for 26 conditions/prevention), and structured implicit review physician-rated care (a single global rating of care for three chronic conditions and overall acute, chronic, and preventive care), were used to assess the quality of care provided to 621 patients at 26 facilities in two Veterans Affairs regions. The authors found moderate to high agreement in quality scores across the three profiling systems for most clinical areas, indicating that all three were measuring a similar construct called "quality." E. A. Kerr et al. (2007) Quality by Any Other Name? A Comparison of Three Profiling Systems for Assessing Health Care Quality. Health Services Research 42, 2070–2087.
Pay-for-Performance
Quality Incentives' Effect on Care
An observational study was used to assess the levels of recommended care received by preferred provider organization members receiving care from physicians who participated in a quality incentive program, compared with those receiving care from physicians who did not participate. The authors found a consistent, positive association between having seen only program-participating providers and receiving recommended care, suggesting that physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether patients receive high-quality, recommended care. A. S. Gilmore et al. (2007) Patient Outcomes and Evidence-Based Medicine in a Preferred Provider Organization Setting: A Six-Year Evaluation of a Physician Pay-for-Performance Program. Health Services Research 42, 2140–2159.
P4P: Improving Care for Chronic Illnesses
The authors outline a strategy to improve the care of Americans with severe chronic illnesses. Specifically, it includes: the federal government investing in a program to improve the scientific management of chronic illnesses, and the Centers for Medicare and Medicaid Services extending its pay-for-performance (P4P) agenda to increase chronically ill patients' access to evidence-based prospective care. J. E. Wennberg et al. (2007) Extending the P4P Agenda, Part 2: How Medicare Can Reduce Waste and Improve the Care of the Chronically Ill. Health Affairs 26, 1575–1585.
Patient Safety
"Blame-Free" Error Analysis
Dana-Farber Cancer Institute's (Boston) "Principles of a Fair and Just Culture" define behavioral expectations for when an error occurs. They focus not just on patient safety, but on a culture of safety and transparency in all the organization's functional areas, including nonclinical departments. Introducing these principles is a major undertaking; it requires continual education and discussion among staff at all levels and a commitment to examining and changing many of the systems, policies, and procedures that guide an organization's work. M. Connor et al. (2007) Creating a Fair and Just Culture: One Institution's Path Toward Organizational Change. Joint Commission Journal on Quality and Patient Safety 33, 617–624.
Managed Care and Quality for Medicaid Beneficiaries
This study used 11 quality indicators from the Healthcare Effectiveness Data and Information Set (applicable to the Medicaid population) to compare the quality of care within and between patient populations in three types of managed care plans: those serving predominantly Medicaid enrollees, those serving predominantly commercial enrollees, and those serving substantial numbers of both types of enrollees. It found Medicaid managed care enrollees receive lower-quality care than commercial managed care enrollees, with no differences in quality between Medicaid-only plans and commercial plans. B. E. Landon et al. (2007) Quality of Care in Medicaid Managed Care and Commercial Health Plans. Journal of the American Medical Association 298, 1674–1681.
Improving Quality and Efficiency at the State Level
New data on personal health spending, quality, and health system performance at the state level show that personal health spending is not related to mortality or quality, but Medicare spending is closely linked to preventable hospitalization. Thus, the authors conclude that state policy officials should focus on improving health care quality and efficiency in tandem with their efforts to increase health insurance coverage. K. Davis and C. Schoen (2007) State Health System Performance and State Health Reform. Health Affairs Web Exclusive 26, w664–w666.
Pediatric Care and Quality
Quality indicators were developed, using a RAND–UCLA modified Delphi method, to assess whether pediatric outpatients randomly selected from 12 metropolitan areas received recommended care. Children in the study, on average, received 46.5 percent of indicated care, with quality varying according to the clinical area. The authors conclude that strategies to reduce these deficits, which are similar in magnitude to those reported for adults, are needed. R. Mangione-Smith et al. (2007) The Quality of Ambulatory Care Delivered to Children in the United States. New England Journal of Medicine 357, 1515–1523.
International Survey Supports "Medical Homes"
A new Commonwealth Fund study found that having a "medical home," or a regular source of care that is accessible and helps coordinate care, is associated with more positive patient experiences. The international survey, which included about 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, also identified wide differences among countries in terms of access to care, availability of after-hours care, and coordination, as well as areas of shared concern. C. Schoen et al. (2007) Toward Higher-Performance Health Systems: Adults' Health Care Experiences in Seven Countries, 2007. Health Affairs Web Exclusive 26, w717–w734.
Healthy People 2010 and Disparities
At mid-decade, Healthy People 2010 objectives have most frequently led to improvements in the health of the total population, without any reduction in relative disparities among racial and ethnic groups. The authors conclude that, because strategies to maximize improvement in overall population health may have little or no impact on relative disparities—or may even cause them to increase—an independent commitment to eliminating disparities might be necessary. K. Keppel et al. (2007) Improving Population Health and Reducing Health Care Disparities. Health Affairs 26, 1281–1292.
Quality Reporting
Standardizing Quality
An increasing number of quality measures are being reported publicly, yet the measurement of quality in health care is neither standardized nor consistently accurate and reliable. The authors conclude that health care has much to learn from the reporting standards for financial data and pharmaceutical information, and that the time has come to create a stronger environment to help protect patients, clinicians, and payers from misinformation regarding quality of care and to help ensure public trust in the health care profession. P. J. Pronovost et al. (2007) The GAAP in Quality Measurement and Reporting. Journal of the American Medical Association 298, 1800–1802.
Evaluating Safety Scorecards
This commentary proposes a framework to help health care organizations more effectively and efficiently develop their safety scorecards, evaluate their validity, and understand measures that are appropriate to present as rates. The goal is to enable them to better address the question, "are patients safer?" P. J. Pronovost et al. (2007) A Framework for Health Care Organizations to Develop and Evaluate a Safety Scorecard. Journal of the American Medical Association 298, 2063–2065.
Tiering Hospitals
Four alternative tiering strategies that combine hospital quality and cost data to designate "preferred" hospitals (defined as those ranking in the top quartile) were compared in five markets (Boston, Miami, Phoenix, Seattle, and Syracuse). The authors found that these tiering strategies led to substantially different results, suggesting the need for clear prioritization by payers and the application of more rigorous methods to identify high-value hospitals. M. B. Rosenthal et al. (2007) Using Performance Data to Identify Preferred Hospitals. Health Services Research 42, 2109–2119.
Performance Profiling Systems
Three different methods of performance measurement, focused explicit (38 measures for six conditions/prevention), global explicit (372 measures for 26 conditions/prevention), and structured implicit review physician-rated care (a single global rating of care for three chronic conditions and overall acute, chronic, and preventive care), were used to assess the quality of care provided to 621 patients at 26 facilities in two Veterans Affairs regions. The authors found moderate to high agreement in quality scores across the three profiling systems for most clinical areas, indicating that all three were measuring a similar construct called "quality." E. A. Kerr et al. (2007) Quality by Any Other Name? A Comparison of Three Profiling Systems for Assessing Health Care Quality. Health Services Research 42, 2070–2087.
Pay-for-Performance
Quality Incentives' Effect on Care
An observational study was used to assess the levels of recommended care received by preferred provider organization members receiving care from physicians who participated in a quality incentive program, compared with those receiving care from physicians who did not participate. The authors found a consistent, positive association between having seen only program-participating providers and receiving recommended care, suggesting that physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether patients receive high-quality, recommended care. A. S. Gilmore et al. (2007) Patient Outcomes and Evidence-Based Medicine in a Preferred Provider Organization Setting: A Six-Year Evaluation of a Physician Pay-for-Performance Program. Health Services Research 42, 2140–2159.
P4P: Improving Care for Chronic Illnesses
The authors outline a strategy to improve the care of Americans with severe chronic illnesses. Specifically, it includes: the federal government investing in a program to improve the scientific management of chronic illnesses, and the Centers for Medicare and Medicaid Services extending its pay-for-performance (P4P) agenda to increase chronically ill patients' access to evidence-based prospective care. J. E. Wennberg et al. (2007) Extending the P4P Agenda, Part 2: How Medicare Can Reduce Waste and Improve the Care of the Chronically Ill. Health Affairs 26, 1575–1585.
Patient Safety
"Blame-Free" Error Analysis
Dana-Farber Cancer Institute's (Boston) "Principles of a Fair and Just Culture" define behavioral expectations for when an error occurs. They focus not just on patient safety, but on a culture of safety and transparency in all the organization's functional areas, including nonclinical departments. Introducing these principles is a major undertaking; it requires continual education and discussion among staff at all levels and a commitment to examining and changing many of the systems, policies, and procedures that guide an organization's work. M. Connor et al. (2007) Creating a Fair and Just Culture: One Institution's Path Toward Organizational Change. Joint Commission Journal on Quality and Patient Safety 33, 617–624.