State Quality Improvement Institute: Overview and Progress Report, Year One February 2009 www.academyhealth.org 1 Table of Contents Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Why Reform? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 About the State Quality Improvement Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Elements of the State Quality Improvement Institute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 State Action Plans for Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Engaging State Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Technical Assistance Content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Takeaway Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Technical Assistance Focuses on Major Policy Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Delivery and Financing Systems Reform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Payment Reform/Purchasing Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Care Coordination, Chronic Care Management and Population Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Medical Homes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Other Care Coordination and Chronic Disease Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Population Health Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Transparency/Data Collection and Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Data Integration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Performance Measurement and Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Appendix 1: State Quality Improvement Institute Kick-off Meeting Faculty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Appendix 2: State Quality Improvement Institute Cyber-seminars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Appendix 3 State Quality Improvement Institute State Profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Appendix 4: State-Reported Policy Levers and Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 2 State Quality Improvement Institute: Overview and Year 1 Progress Report Executive Summary In 2008, The Commonwealth Fund around specific improvement strategies. The United States continues to experience and AcademyHealth launched the State Important strategies under way in the rising health care costs and gaps in quality Quality Improvement Institute (SQII) to states include implementation of medical of care. In 2007, the Commonwealth Fund complement the Scorecard by providing homes and care coordination strategies, released its State Scorecard on Health System technical assistance for state quality adoption of population health initiatives Performance (Scorecard) using state-specific improvement efforts. Through a competitive to reduce chronic disease risk in the performance measures in five important process, nine states—Colorado, Kansas, community, improved chronic disease aspects of care: Massachusetts, Minnesota, New Mexico, management to improve outcomes Ohio, Oregon, Vermont, and Washington and avoid costly hospitalization and • Access — were selected to participate in an re-hospitalization, and use of data for • Quality intensive process of state-level planning and performance improvement and public • Avoidable Hospital Use and Costs engagement with expert faculty to facilitate reporting. The SQII’s expert faculty is • Equity their reform efforts. working closely with multi-stakeholder • Healthy Lives state teams to support their efforts to The SQII facilitated ongoing contact identify and adopt evidence-based models The Scorecard was envisioned as a quality between high-level state participants for systemic transformation. improvement tool to assist states in and expert faculty to support state identifying strengths and weaknesses and efforts to improve care in three priority This progress report describes important to quantify opportunities for improvement. areas: delivery and financing systems elements of the technical assistance The Scorecard’s state performance rankings reform, chronic care/population health provided, outlines the efforts of the help states target their efforts to improve improvement, and data integration/ participating states, and lays the quality and contain costs. transparency. Following their start-up groundwork for revisiting progress at the planning phase, SQII states began the state level at the end of the State Quality process of implementing action plans Improvement Institute project. 3 Introduction Exhibit 1: State Scorecard Summary of Health System Performance Across Dimension Overview The United States health care system is troubled by rising costs and variability in the cost and quality of health care services. In 2007, The Commonwealth Fund’s Commission on a High Performance Health System released a State Scorecard on Health System Performance (Scorecard) illustrating state-by-state performance on multiple access, cost, and quality indicators. The Scorecard showed dramatic differences in state performance (Exhibit 1). Many states perform consistently above average on indicators of health system performance—yet all states have room for improvement. By closing the gaps between the highest performing and lowest performing states, there is a tremendous opportunity to reduce mortality, improve quality, and control costs. The Commonwealth Fund’s Commission on a High Performance Health System SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2007 has challenged the federal government and states to move toward high quality, goal of the SQII is to assist states that are opportunities for systemic changes to drive efficient, and equitable care through ready to make or have made substantial improved efficiency and quality of care. systemic transformation. Key guiding commitments to quality improvement, and strategies recommended by the • Colorado is seeking technical assistance to facilitate development of concrete action Commission for national reform are: to improve coordination of care in the plans for further progress. The SQII serves state. This strategy is seen as essential as a convener to help engage stakeholders— • Extending comprehensive, affordable, state agencies, health plans, hospitals, payers, to improving the quality and efficiency and seamless insurance coverage to all; of care for both children and adults. physicians and other practitioners, and • Aligning incentives to reward high- The state is also exploring replication consumers—in reaching accord on state quality, efficient care; of approaches used in states such as health quality problems and action items to Maine, Minnesota, and Massachusetts • Organizing the health system to achieve improve quality. Through the SQII, states are to improve collaboration around and accountable, coordinated care; matched with expert faculty with expertise in implementation of evidence-based the areas selected for improvement by state • Investing in public reporting, evidence- practice through use of information, based medicine, and the infrastructure participants. The SQII approach enables purchasing strategies, and pay for necessary to deliver the best care; and states to select improvement targets and performance. access expert technical assistance based on • Exploring creation of a national recurring state needs. entity that sets aims for health system • Kansas requested technical assistance to develop measures and standards to performance and priorities for States participating in the SQII achieve the goal of having true medical improvement, monitors performance, represent a range of rankings on The homes for enrollees in Medicaid, the and recommends practices and policies.1 Commonwealth Fund Scorecard indicators State Children’s Health Insurance In 2008, AcademyHealth and The and are at different stages of examining or Program (SCHIP), and the state Commonwealth Fund (see Exhibit 2) implementing health care reform. All have employee health benefits program. The launched the SQII to help make information made a commitment to developing a state- state is also interested in developing presented in the Scorecard actionable specific action plan to examine tools for examining and improving by states for quality improvement. The indicators linked to avoidable hospital 4 costs. The state’s approach is to link and improvement (including patient • Oregon views the development and chronic care improvement and value- experience and engagement with care), alignment of quality metrics as a primary based purchasing by demonstrating cost containment, and payment reform. goal of the SQII technical assistance. The that appropriate care in cost-effective The SQII will leverage their efforts assistance will support implementation primary care settings can reduce overall by working through public/private of a medical home approach consistent health care system costs while improving partnerships. with the state’s overall reform strategy. population health. Oregon also recognizes a need to • New Mexico will use technical assistance orchestrate and align the state’s multiple • Massachusetts will use SQII technical to increase the state’s understanding of quality-related assets. assistance to further refine its data sources available for decision-making. understanding of the current needs and The Robert Wood Johnson Foundation • Vermont has made substantial progress challenges facing the state, in particular Center for Health Policy at the University toward comprehensive reform through the high cost of care and high rate of of New Mexico will lead a statewide effort the Vermont “Blueprint for Health.” The avoidable re-hospitalization. Their goal to convene and engage key state and local state will engage in SQII activities using is to reduce the overall cost of care in government executives and legislative the Blueprint as the context for making the state. The state has selected several policymakers, and major providers of both systems change. Quality improvement disease-specific indicators (diabetes for private and public health services. efforts will include the development of preventive care and congestive heart medical homes, community-based care failure for re-hospitalization rates) as a • Ohio will use the SQII opportunity coordination, public health strategies, to engage stakeholders who will work method to pilot strategies that could be and widespread adoption of electronic together to identify and prioritize health used as templates for population-wide medical records and patient registries. needs and systematic interventions. initiatives. Technical assistance will help to drive • Washington will deploy technical • Minnesota plans to use SQII technical creation or utilization of tools to assistance from the SQII to strengthen assistance to develop a plan to accelerate measure impact, ways to build on the primary care system through a the implementation of recent legislation existing initiatives, and best practices variety of initiatives that target quality that addresses quality measurement from other states. improvement, improved access and capacity, increased affordability, and patient-centered care. The focus of the technical assistance will be Exhibit 2: About the Sponsors to help identify factors associated AcademyHealth is the professional home for health services researchers, policy with successful implementation of analysts, and practitioners, and a leading, non-partisan resource for the best in a medical home, including provider health research and policy. AcademyHealth promotes interaction across the health engagement, information management, research and policy arenas by bringing together a broad spectrum of players reimbursement, and improving care to share their perspectives, learn from each other, and strengthen their working management capability. relationships. AcademyHealth seeks to improve health and health care by generat- ing new knowledge and moving knowledge into action. AcademyHealth offers a portfolio of services and projects for states in addition to the SQII. In other tech- Through the SQII, The Commonwealth nical assistance for states, AcademyHealth has tracked state health insurance Fund and AcademyHealth are cultivating reform through the State Coverage Initiatives program (SCI). SCI offers a Coverage a focal point within each state to engage Institute and technical assistance to states interested in enacting health insurance stakeholders and provide leadership for coverage strategies. For more information, visit: www.academyhealth.org collaborative health care reform. This progress report describes the SQII and The Commonwealth Fund is a private foundation that aims to promote a high per- articulates elements of transformational forming health system that achieves better access, improved quality, and greater change. It describes key systems elements efficiency, particularly for society’s most vulnerable, including low-income people, of reform advocated by the SQII’s expert the uninsured, minority Americans, young children, and elderly adults. The Fund faculty and the changes planned by state carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. The Program on participants. In 2009, AcademyHealth will State Innovations aims to improve state and national health system performance by report back on the states’ progress. supporting, stimulating, and spreading integrated, state-level strategies for expand- ing access to care and promoting high-quality, efficient care, particularly for vulner- able populations. For more information, visit: www.commonwealthfund.org 5 Why Reform? A brief synopsis of underlying problems in and quality, and that engage all of the The case for health care reform at the state the health care system is offered in Exhibit 3. participants in the health care system. and national levels has been made effectively The SQII encourages states to strategically and is not repeated in this progress report. States and other payers are positioned to deploy their purchasing and regulatory Many of the issues discussed here have been exert leverage as purchasers to increase leverage, and to consider interlocking thoroughly examined in reports by The the value of services provided for dollars strategies for reform of both health care Commonwealth Fund, including its 2006 spent. This leverage can be better deployed financing and delivery systems. Framework for a High Performance Health through strategies that address both cost System for the United States.2 Exhibit 3: Problems Driving the Need for Reform Many challenges of the health care system are interrelated—for example, it is difficult to control cost without reducing the new onset of disease or the inefficiencies embedded in the current health care system. States considering reforms recognize the need to de- velop multi-pronged approaches to reform. Important factors considered by states include: • High rates of uninsured: According to the Kaiser Family Foundation, 45 million non-elderly Americans are uninsured. Lack of insurance is associated with lower access to preventive and chronic care services.3 It also results in cost shifting to the private sector and is a factor in health care inflation and reduced health status. • Access to care: Many populations do not have access to care for preventive services or management of chronic disease. Rea- sons for lack of access may include uninsurance, unavailability of providers, or cultural barriers. Lack of primary care access often drives higher use of emergency services and poorer health.4 • Increasing rates of chronic disease: Forty-five percent of the population has at least one chronic disease. The Centers for Disease Control reports chronic diseases are the leading cause of death and disability, and that much of the burden of disease is preventable.5 Prevalence of chronic disease including diabetes and heart disease is rising,6 along with preventable risk factors such as obesity, and non-preventable risk factors such as age. The obesity trend is accelerating: more than 65 percent of the population now are considered overweight or obese.7 Without strategies to reduce risk, prevent disease and to manage diseases more effectively to prevent complications, costs of care will continue to spiral upwards. Strategies for preventing chronic disease are needed at the population, provider, and patient levels. • Gaps and variations in quality: Researchers have shown significant variations in the quality of care delivered across medical conditions, with high quality care being delivered only an average of 50 percent of the time.8 In many cases, poor quality of care accounts for higher rates of complications and higher cost. In multiple studies to examine regional cost variation and the underly- ing factors of the variation, researchers at Dartmouth Medical School have shown that variations in spending are highly associated with variations in supply, and that higher spending and utilization are not correlated to better outcomes.9 The Dartmouth team has concluded that a fragmented care management system has lead to high overall health services utilization without commensurate improvements in health outcomes.10 • Increasing costs: The costs of health care services are increasing and health care as a percent of state spending is steadily ris- ing. State spending on health increases on average 5 percent per year, with states spending between 8 and 20 percent of state budgets on health care.11 A significant portion of costs could be avoided by preventing underlying health problems and reducing inefficient or wasteful practices.12 • Misaligned incentives: Reimbursement systems for health care services promote the use of more care and higher intensity care, rather than coordinated, patient-centered interventions.13 Physicians and hospitals that adopt more efficient practices and reduce the volume of visits actually may lose income rather than reap rewards for better care. Providers have not typically moni- tored their performance on efficiency or clinical metrics, and have not been deeply engaged in competitive strategies to improve. Competition based on price and quality, routine in other sectors, rarely happens in the health care market. Initiatives such as pay-for-performance and some medical home strategies have attempted to align payments with higher-quality, better-coordinated care.14 • Insufficient information for decision-making: At all levels of the health care system—patients, providers, and the govern- ment—there is limited information on the cost and quality of services. Neither patients nor payers have sufficient information to select high quality providers.15 Underlying factors include immature performance measurement strategies,16 limited use of informa- tion technology, and siloed, rather than inter-operable, information systems. 6 About the State concrete examples where innovations have been adopted at the state or national levels; • Monthly email progress updates and Quality Improvement they also offered individualized feedback bi-monthly calls with team leaders. This ongoing flow of information enables Institute to SQII states (see Appendix 1 for listing of AcademyHealth to target technical expert faculty). assistance through expert faculty, based Elements of the State Quality on immediate state needs, and to help Improvement Institute • Distance-learning. AcademyHealth states share their progress, challenges, continues to host a series of “cyber- The SQII is an intensive technical assistance seminars” to help states drill down into and lessons learned. program designed to help states plan for specific areas of systems change (see concrete improvements in health care • Action planning. States are expected to Appendix 2 for cyber-seminar descriptions). develop specific action plans and to refine delivery systems. Recommended them in several stages. The state action approaches include value-based purchasing, plans incorporate activities by multiple data collection and transparency, care coordination, disease prevention and population-based health promotion. The Exhibit 4: About the SQII Selection Process nine participating states—Colorado, Kansas, Massachusetts, Minnesota, New Requirements for States: Mexico, Ohio, Oregon, Vermont, and • Each state team must include an overall leader designated by its governor. Washington—were selected through a competitive process using criteria described • Team members must include executive and legislative policymakers and key program administrators. in Exhibit 4. Following a call for proposals, an • Team composition may include necessary public and private organization repre- sentatives. independent panel reviewed the state applications and determined that the nine • States must show commitment of team participants for the duration of the pro- states selected had the combination of gram. commitment, leadership, and resources necessary to build on successful efforts • States must show commitment of state resources to implement quality improve- ment initiatives. in the area of health care quality and to achieve substantive additional reforms. Resources provided from the SQII include: Selection criteria: AcademyHealth and The Commonwealth Fund selected qualify- ing states to participate in the SQII based on the following criteria: • State site visits. A team from AcademyHealth and The Commonwealth • Support from the governor and designation of an appropriate team leader. Fund visited each state to help coalesce stakeholders and begin the planning • A proposed team that reflects capability to address goals laid out in the application. process. • Clearly articulated goals for improvement based on existing performance metrics • National Technical Assistance Conference from the Scorecard. (Kick-off Meeting). States were funded to bring teams of up to eight members • Proposed innovative approaches to address the chosen quality improvement to a national technical assistance meeting indicators that examine state policy levers relating to value-based purchasing, in June 2008. Technical assistance was data reporting, care coordination, and promoting wellness/disease prevention. provided through group and individual • Demonstrated ability to mobilize key state officials and other community stake- state sessions. holders. • Roster of technical assistance experts. • Presence of organizational structures to accomplish the objectives of the SQII AcademyHealth identified thought leaders (e.g., interagency task force; health care commission). from the state and national levels to engage with state teams during the Kick- • Demonstrated ongoing commitment to implementing the strategies developed during the SQII. off Meeting and during the course of the project. These subject matter experts offered Additional state information can be found on the State Quality Improvement Institute Web site: www.academyhealth.org/state-qi-institute/index.htm 7 stakeholders and outline a timeframe for State Action Plans for Change Through the application process, states achieving milestones. States participating in the SQII have engaged in planning and development made significant commitments to the to select a subset of Scorecard measures • Implementation of action plan project. States participating in the SQII as targets for quality improvement. Prior activities. For the duration of the State vary in population sizes, geographies, to entering the SQII program, several Quality Improvement Institute, states are and approaches to health care reform. states, including Massachusetts, Vermont, committed to participating in Institute Each state, however, recognizes the need Minnesota, and Oregon had begun the technical assistance activities, reporting to examine the “levers”—positive and process of comprehensive health care on progress, and meeting the milestones negative incentives that drive behaviors— reform. These states are using technical established in their action plans. by which reform can be enacted. assistance from the SQII to help integrate Exhibit 5: Initial Scorecard Measures Selected by States Indicator States Percent of Adult Diabetics Who Received Recommended Preventive Care CO, MN, NM, OH, VT Percent of Children with a Medical Home CO, KS, OR, WA Percent of Adults Age 50 and Over Who Received Recommended NM, OH, VT Screening and Preventive Care State performance on Selected Scorecard Indicators 2007 Scorecard: Percent of Scorecard 2007: Percent of Adults 2007 Scorecard: Percent of Children with Both a Medical Age 50 and Older Who Received Adult Diabetics Received and Dental Preventive Care Recommended Screening and Recommended Preventive Care* Visit in the Past Year* Preventive Care* Best 65.4% Best 74.9% Best 50.1% MN 58.9% MA 74.9% MN 50.1% NM 50.3% VT 70.7% MA 46.7% CO 50.2% OH 61.3% VT 44.4% MA 48.9% KS 60.7% WA 42.0% WA 48.5% WA 60.5% CO 41.2% VT 47.2% CO 57.7% OR 40.0% KS 43.2% NM 55.3% KS 39.7% OH 39.2% MN 55.0% NM 38.7% OR NA OR 52.2% OH 38.1% Median All Median All Median All 42.4% 59.2% 39.7% States States States SQII Priority for: SQII Priority for: MN, NM SQII Priority for: NM, OH, VT CO, MN, NM, OH, VT 2004 data* *2003 data * 2004 data 8 their efforts across priority areas to impact Engaging State Stakeholders Health reform recommendations delivered multiple indicators of quality. Other states Prior to the start of the program, to the governor and the legislature on participating in the SQII selected more participating state teams represented varying November 1, 2007 were built on a platform discrete health care indicators. During the levels of engagement from health care of stakeholder feedback and support. planning process of the SQII, all of the stakeholders, including physicians, hospitals, The recommendations were the result of states recognized the interrelated nature the state legislature, consumers, and state deliberations of the KHPA Board, four of information management, payment agencies. Either before or as a result of the Advisory Councils (140 members), a 22 processes, quality improvement, and access SQII Kick-off Meeting, all of the states community listening tour, and feedback on improving health care outcomes. Each created a process for engaging stakeholders from numerous stakeholder groups and state committed to addressing these factors to assure that reforms are enacted with the other concerned Kansans. Going forward, in quality improvement activities. A more support of key constituents. For example, Kansas is using the SQII process to begin to detailed description of the SQII states is participating states have implemented the define and operationalize a new legislative available in Appendix 3. Exhibit 5 shows following approaches: mandate to include medical homes in the the measures most frequently proposed Medicaid program and the state employee by SQII state participants along with their plan. Kansas will seek stakeholder rankings on selected indicators. • Minnesota has a history of collaborative engagement in defining a medical home in experimentation in cost and quality statute and examine purchasing strategies innovations. In 2004 the state created a Through the SQII’s technical assistance, that provide payment incentives for public/private purchasing consortium states examined factors influencing health coordinated care and wellness. called the SmartBuy Alliance. The state care and cost outcomes at the state level, also engaged stakeholders in a 2007 and are implementing improvements to impact specific quality measures. Each reform initiative through a Governor’s Transformation Task Force and the Technical Assistance state has: Legislature’s Health Care Access Content Commission. These multi-stakeholder • Convened a high level team sanctioned engagement initiatives resulted in Takeaway Strategies by the governor. Teams could include Technical assistance provided by successful passage of comprehensive the governor’s health policy advisor, the AcademyHealth and The Commonwealth reform legislation in 2008 that has become health and/or health services department Fund encouraged states to link quality the platform for the state’s Quality secretary, the Medicaid director, the improvement with state purchasing Improvement Institute work. insurance commissioner, legislators (or approaches. The June 2008 Kick-Off Meeting staff), and the state employee health plan • Ohio conducted an intensive assessment offered all of the state teams an opportunity administrator. Many states also included of state resources, stakeholders, and health to examine interrelated problems in the representatives from private payers, health status indicators and convened an Ohio health care system and hear from each other plans, major purchasers/employers, Health Quality Improvement Summit and expert faculty about potential solutions. and the advocacy community, as well as as part of their SQII initiative. The SQII representatives from the medical provider Team is pursuing a strategy to coalesce community, including hospitals, physicians, diverse stakeholders around a portfolio The technical assistance framework offered and other practitioners. of interventions to enable short-term to SQII participants posits that cost control and long-term return on investment, be must embody an array of purchasing • Developed a draft and final action plan actionable by a wide array of public and strategies that reduce demand for services that identifies specific quality indicators (by creating a healthier population), private stakeholders, and be informed by that can be used to identify progress and reduce the volume of services (by reducing the multiple local initiatives. The Ohio benchmark successes. Each action plan also inefficiency and increasing coordinated Summit, which took place November includes specific process steps for achieving care), and improve the quality of care 17-19, 2008 engaged stakeholders in results. by promoting coordinated, evidence- identification of the top 12 strategies that • Participated in onsite and electronic will transform Ohio’s health care system based, patient-centered care for acute and technical assistance opportunities provided into a high quality, cost-effective, high- preventive services. This framework is by AcademyHealth for individual states and performing system. consistent with the recommendations of The for all of the SQII participants. Commonwealth Fund’s Commission for a • Kansas’s legislature in 2007 required the High Performance Health System. Kansas Health Policy Authority (KHPA) to convene a deliberative process to make recommendations on health care reform. 9 Overarching messages from experts involved assistance (see Appendix 4 for policy Off meeting worked with individual states in providing technical assistance about what levers and approaches being used by to demonstrate that payment reform is makes state adoption successful/effective participating states). one part of an overall purchasing strategy. include: They recommended that states use their Delivery and Financing Systems leverage as purchasers to effect change; • States have an important role to convene Reform each state should go through an exercise to stakeholders with an interest in cost and Payment Reform/Purchasing Strategies: identify what value means in health care quality. The U.S. health care system is composed and how that translates into the state’s of many inter-related parts. As financing • Stakeholders need to be involved in a approach to buying, creating incentives, expert Harold Miller, M.S., of the meaningful way in the development and using cost and quality measures. Pittsburgh Regional Health Initiative process. explained to SQII participants, variables Elliott Fisher, M.D., M.P.H, of Dartmouth • Policy development and clinical practice contributing to health care costs include Medical School provided information to improvement are interrelated; both the people, the number of health SQII participants showing that a significant policy change and clinical improvement conditions per person, the cost of services proportion of health care costs are driven by are needed. to care for each condition, and the inefficiencies and unnecessary variations in number of episodes per condition during • Pilot programs are effective for testing the health care system. Dr. Fisher used the which care is provided. This equation is concepts at the local level that could be Dartmouth Atlas data to show that rather graphically illustrated in Exhibit 7. Mr. expanded statewide. than improving outcomes, receiving a high Miller noted that state or federal efforts to volume of health services reduces health • States can learn from each other to identify control costs in one part of the cost of care care quality and patient satisfaction. Care models for reducing gaps in quality. continuum typically result in the growth volume is driven by availability of specialty of costs in another area, as if the state had services and providers, rather than by patient • Alignment of payment and incentives are pushed on one side of a balloon, only to health needs. Analysis of these problems needed to promote the desired consumer, see another part of the balloon swell. provider, and purchaser behavior. led Fisher to advocate for changes in the payment methodology from fee-for-service Mr. Miller and other experts concluded • Robust analysis of data is needed to identify that simultaneous efforts are needed to to a bundled care approach, which pays for trends and opportunities for system an episode of care rather than a single service. improvement. slow the pipeline of individuals needing States were encouraged to consider ways to chronic care, change payments to reward pay more for higher quality care rather than • Better approaches to care coordination— effective and efficient care, and improve just rewarding volume. such as those included in a medical quality of care. Faculty experts at the Kick- home—can introduce efficiencies and enhance patient engagement in health. • Care coordination is an approach to Exhibit 7: “The Health Care Cost Balloon” reducing health care disparities and improving population health. • Providers (physicians, hospitals and other practitioners) need support to deliver Variables Contributing to the Cost of Care care more effectively, including financial resources, information technology #Episodes #/Type resources, and technical support for Cost #Conditions of Care Services #Processes Cost = X X X X practice improvement. Person Person Condition Episode Service Process of Care • Measurement, feedback and evaluation are essential for all participants in the health care system. Health Care Cost “Balloon” Technical Assistance Focuses on Major Policy Issues The following section captures some of the important themes that have been SOURCE: Harold D. Miller, NRHI, PRHI examined thus far through SQII technical 10 Care Coordination, Chronic Care care as is now rewarded. Medical homes coordination and outcomes. States are Management, and Population Health are anticipated to be a cost effective collaborating with health plans and Medical Homes: Technical assistance investment to avert use of higher-cost physicians to examine opportunities to use provided through the SQII was designed services. medical homes to improve coordination to bolster state strategies to enhance and outcomes. As part of the SQII action availability of “medical homes.” While Faculty member Michael Bailit, founder plans, states are defining the medical home there is no universal definition of a of Bailit Health Purchasing and a concept, identifying ways to engage the medical home, Sarah Hudson Sholle, consultant to government agencies, state’s physicians, and conceptualizing Dr.Ph., National Committee for Quality discussed the importance of linking reimbursement incentives. Assurance (NCQA), outlined essential payment to practice improvement. As elements of a medical home as defined by an example, he talked about a project • Washington State adopted legislation in NCQA. According to NCQA, important he is supporting in Pennsylvania. He 2008 to expand use of medical homes. components of a medical home include: noted that, in Pennsylvania, physicians The state will build on its history of must meet practice characteristics collaboration with stakeholders and criteria for a medical home to be eligible widespread agreement on elements • Standards for communicating with for significantly increased payments. of the “Chronic Care Model.” Medical patients and offering timely access; These payments specifically support the home activity will focus on defining • Availability and use of data to development of a primary care team that the concept of the medical home to track patient communications and is physician-led and patient-centered. In underlie subsequent development of interventions; the Pennsylvania model, payments will performance measures and an associated be reduced over time as infrastructure reimbursement system and incentives for • Use of tools—paper or electronic— is developed and more physicians are improved performance. Improving the to track patient information including eligible for pay-for-performance incentive patient experience with the health care interventions, health status, and payments based on outcomes. Payments in system and thus more fully engaging in laboratory tests; the first years of the program are viewed care is another important element of the • Use of data (such as registries) to track as an infrastructure investment. Of note, Washington plan. Technical assistance patients by diagnosis or condition; physicians in the program are required from the SQII will help the state learn to treat all patients as medical home from other state models, adopt evidence- • Implementation of evidence-based care patients, not to distinguish by patient based practices, and design performance management guidelines; or insurer. In practice this means the and evaluation metrics. medical home concept is embedded in • Offering programs to educate, support, and engage patients in caring for their the practice through care coordinators or Other Care Coordination and Chronic health needs; and case managers to carry out the enhanced Disease Management: Faculty member coordination activities. Ken Thorpe, Ph.D., of Emory University • Measuring performance at meeting guidelines and taking action to improve noted that approximately 75 percent of Faculty members emphasized that delivery of care. health care spending nationally is linked successful implementation of medical to patients with one or more chronic homes requires robust physician level conditions. About two-thirds of the data systems to track and monitor patient The NCQA model provides one set of growth in spending is due to a rise in status. Medical homes are viewed as a benchmarks by which states can recognize prevalence of treated disease. For example, potential way to reduce health disparities and reward physicians who incorporate the increase in diabetes spending alone by enabling physicians to identify needs various aspects of a medical home into represents a five percent increase in health and provide the intensity of care needed their practice. NCQA notes that alignment care spending. Dr. Thorpe reported that by various populations. of financing and practice support are the Centers for Disease Control and necessary to reflect the costs associated Prevention (CDC) found that about 80 with a higher intensity of care delivery Several states participating in the SQII percent of cardiovascular risk factors are and the physician office restructuring are developing state-level consensus on preventable through lifestyle, diet, and that underpin an effective medical home. the definition of a medical home and quitting smoking. Dr. Thorpe advocated Enhanced payments for medical homes on payment policy. Colorado, Kansas, that states both work to prevent chronic will incentivize more coordination of care, Oregon, Vermont, and Washington are disease and to improve quality of care as rather than encouraging a high volume of conducting pilot testing of medical integral strategies to improve health. home interventions to improve care 11 In addition to improving chronic improve the transition of care for future demand for health care services care in ambulatory settings to avoid specified conditions, using congestive and change the trends for current at-risk hospitalizations, reduction of preventable heart failure (CHF) as the sentinel populations. re-hospitalization has emerged as an condition for process improvements. important focal area amenable to change. Several states participating in the SQII Population Health Strategies: States Amy Boutwell, M.D., an expert from the embraced the concept of promoting increasingly recognize the need to marry Institute for Healthcare Improvement population health as a cost management public health and acute care interventions (IHI), engaged SQII states in a discussion tool by building linkages to the public to slow the growth in demand for health of how to use data to identify preventable health systems. care services. Population-based health re-hospitalizations, and approaches to interventions are expected to improve reducing re-hospitalization rates. She the health of the entire population. SQII • Minnesota recently enacted noted that 17 percent of hospitalized comprehensive health care reform technical assistance focused on ways that Medicare patients are re-hospitalized that, among other things, establishes a states can improve overall health of the within 30 days, costing that program alone statewide health improvement program state populations. For example, faculty $15 billion per year, $12 billion of which to reduce obesity and tobacco use and member Joseph Thompson, M.D., the may be preventable. Dr. Boutwell focused other problems that impact the rates of Arkansas Surgeon General, highlighted on using hospitalization as a sentinel event chronic disease. Arkansas’ multi-pronged strategy to indicating a highly sick person who may combat rising rates of childhood obesity. States also recognized that, in addition to need more care coordination to reduce Using state-specific data from multiple reducing the long-term cost of services, subsequent re-hospitalizations. The sources, Arkansas built the case for quality improvements must be driven by IHI has developed models for reducing stakeholders that obesity is a driving factor addressing the health of the population – preventable re-hospitalizations through in overall health care costs and morbidity. and thus reducing the number of people improved discharge planning, enhanced who need the services. communications, and coordinated In Arkansas as elsewhere, childhood handoffs of patients from hospitals to ambulatory care providers. obesity is filling the pipeline with a • Vermont used its “Blueprint for Health” generation of individuals with poor health, to stimulate a culture of prevention, lower quality of life, and higher health or “Community Activation” across Several states participating in the care costs. Dr. Thompson pointed out Vermont. The Blueprint supported the SQII embraced the goal of improving that Arkansas pays for the costs of obesity development of community prevention coordination of acute care services to in its state employee insurance program programs in both Blueprint and non- reduce costs by avoiding complications as well as in Medicaid, SCHIP, and other Blueprint communities. These programs and exacerbations of chronic disease. public programs. With data from the state are designed to reflect local input based Others focused specifically on reducing employee insurance program, Arkansas on local resources and needs. Examples preventable re-hospitalizations, which began by relating employee behavioral include exercise and walking programs, can be identified using available data and risk factors to actuarial risk. As a result, community walking maps, structured can be used to identify care management the state adopted an innovative insurance information for patients and providers improvement opportunities in inpatient design to incentivize risk reduction. The oriented toward healthy lifestyles, and outpatient settings. Arkansas state employee plan adopted first enhanced smoking cessation efforts and dollar coverage for preventive care, offered other initiatives. The state is seeking to • Massachusetts, in its final action discounts for employees with no risks, create a cultural transformation and a plan, has established a goal to and adopted incentives for individuals sustainable prevention infrastructure. improve the quality of transitions of to reduce risk. The purchasing strategy care (hospital discharge) to reduce layers on to a public health-oriented hospital readmissions. The state will Transparency/Data Collection and prevention strategy enacted in prior develop pilot programs in hospitals to Reporting years. In 2003, Arkansas enacted enabling improve care of chronic conditions and States are recognizing that, at all levels legislation to coordinate statewide, multi- reduce readmissions, and will partner of the health care system, effective sector efforts to combat obesity. The with other stakeholders such as the management of data and information is legislation encourages schools to adopt Massachusetts Hospital Association. The essential to accountability. “Transparency” physical fitness programs and healthier state will use data to identify the top 10 is the term used to convey the concept menus, and establishes a measurement conditions with high readmission rates that patients, physicians, and payers and tracking program for evaluation of and will identify and pilot evidence- (including the state) should have access to children’s body mass index. The Arkansas based hospital discharge plans that comparative cost and quality information example illustrates tactics to both reduce 12 that will help them make better health care and efficiency in health care, affordable comparative reporting. Faculty member decisions. and sustainable health care, promoting Tim Ferris, M.D., M.P.H., of the Mass health and wellness, stewardship, and General Physicians Organization, and SQII technical assistance focused on education and engagement of the public. a senior scientist in the Partners/MGH identifying potential methods to link Kansas SQII activities will focus on Institute for Health Policy, highlighted information in meaningful ways and medical home implementation using the need to develop meaningful translating data into actionable information. a data-driven approach to defining the performance measures and to use them SQII participants recognized that better content and reimbursement strategy in a collaborative manner to support use of clinical information in physician for medical homes. The state convened physicians and other providers in making decision-making supports practice-level the Kansas Medical Home Planning changes. Measurement must be linked to improvements. At the level of systems group charged with examining data for incentives and rewards that will engage accountability, experts encouraged SQII high-cost diagnoses for Kansas Medicaid participants in a collaborative manner. participants to use plan-, state- and national- and the State Employee Health Benefit Ernie Moy, M.D., M.P.H., of the Center for level data to examine statewide health trends plan. By linking data and best practice Quality Improvement and Patient Safety and to drive value-based purchasing. information to its medical home at the Agency for Healthcare Research and pilot, Kansas intends to implement a Quality (AHRQ), identified a number Data Integration: A model for state-level medical home model that will result in of resources available to assist states in integration of data was presented by measurable improvements of targeted developing comparative reporting tools Anthony Rodgers, Director of the Arizona health care indicators. at the state, community, health plan, and Health Care Cost Containment System hospital level. (AHCCCS), Arizona’s Medicaid program. • Vermont used its Blueprint for Healthy Vermont as the vehicle to create an Mr. Rodgers described the AHCCCS data SQII states are working toward making infrastructure to collect data from integration initiative, which was developed available comparative information on multiple levels in the health care to provide better information for evidence- plans, hospitals, and physicians to both system (medical records, claims, and based decision-making. Arizona is creating promote quality improvement in the laboratory values) and to produce a statewide all-payer data exchange to provider organizations, and to help integrated information for decision- underpin future state reform activities, consumers make selection decisions based making. Vermont strategies include the starting with the AHCCCS program. The on value. Consumer experience is seen as development of registries, independent state’s goal is to integrate data across the an increasingly important measurement chart review to assess physician continuum of care from ambulatory to due to its potential to “engage” consumers performance, and evaluation. Vermont inpatient and long term care. In addition in comparative shopping for quality and has also taken a leading role to expand to its current all-payer claims data base, cost. Physician engagement is important to the use of electronic medical records the AHCCCS program has a goal to drive competition on the basis of quality (EMRs). In 2008, the state implemented incorporate information on the patient and efficiency. a systematic health information perspective through “experience of care” exchange infrastructure. As this platform surveys and other data sources. Arizona is expanded, it will include a Web- • Minnesota engaged physician groups uses integrated data to examine system in self measurement and improvement based clinical tracking system, shared trends such as over- and under-utilization through the Minnesota Community data management and analyses, and of medical services, and to increase Measurement (MCM) initiative, and multi-payer claims. This data system accountability of purchasing. As a caveat will continue to promote transparency will be used to inform and evaluate to other states, Mr. Rodgers noted that as an important bedrock of value-based Vermont’s medical home pilot program. the interplay of policy, politics, market purchasing. Physician-lead measurement To facilitate adoption of information conditions, and management operations has been an effective strategy for getting technology, Vermont established a loan impact the capability of state programs to buy-in and establishing credibility of and grant program to help physicians integrate and analyze data sources. measurement efforts. Minnesota’s goal cover capital investments in electronic is to provide real-time measurement health record systems in Blueprint Several SQII states have tied their reform feedback to physicians linked with communities. activities to improved use of data and clinical prompting through EMRs. increased transparency of information. This will enable physicians to see their Performance Measurement and Reporting: performance results immediately rather • Kansas incorporated the use of data Increasingly, states are looking at data than seeing a report six months later. as a fundamental premise in its health and information as a way to fully engage Purchasers in the state believe that policy activities. Data are focused upon consumers and physicians through transparency is critical to value-based the six principles: access to care, quality 13 purchasing by consumers, plans, and the state. The state attributes success of Endnotes 9 Fisher E. et al. “The Implications of Regional Variations in Medicare Spending. Part 1: The 1 The Commonwealth Fund Commission on Content, Quality, and Accessibility of Care,” the MCM initiative to the willingness a High Performance Health System, A High Annals of Internal Medicine, Vol. 138, No. 4, pp. of purchasers to establish performance Performance Health System for the United 273-87. standards and pay-for-performance States: An Ambitious Agenda for the Next President, November 2007. Accessed at 10 Wennberg, J. et al. “Tracking the Care of Patients programs. Minnesota is working to www.commonwealthfund.org/publications/ with Severe Chronic Illness. The Dartmouth achieve a statewide goal in which better publications_show.htm?doc_id=584834 on Atlas of Health Care 2008 (Executive Summary),” February 19, 2009. The Dartmouth Institute for Health Policy and performance is paid more than lower Clinical Practice, April, 2008. Accessed at performance by tying reimbursement to 2 The Commonwealth Fund Commission on www.dartmouthatlas.org/atlases/2008_Atlas_Exec_ performance levels. a High Performance Health System, Framework Summ.pdf on February 19, 2009. for a High Performance Health System for the United States, August 2006. Accessed at 11 Kaiser Family Foundation State Health Facts. Accessed at www.statehealthfacts.org/ Conclusion www.commonwealthfund.org/usr_doc/ Commission_framework_high_performance_943. comparemaptable.jsp?ind=598&cat=5 on pdf?section=4039 on February 19, 2008. October 5, 2008. States are leading the way in implementing reforms to address the intertwined 3 Kaiser Commission on Medicaid and the 12 Wennberg, J. et al. “Tracking the Care of Patients Uninsured. “The Uninsured and the Difference with Severe Chronic Illness. The Dartmouth problems of rising costs, gaps in quality, Health Insurance Makes. Fact Sheet,” September, Atlas of Health Care 2008 (Executive Summary),” and a progressively less healthy U.S. The Dartmouth Institute for Health Policy and 2008. Accessed at: www.kff.org/uninsured/ population. AcademyHealth and The upload/1420-10.pdf on February 19, 2009. Clinical Practice, April, 2008. Accessed at: Commonwealth Fund are collaborating www.dartmouthatlas.org/atlases/2008_Atlas_ 4 Committee on the Future of Emergency Care Exec_Summ.pdf on February 19, 2009. with states to provide evidence-based in the United States Health System. “Hospital- technical assistance to enhance their Based Emergency Care: At the Breaking Point,” 13 Committee on the Quality of Health Care in Institute of Medicine National Academy Press. America. Crossing the Quality Chasm: A New efforts. Technical assistance is organized Health System for the 21st Century. Institute of Washington, D.C. 2006. around the themes of improved Medicine National Academy Press. Washington, purchasing strategies, improved chronic 5 U.S. Centers for Disease Control and Prevention, D.C. 2001. National Center for Chronic Disease and Health care management and the prevention 14 Berenson, R. et al. “A House Is Not a Home: Promotion. Accessed at www.cdc.gov/nccdpho/ of disease, and increased availability index.htm on February 19, 2009. Keeping Patient at the Center of Practice Redesign,” of data for decision-making. The nine Health Affairs, Vol. 27, No. 5, pp. 1219–30. 6 Thorpe K. et al. “Which Medical Conditions states participating in the SQII are Account For The Rise In Health Care Spending?,” 15 Collins, S. and K. Davis. “Transparency in Health trying a spectrum of approaches. All Health Affairs, August 25, 2004, pp. W437-45. Care: The Time Has Come,” The Commonwealth Accessed at http://content.healthaffairs.org/cgi/ Fund, March 15, 2006. have recognized the need for reforms, reprint/hlthaff.w4.437v1?maxtoshow=&HITS=10 and are working to engage important &hits=10&RESULTFORMAT=&author1=thorpe& 16 Committee on Redesigning Health Insurance stakeholders—purchasers, providers, Performance Measures, Payment, and andorexactfulltext=and&searchid=1&FIRSTINDE Performance Improvement Programs. health plans, patients and policy makers— X=0&resourcetype=HWCIT on February 19, 2009. “Performance Measurement: Accelerating to promote system-wide transformation. 7 Flegal K. et al. “Prevalence and Trends in Obesity Improvement,” Institute of Medicine National By helping the states orchestrate their Among US Adults 1999-2000,” Journal of the Academy Press. Washington, D.C. 2006. efforts, the SQII will promote alignment, American Medical Association,Vol. 288, pp.1723-27. innovation, and hopefully, large scale 8 McGlynn, E. et al. “The Quality of Health Care improvements at the state level. Delivered to Adults in the U.S.,” New England Journal of Medicine, Vol. 348, No. 26, pp. 2635-45. 14 Appendix 1: State • Maulik Joshi, Dr.P.H., M.H.S.A. – President at the University of Arkansas for Medical Sciences; Practicing General Pediatrician at Quality Improvement & CEO, Network for Regional Healthcare Improvement (NRHI) Arkansas Children’s Hospital Institute Kick-off • Neva Kaye – Senior Program Director, • Ken Thorpe, Ph.D., M.A. – Robert Meeting Faculty National Academy for State Health Policy W. Woodruff Professor, Chair of the Department of Health Policy & • Harold Miller – President, Future Management, Rollins School of Public During the June 2008 Kick-off Meeting, 12 Strategies, LLC; Strategic Initiatives Health of Emory University; Co-directs the expert faculty from think tanks, academia, Consultant, Pittsburgh Regional Health Emory Center on Health Outcomes and consulting firms, and state and federal Initiative and the Jewish Healthcare Quality agencies provided in-depth technical Foundation, Pittsburgh; Adjunct Professor assistance to the state teams. These health of Public Policy and Management, • Paul J. Wallace, M.D. – Medical Director, services and policy researchers encouraged Carnegie Mellon University’s Heinz School Health and Productivity Management state teams to think creatively about of Public Policy and Management Programs; Senior Advisor, The Care how to go about designing their quality Management Institute and Avivia Health, improvement efforts, and demonstrated • Ernie Moy, M.D., M.P.H. – Medical The Permanente Federation their extensive experiences and knowledge Officer, Center for Quality Improvement and Patient Safety, Agency for Healthcare Faculty areas of expertise and/or research throughout the meeting. Expert faculty Research and Quality (AHRQ) include: Chronic Care Management, included: Medical Homes & Care Coordination, • Anthony Rodgers – Director, Arizona Purchasing and Using the State’s • Michael Bailit – Principal, Bailit Health Health Care Cost Containment System Purchasing Power, Policy and Politics Purchasing LLC of Quality Improvement, Quality • Sarah Hudson Scholle, Dr.P.H., M.P.H. – Improvement Implementation, Primary • Amy Boutwell, M.D., M.P.P. – Content Assistant Vice President for Research and Director, Institute for Healthcare Analysis, National Committee for Quality Care, Measuring Quality, Payment Reform, Improvement (IHI) Assurance (NCQA) Public-Private Partnerships/Engaging Key Stakeholders, Hospitals/Readmissions, • Timothy G. Ferris, M.D., M.Phil, M.P.H. – • Joseph W. Thompson, M.D., M.P.H. Health Disparities, Early Childhood Medical Director, Mass General Physician’s – Director, Arkansas Center for Health Health, Health Information Technology, Organization; Senior Scientist, Partners / Improvement; Surgeon General for the Public Reporting/Transparency/Data, and MGH Institute for Health Policy State of Arkansas; Associate Professor in Population Based Health Care/Wellness. the Colleges of Medicine and Public Health 15 Appendix 2: primary care Medical Homes to Medicaid beneficiaries in North Carolina. Scott Leitz, Minnesota Assistant Commissioner of Health, spoke about State Quality Minnesota’s new health reform bill that was Improvement Institute Dr. Tom Mahoney, chief executive officer enacted in May of this year. In his role as Cyber-seminars and executive director at the Rochester assistant commissioner, Scott oversees and Individual Practice Association (RIPA), an directs the department’s efforts on health care individual practice association with 3,200 policy development, and he is spearheading A central feature of the technical assistance the Pawlenty administration’s efforts on providers, explained how RIPA engaged component of the SQII is a series of four health policy and reform. physicians while implementing a managed cyber-seminars, each of which address a care program and the lessons learned from distinct quality improvement topic that is Cyber-seminar 3: Using Delivery this experience. Among other points, he of particular concern to the participating System Redesign & Payment highlighted the importance of providing states. As of January 2009, three of the Reform to Reduce Hospital clear, actionable, and transparent data, the four cyber-seminars had occurred, with Readmissions need to reframe “Quality vs. Cost” measures, each event featuring presentations by three This cyber-seminar gave states a better sense and the central role of establishing trust faculty experts, followed by a question of the varied roles a state can play in the among all parties involved. |and answer period. The slides, transcript, process of reducing hospital readmissions and audio recording of each cyber-seminar issues through system redesign and payment Cyber-seminar 2: Using Information can be found on the SQII Web site: reform. The cyber-seminar also explored to Help Providers Improve: What is www.academyhealth.org/state-qi-institute/ the important role of using data to reduce the State’s Role? technicalassistance.htm. readmissions and the process of engaging This cyber-seminar gave states a better sense of the role that a state can play in the important stakeholders. Cyber-seminar 1: Engaging process of designing a data collection and Physicians in Health System Reform reporting framework, as well as the potential Dr. Amy Boutwell, content director at the This cyber-seminar gave states a better benefits to a state from partnering with Institute for Healthcare Improvement sense of the importance of engaging other stakeholders. This cyber-seminar also (IHI), presented on IHI’s work addressing physicians in the reorganization of the explored the improvements in the quality readmissions related issues, and provided health care delivery system, identifying the of care that can occur when providers some overall context on the issue of role of physicians in coordinating care, collaborate and learn from each other. preventable hospitalizations and the issue promoting prevention and improving of re-hospitalizations. the overall quality of health care, and Susie Dade, director of quality improvement differentiating between physicians’ tasks and administration for the Puget Sound Harold Miller, president and CEO of and those of others in the health care Health Alliance in Washington State, the Network for Regional Healthcare system. The cyber-seminar also explored discussed the work of the Health Alliance. Improvement, director of The Center for how purchasing strategies, performance She works with others in the community to Healthcare Quality and Payment Reform, measurement, and reporting can be used identify quality improvement opportunities and a Strategic Initiatives consultant for as tools for engaging physicians and how and to stimulate and encourage system the Pittsburgh Regional Health Initiative, physicians may be impacted by the unique and practice changes that will result in discussed the central role payment reform realities of individual communities. improved delivery of care for patients with can play in reducing hospital admissions. chronic diseases and increased participation Since 2006, Harold has been working in prevention-related activities. Michael Bailit, founder of Bailit Health on a number of initiatives to improve Purchasing, LLC, detailed his efforts the quality of health care services and Dr. Vahé Kazandjian, president of the in Pennsylvania as that state works to to change the fundamental structure of Maryland-based outcomes research implement the Chronic Care Model and center, The Center for Performance health care payment systems in order to Medical Homes, and the role of physicians Sciences (CPS) and senior vice president support improved value. at various levels of that process. for the Maryland Hospital Association (MHA), discussed his research and Kim Streit, vice-president of Healthcare Dr. Charles Willson, clinical professor of policy responsibilities for the Quality Research and Information for the Pediatrics at the Brody School of Medicine Indicator Project, the largest national Florida Hospital Association, detailed the at East Carolina University and a consultant and international effort to measure partnership between the Florida Hospital to the Community Care of North Carolina and compare indicators of hospital Association and the Florida Department program, focused his presentation on the performance. He also spoke more broadly of Health, which demonstrates how states process and results of the Community about some of the activities currently can play a vital role in encouraging the use Care program, which works to provide underway in Maryland. of data to reduce readmissions. 16 Appendix 3 - State Quality Improvement Institute State Profiles SQII Profile - Colorado State Name: Colorado Environment In January 2008, the Colorado Blue Ribbon Commission for Health Care Reform issued a final report to the General Assembly outlining recommendations for comprehensive reform to improve health insurance coverage and manage costs. The Commission recommended an individual insurance purchasing mandate along with initiatives to improve efficiency, connect individuals with appropriate care and coordinate programs. Prior to this, in May 2007, Governor Bill Ritter signed legislation establishing medical homes for children on public insurance in Colorado and mandating a study on the efficacy of the medical home model of care for children. In 2008, the governor created a Center for Improving Value in Health Care (CIVHC). The mandated role of CIVHC is to inventory health care assets in Colorado, identify priorities for improvement, and develop recommendations for funding support and legislative initiatives. CIVHC will be lead by the Colorado Department of Health Care Policy and Financing, in collaboration with the Governor’s Office of Policy Initiatives. Important problems identified by the state include deficits in delivery of high quality, accessible health care and significant spending increases in the Medicaid program not paralleled by commensurate quality improvements. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 22 Access: 35 Quality: 30 Avoidable Hospital Use and Costs: 15 Equity: 43 Healthy Lives: 2 State Agency Lead for SQII State of Colorado Department of Health Care Policy and Financing - Joan Henneberry, Executive Director Final Action Plan Targets Colorado will focus on getting CIVHC established, staffed, and fully funded by June 2009. CIVHC will bring consumers, business leaders, health care providers, insurance companies, and state agencies together around a common agenda. This group will develop strategic recommendations to identify, implement, and evaluate quality improvement strategies. The CIVHC steering committee has established task forces based on the “It Takes a Region” model for 1) aligning benefits/finances, 2) consumer engagement, 3) transparency/public reporting, and 4) delivery system improvement. Each task force must complete two sustainable QI projects of their selection by June, 2009. The state plans to establish functioning learning network for regional quality improvement efforts throughout the state and coordinate inter-regional communication of health information. Strategies Colorado aims to be a leader in national health care reform. This includes chronic care improvement through disease management programs and increasing use of value-based purchasing to leverage the state’s purchasing power to drive cost efficiency and quality improvement. Colorado will improve measurement and engagement of providers as a foundation for effective pay for performance tests. Colorado will collaborate with health care providers to identify and implement standardized performance measures and reward providers for meeting targets and achieving improvement. The state is also working toward enhanced use of Medicaid managed care and creation of a statewide medical home concept. Continued on next page 17 SQII Profile - Colorado (Continued) Assets Colorado has numerous reform initiatives, including the Blue Ribbon Commission for Health Care Reform and a “Quality Forum.” The Colorado Department of Health Care Policy and Financing (HCPF) convened the Quality Forum with representatives from relevant state agencies, legislators and health care organizations representing consumers, businesses, health care provider organizations. The Forum selected indicators for the SQII with the intent of enhancing programs that have received legislative attention or have improvement initiatives under way. This will augment the momentum and provide leverage for the target improvements. Colorado’s Quality Forum will also guide establishment of quality indicators, measures, and improvement goals to form the basis of the new CIVHC. Challenges Colorado is concerned with rising medical costs and lack of coordination in its Medicaid program. In Fiscal Year 2006-2007, Colorado Medicaid served 393,077 beneficiaries at a total cost of over $2.06 billion, a 77 percent increase from the year 2000. Colorado identified a subset of high-needs, high-cost beneficiaries who are driving a significant portion of total Medicaid spending. This is an important population to target for care coordination and preventive strategies. This will be carried out in context of Colorado’s broader health reform agenda. Although Colorado notes as an asset a number of government programs and non-governmental organizations dedicated to the improvement of quality and cost containment in health care, the state notes the needs for greater coordination of efforts.  Stakeholder Engagement The new Colorado Center for Improving Value in Health Care is charged with convening a health care quality steering committee consisting of relevant state agencies, health care stakeholder organizations and individuals. The Center’s mandate states that major stakeholder groups representing public agencies, plans, providers, and consumers participate, along with representatives of the governor’s office. Ongoing initiatives in the state include the Colorado Integrated Care Collaborative, a partnership between the Colorado Department of Health Care Policy and Financing; the Center for Health Care designed to develop models for serving high-needs, high-cost beneficiaries statewide; and the Colorado Clinical Guidelines Collaborative (CCGC) a non-profit coalition of health plans, physicians, hospitals, employers, government agencies, quality improvement organizations, and other entities working to implement systems and processes, using evidence-based clinical guidelines. The state QIO, the Colorado Foundation for Medical Care (CFMC), also offers a variety of interrelated services addressing cost management and quality improvement. 18 SQII Profile - Kansas State Name: Kansas Environment Reforming Kansas’ health care system became a priority policy issue in 2002 under the leadership of Governor Kathleen Sebelius. The Kansas Health Policy Authority (KHPA) was created in 2005 as an independent agency within the executive branch. The KHPA Board established three broad priorities for health reform: 1) promoting personal responsibility – for healthy behaviors, informed use of health care services, and sharing financial responsibility for the cost of health care; 2) promoting medical homes and paying for prevention – to improve the coordination of health care services, prevent disease before it starts, and contain the rising costs of health care; and 3) providing and protecting affordable health insurance – to help those Kansans most in need gain access to affordable health insurance. Health reform recommendations were delivered to the governor and the legislature on November 1, 2007. Legislation enacted a number of the recommendations in 2008 including a provision that establishes medical homes in the Kansas Medicaid program and State Employee Health Plan. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 20 Access: 17 Quality: 19 Avoidable Hospital Use and Costs: 26 Equity: 34 Healthy Lives: 27 State Agency Lead for SQII Kansas Health Policy Authority (KHPA) - Dr. Marcia Nielsen, Executive Director Final Action Plan Targets (1) 85 percent of all children in Kansas will have a medical home by 2012; and (2) Avoidable hospitalization for pediatric asthma in Kansas will be reduced to no more than 82 per 100,000 for children aged 0 to 17 years by 2012. Strategies Kansas ranks 19th on Quality measures and 26th on Avoidable Hospital Use & Costs measures on the Commonwealth Scorecard. With technical assistance from the SQII, Kansas will begin to operationalize the new legislative mandate to include medical homes under Medicaid and the state employee plan. They will develop plans for reforms that link wellness and better care management to improve cost effectiveness in the health care system. As process steps for implementation of medical homes, Kansas will seek stakeholder engagement in defining a medical home in statute and examine purchasing strategies that provide payment incentives for coordinated care and wellness. Assets KHPA is charged with developing a statewide health policy agenda to include the efficient purchase of health care services, the promotion of public health oriented strategies, and data driven health policy to coordinate health and health care for Kansas. The KHPA is required by statute to adopt health indicators and include baseline and trend data on health costs and indicators in each annual report to the legislature. A Kansas Consumer Health Care Cost and Quality Transparency Project (Kansas Health Online, www.kansashealthonline.org) is currently underway to collect and make available existing health and health care data resources to the Kansas consumer. By 2010 Kansas will implement medical home incentive payments/contractual rate adjustments in the state employee and Medicaid programs, and will continuously evaluate the impact of the changes. Challenges The state faces political and budget challenges to enhancing Medicaid payments associated with medical homes. While the state legislature recently passed development of medical home model there is no immediate plan to increase reimbursement or payment methodology for Medicaid providers. Stakeholder Engagement Kansas Medical Society and Kansas Hospital Association are developing a model similar to the “Iowa Quality Collaborative.” The initiative has the potential to facilitate widespread adoption of the medical home model by providers and could serve as a valuable means to engage consumers and providers in the development and implementation of the medical home concept. 19 SQII Profile - Massachusetts State Name: Massachusetts Environment In 2006, Massachusetts enacted universal coverage legislation that required individuals with access to affordable coverage to obtain or purchase it. The law provided for expanded Medicaid eligibility, government subsidies, and insurance market reform to ensure affordability. The state reports that 72,000 individuals have enrolled in Medicaid/SCHIP, 191,000 have purchased private insurance, either on their own or through their employers, and that 176,000 have enrolled in the state’s subsidized plan. As of March 31, 2008, the number of Massachusetts residents enrolled in health insurance increased by more than 439,000. Since reform was enacted, the state has engaged in planning efforts to improve quality of care, improve the health of the population and leverage information and purchasing powers to improve value. Massachusetts identified improved coordination of care as an important strategy for improving quality, reducing disparities, and avoiding unneeded hospital costs. In August 2008, Massachusetts enacted S. 2863 as a cost containment, efficiency and transparency component to the reform initiative. Massachusetts continues to focus on system improvements initiatives including: 1) adoption of consistent payment policies for serious reportable events; 2) coordination and alignment of performance measures and incentives; 3) payment methodology reform; 4) disease management and wellness initiatives (with an initial focus on diabetes); and 5) administrative simplification. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 8 Access: 2 Quality: 3 Avoidable Hospital Use and Costs: 35 Equity: 1 Healthy Lives: 20 State Agency Lead for SQII Executive Office of Health and Human Services - Dr. JudyAnn Bigby, Secretary Final Action Plan Targets Goal 1: Residents of Massachusetts will live in communities that support healthy lifestyles for the prevention and management of chronic conditions. Goal 2: Primary care providers in Massachusetts will provide high quality chronic illness care characterized by productive interactions between practice team and patients that consistently provide the assessments, support for self-management, optimization of therapy, and follow-up. Goal 3: Massachusetts acute care hospitals will improve the quality of transitions of care (hospital discharge) to reduce hospital re-admissions. Improve the care of patients with chronic illness while in the hospital. Goal 4: Massachusetts residents with a chronic disease will have a clear understanding of their condition, develop self- management skills, and will assume a shared responsibility for their condition with their healthcare provider. Goal 5: Reform payment policies and align measurements with the priorities and goals of the SQI plan. Goal 6: The Commonwealth will have a Chronic Care Information System that supports statewide implementation of the Blueprint for both individual and population-based care management. Continued on next page 20 SQII Profile - Massachusetts (Continued) Strategies Massachusetts’s work with the SQII is aligned with broader efforts to improve health care quality. The state has proposed to first use marker diseases/conditions and then expand from the pilot test stage to statewide adoption. Massachusetts will be working to build an accountable healthcare system. The system should focus on the patient by optimizing services and payment to maximize health outcomes and address the multiple and complex determinants of health and health care. The state created an umbrella initiative, HealthyMass, to provide the structure for strategy development, project coordination, and plan implementation. The organizing framework for the SQII Action Plan relies on elements of the Chronic Care Model and the Medical Home. The Commonwealth of Massachusetts will pursue a multi-faceted approach that includes improvements in clinical care, public health, and health policy (payment for, organization of, and delivery of services). The state will engage stakeholders to create a critical mass for innovation and will build public and private partnerships and collaborations necessary to effect change. Assets Massachusetts has multiple programs and entities in place to address common goals and implementation of the health reform activities. The state has a legislatively established Health Care Quality and Cost Council, a Medicaid pay-for- performance program, and a Health Disparities Council. The mission of the Health Care Quality and Cost Council is to develop and coordinate the implementation of statewide health care quality improvement goals that lower or contain the growth in health care costs while improving quality of care, including reductions in racial and ethnic health disparities. Challenges The state has noted its low rankings in measures related to cost management and coordination of care for hospitalized patients. Under the “Avoidable Hospital Use and Costs,” Massachusetts was ranked 48th in the nation for the total single premium per enrolled employee at private-sector establishments that offer health insurance. The rate of increase in health insurance premiums in Massachusetts is significantly higher than the national average (13 percent in the state from 2005- 2007 compared to 6 percent nationally) and outpaces general inflation rates and wage increases. Massachusetts notes the interrelated nature of many of the measures, where preventive opportunities missed are an underlying factor in higher rates of re-hospitalization and overall costs. Stakeholder Engagement In a unique strategy to align state health promotion and purchasing efforts, the state engaged nine diverse state entities as signers of a memorandum of agreement entitled the Healthy Massachusetts Compact. These goals were adopted with input and advice from its Advisory Committee, which includes representation from consumers, business, labor, health care providers, and health plans. The SQII team, Department of Public Health, agencies signed on to the Healthy Massachusetts Compact, Massachusetts Medical Society, the Massachusetts Hospital Association, and others are participating in the strategy implementation for HealthyMass and other reform work. 21 SQII Profile - Minnesota State Name: Minnesota Environment Minnesota has a history of experimentation in cost and quality innovations, including the SmartBuy Alliance, the Buyers Health Care Action Group, and other initiatives to promote optimal care. In 2008, Minnesota enacted comprehensive health care reform legislation. The reforms adopt recommendations of Governor Tim Pawlenty’s Transformation Task Force and the Legislature’s Health Care Access Commission. The legislation creates a comprehensive health care package that addresses the following areas: public health, health care affordability, chronic care management, payment reform, cost and quality transparency, administrative efficiency and health care cost containment. Information about the reform can be found at: www.health.state.mn.us/divs/opa/08reformsummary.html. Minnesota has been a leader in provider measurement and information transparency. By deploying community assets to develop evidence-based practice standards and performance measures, Minnesota has engaged support of physicians in continuous process improvement. Payers and plans have used both financing and data transparency to direct patients to higher performing providers and reward the providers for high quality care. The current reform initiative builds on and expands the state’s work in transparency of information, innovative reimbursement/payment methods, and continuous improvement in care management. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 11 Access: 9 Quality: 12 Avoidable Hospital Use and Costs: 10 Equity: 38 Healthy Lives: 7 State Agency Lead for SQII Governor’s Health Cabinet and Commission of Human Services – Cal Ludeman, Commissioner of Human Services, Minnesota Department of Employee Relations and Chair, Governor’s Health Cabinet Final Action Plan Targets Minnesota’s action plan addresses the need for technical assistance to integrate elements of the reform bill, build on the state’s infrastructure and successes, and create measurable improvements. Goals are to reduce rate of cost increase, improve population health, and improve patient experience. Strategies The state action plan is consistent with the state’s efforts to implement the comprehensive reform legislation. Minnesota will address purchasing, care improvement, and transparency through: • The development of standardized sets of measures by which to assess the quality of health care services; • The development of a system of quality incentives, under which providers are eligible for quality-based payments that are in addition to existing payment levels; • The development of a peer grouping system for providers based on a combined measure that incorporates both Provider risk-adjusted cost of care and quality of care; • The development of definitions of baskets of care; and • The publication of results from the peer grouping initiative. Continued on next page 22 SQII Profile - Minnesota (Continued) Assets Minnesota has achieved relatively high quality at costs that are relatively low compared to other states. The state has a history of collaboration between private sector providers, health plans and the public sector. State assets for measurement include the Institute for Clinical Systems Improvement (ICSI) and Minnesota Community Measurement (MNCM). The Buyers Health Care Action Group (BHCAG) is an employer purchasing coalition working toward value-based purchasing, transparency of information, consumer engagement, and quality-based competition among providers. The “Smart Buy Alliance” was created in 2004 as a unique public-private partnership of health care purchasers. The goal of the Smart Buy Alliance is to streamline health care purchasing to make the health care system more efficient and accountable. Members of the Alliance represent government purchasers, large employers, small employers, and labor unions representing over 60 percent of state residents. One goal of the Alliance is to adopt uniform methods of measuring quality of care and results and to purchase health care based on those measurements. Challenges Minnesota’s experimentation with value based purchasing has demonstrated some of the reverse incentives incorporated in the financing system. The state notes that in model chronic care management programs at two hospital systems reduced readmissions due to better care. This resulted in lost revenue to the hospitals. The state is committed to payment reform that would eliminate the “success paradox” that penalizes providers for improvement in patient’s health. Stakeholder Engagement The state has a long history of collaboration on purchasing, care improvement and transparency. Stakeholders are involved in many of the community assets and organizations identified above. In addition, Minnesota has both a Governor’s Health Care Transformation Task Force and the Legislative Commission on Health Care Access. Stakeholders include purchasers, providers, consumers and organizations representing evidence-based practice such as ICSI and MNCM. 23 SQII Profile - New Mexico State Name: New Mexico Environment New Mexico is a rural state with significant challenges in access to care. State leaders have recognized that the key to successful quality improvement is reducing the vast variation in access to care, particularly in rural communities. Governor Bill Richardson introduced health care reform legislation that would expand coverage and consolidate public health funding programs to improve efficiency and increase use of electronic health records. The governor has also identified a number of public health priorities– childhood vaccination levels, teen pregnancy rates, obesity, and hospital care in the state strategic plan. Ultimately the State has identified a need to re-orient the system towards health promotion and disease prevention to reduce health disparities and improve health. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 35 Access: 50 Quality: 41 Avoidable Hospital Use and Costs: 5 Equity: 41 Healthy Lives: 14 State Agency Lead for SQII Robert Wood Johnson Foundation Center, University of New Mexico - Robert O. Valdez, Executive Director Final Action Plan Targets New Mexico will use Year 1 to focus on building a coalition to support health care quality improvement. After the stakeholder engagement phase the state will turn to a long-term agenda of performance measurement, standard setting, and interventions. Strategies The project will engage in regular analysis of the various data systems available in New Mexico to assess progress and identify areas of opportunity. The RWJF Center will engage a coalition of state and local government officials, health services researchers, and private and public health care providers to: 1) Develop the information necessary for the quality improvement process; 2) Analyze county-level population characteristics, care delivery system characteristics, and performance; 3) Identify federal, state, local, and organizational policies that affect system performance or impede individuals/ families from engaging in desired behaviors; 4) Identify care delivery practices amenable to improvement; and 5) Identify opportunities to improve system performance or support individual/families to engage in desired behaviors. The state has indicated it will address local quality improvement efforts aligned with its diverse population groups. New Mexico anticipates the need for state-level health policy that addresses the social, cultural, geographic, linguistic, and economic factors that affect health care in these communities that require change or modification as well as system delivery changes or enhancements. Assets The state has opportunity to leverage its purchasing power due to the high proportion of individuals (particularly children) in New Mexico covered by Medicaid, SCHIP or state-funded public assistance programs. New Mexico has a number of targeted initiatives in place, including a Clinical Prevention Initiative, New Mexico Immunization Coalition, New Mexico Takes on Diabetes, and Medicare hospital quality reviews. Challenges Although New Mexico is committed to transparency of data, state leaders note that, in the context of under-service and provider shortages, it is challenging to implement the concepts of using performance data to guide physician/hospital selection in rural areas. In addition, New Mexico’s high uninsurance rate makes it difficult to change provider behavior through payment reform strategies. Stakeholder Engagement The New Mexico Quality Improvement Institute steering committee proposed to convene a larger body of stakeholders including state and government officials in the Health and Human Services departments and representatives of a variety of medical, dental, private and public health provider communities. 24 SQII Profile - Ohio State Name: Ohio Environment Governor Ted Strickland has announced an interest in health care reform that would include quality improvement. The state focuses its planning and development efforts in three areas: Creation of the Office of Healthy Ohio; Participation in the State Coverage Institute; and Creation of the Health Information Partnership Advisory Board. Since 2007, directors of state agencies and other state entities that relate to health and health care have been convening in a series of facilitated sessions to develop a vision for a Healthy Ohio. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 24 Access: 15 Quality: 23 Avoidable Hospital Use and Costs: 37 Equity: 14 Healthy Lives: 41 State Agency Lead for SQII Office of Governor Ted Strickland - Amy Rohling McGee, Executive Assistant for Health and Human Services Policy Final Action Plan Targets The SQII Team will implement a strategy to coalesce diverse group of stakeholders around a portfolio of strategies that would underpin systematic reform. Ohio will convene stakeholders to solicit input on approaches for the state that would: 1) Offer opportunities for short and long term return on investment (quantified in both human and monetary terms); 2) Be actionable by a wide array of stakeholders (state government, insurers, employers/purchasers, providers, consumers); and 3) Be informed by a variety of local initiatives that are ongoing throughout the state. Strategies The Ohio Quality Improvement Institute Team executated a Ohio Health Quality Improvement Summit in November 2008. The calling question for this statewide Summit was: “What are the top 10 strategies that will transform Ohio’s health care system into a high quality, cost-effective, high performing system that optimizes the health of Ohioans by 2013?” The state developed a report from the meeting and will be using its multi-stakeholder group to identify high impact interventions. Assets The Office of Healthy Ohio, created in 2007, addresses health promotion, disease prevention, and health equity through the enhancement of existing programs, improved coordination across agencies and organizations, and increased accountability. Ohio participates in the Robert Wood Johnson Foundation (RWJF)/AcademyHealth “State Coverage Institute” to develop reforms to provide affordable coverage to Ohio’s uninsured residents. The effort is supported by a 40-person Health Care Reform Advisory Group which includes representatives of all the key stakeholders, including consumer advocates, hospitals, doctors, insurers, large and small employers, free clinics, community health centers, and state and local officials. Ohio also has a number of private sector initiatives, including participation of two communities in the RWJF “Aligning Forces for Quality” program and two communities that are participating in “Bridges to Excellence.” In addition, the Ohio Business Roundtable has chosen the health care system as a focus; they are investing staff and resources in constructively participating in the process of health reform in Ohio. Challenges Ohio has multiple initiatives in place and observes a need to coordinate and engage stakeholders and set priorities. Stakeholder Engagement The Ohio SQII Plan will build on the organizations that represent public and private sector delivery systems and purchasing agencies. Ohio will engage existing groups as necessary, including the Health Care Coverage Reform Advisory Team, the Healthy Ohio Advisory Team and the Health Information Partnership Advisory Board. Ohio also plans to engage legislators and other stakeholders at key points in the process. 25 SQII Profile - Oregon State Name: Oregon Environment Oregon has a long history of health care reform enacted in the Oregon Health Plan. Oregon has focused on driving value through the prioritized list of health services developed with ongoing community input, along with value-based purchasing initiatives in both the public and private sectors. Value purchasing strategies highlighted by the state include reliance on managed care, evidence-based drug reviews, and pharmacy bulk-purchasing pool in collaboration with Washington State. In 2007, Oregon enacted the Healthy Oregon Act, the state’s latest health reform planning legislation. The law creates the Oregon Health Fund Board, provides a stable policy structure, and calls for a comprehensive reform plan to be presented to the Governor by October 1, 2008. Prior to the legislation, Oregon issued a “Roadmap for Health Care Reform,” which outlines a vision and a framework Oregon can use to move the health care system forward. The Roadmap calls for reforms based on public/private collaboration for value-based purchasing and transparency, adoption of electronic health records, improvements in safety, establishment of medical homes, and support for innovations that promote cost-effective high quality care. The Healthy Oregon Act will be a centerpiece for quality efforts in Oregon. The Office for Oregon Health Policy and Research (OHPR), in partnership with the Oregon Health Policy Commission (OHPC) and the Insurance Division, has initiated transparency efforts in the state with public reporting of hospital cost and quality data and increased system interoperability as goals. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 34 Access: 45 Quality: 36 Avoidable Hospital Use and Costs: 2 Equity: 48 Healthy Lives: 19 State Agency Lead for SQII Oregon Health Policy Commission – Gretchen Morley, Director Final Action Plan Targets 1. Percent of children ages 19 to 35 months who received all recommended doses of five key vaccines. (Oregon ranks 49th for this measure, with a state percentage of 72.9.) 2. Percent of children with a medical home. (Oregon ranks 34th in this measure, with a state percentage of 43.4. The best rate is 61 percent and the median is 47.6 percent.) 3. Percent of Medicare patients whose health care provider always listens, explains, shows respect, and spends enough time with them. (Oregon ranks 38th in this measure with a state percentage of 67.7. The best rate is 74.9 percent and the median for all states is 68.7 percent.) Continued on next page 26 SQII Profile - Oregon (Continued) Strategies Measurement issues are key to the state’s approach. Oregon intends to initiate SQII activities by evaluating current measurement and reporting systems. Oregon has noted that a portion of its performance variation and ranking results is attributed to pockets of under service, and that addressing the needs of these communities may reduce disparities as well as promote systems improvement. The state will promote partnerships to enhance ongoing systems of care, targeted according to state trends data. Strategy 1: Increase availability, reporting, and use of comparable and systematic cost and quality data; Strategy 2: Identify and reward innovative efforts to create high-performing delivery systems that produce optimal long term value; and Strategy 3: Identify and reward innovative efforts to create healthy communities that support healthy choices. Assets The Office for Oregon Health Policy and Research is the lead health policy advisor to the governor’s office and the legislature. OHPR has specific statutory responsibility to monitor cost and performance of health facilities in Oregon. The Oregon Health Policy Commission has responsibility for developing and monitoring the state health policy and advising the administrator of OHPR, the governor and the legislature; the Commission has specific statutory authority to develop a central repository of health data related to cost and quality as well. In addition, the Oregon Public Employees Benefit Board (PEBB) is a national leader in its value-based purchasing efforts. The Division of Medical Assistance Programs (DMAP), Oregon’s Medicaid agency, seeks to drive higher levels of clinical quality performance and improved quality of health care for Oregon Health Plan clients through a combination of efforts including performance measurement, evidence-based care and public reporting. The Oregon Health Care Quality Corporation (QCorp), a multi-stakeholder non-profit organization made up of health plans, physician groups, hospitals, public and private purchasers and consumers, is lead on an Aligning Forces for Quality grant from the Robert Wood Johnson Foundation. The group has provided leadership in developing common measures of ambulatory care and the strategic plan for market-driven change. Acumentra Health is a physician-led, nonprofit organization that serves as the state’s Quality Improvement Organization. In addition, a number of health plans in Oregon, including the largest Medicaid managed care plan, CareOregon, are currently piloting medical home models. Lessons and best practices from these pilots can help other managed care plans determine how medical home services can most effectively and efficiently be delivered to Oregon’s children. Challenges Like other states, Oregon faces the challenge of coordinating multiple initiatives that exist throughout the state. Stakeholder Engagement Stakeholders are engaged in planning and review of the state’s multiple reform programs and reports. OHPR has established a SQII Work Group made up of key stakeholders in Oregon’s quality arena representing purchasers, providers, advocates, and health plans. Along with the governor’s office, the Office for Oregon Health Policy and Research, the Health Policy Commission and the Oregon Health Fund Board, the Institute team includes bi-partisan legislative leadership, PEBB, DMAP, the state public health agency, the Insurance Division, the Patient Safety Commission and QCorp. 27 SQII Profile - Vermont State Name: Vermont Environment Vermont is enacting a variety of reforms under its “Blueprint for Health,” a health care improvement initiative. The Blueprint model calls for pilot testing of innovations in “Blueprint Communities” with subsequent roll out statewide. The Blueprint is codified in statute as the state’s plan for transforming health care delivery through systems-reform based on public-private partnerships. The state is creating a sustainable infrastructure with a priority on improved information exchange to facilitate coordination and care delivery. Vermont is pilot testing initiatives on medical home development and information exchange. The Blueprint implementation is guided by an Executive Committee representing stakeholder perspectives. The 2007 legislative session created new Medical Home Pilot projects, and defined insurer participation in the medical home pilots. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 3 Access: 8 Quality: 8 Avoidable Hospital Use and Costs: 11 Equity: 3 Healthy Lives: 14 State Agency Lead for SQII Office of the Secretary of Administration – Craig Jones, Director, Blueprint for Health Final Action Plan Targets 1. Percent of adults age 50 and older received recommended screening and preventive care 2. Percent of adult diabetics received recommended preventive care 3. Percent of asthmatics with an emergency room or urgent care visit in the past year Strategies Beginning in July 2008, Vermont will pilot test the Blueprint integrated medical home model in 3 communities. The Vermont team is charged with implementing this project linking it to other health initiatives in the state, and monitoring its success. Vermont will also identify strategies to enhance the likelihood that the integrated pilot model will be sustainable. The state will use the following strategies: • Use HEDIS measures to set goals and evaluate quality in the integrated pilot practices. • Use CAHP survey measures to set goals and evaluate patient experience in the integrated pilot practices. • Consider expanded use of surveys to evaluate patient self-management capacity. • Add elements to clinical planning templates that emphasize goals with a high likelihood of helping control health care costs. • Complete the financial model that evaluates the potential return-on-investment association with the Blueprint integrated health and prevention design. • Work with Vermont Medicaid to plan collaborative chart review process. • Work with NCQA regarding a scoring methodology. • Consider Arkansas approach to community activation. • Make sure that a core set of data elements guides the development of the exchange. Guard against piecemeal transmission that leads to data that can’t be used across organizations. • Consider strategies for statewide health risk assessment process that can be used for strategic planning and evaluation of health care delivery and prevention Continued on next page 28 SQII Profile - Vermont (Continued) Assets Beginning in 2005, Vermont has used the Blueprint and state funds in a number of initiatives: provider training and incentives, expanded use of information technology, evidence based process improvement, clinical microsystems training, and self management workshops. The state offers support for community activation and prevention programs statewide. Through the Blueprint, Vermont has developed a statewide “self management network” of regional coordinators and trained leaders. Commercial insurers in Vermont and Medicaid are collaborating on a multi-payer claims-based evaluation of the health and economic impact of the Blueprint medical home pilots as compared to routine care and traditional disease management programs. The collaboration establishes an infrastructure for evaluation using administrative data sources (e.g., annual health maintenance visit, screening and diagnostic procedures, labs, prescribed medications), and the ability to compare Blueprint medical home pilot communities, other Blueprint communities, and non-Blueprint communities. The Blueprint team will work closely with the Quality Improvement Institute to assure that the criteria used to measure the three selected indicators are measurable, clinically meaningful, and nationally relevant. Challenges While Vermont ranks in the top quartile of states on the 2007 Commonwealth Fund State Scorecard on Health System Performance, the state recognizes the need for and opportunity for improvement. Stakeholder Engagement Vermont has demonstrated a sustained statutory and financial commitment to improved quality and health care reform, which in part is attributed to engagement of stakeholders in the planning and implementation process. The state includes diverse perspectives (including state legislators) in the Healthcare Reform Commission and on the Blueprint Executive Committee. Blueprint leadership includes all major stakeholders (as called for in statute) including: the Governor’s Office, the Legislature, Medicaid, commercial payers, hospitals, providers, and others. 29 SQII Profile - Washington State Name: Washington Environment In 2005, Governor Chris Gregoire launched a five point strategy for health care reform: (1) evidence based care, (2) promote prevention, healthy lifestyles and healthy choices, (3) better manage chronic care, (4) create transparency, and (5) better use information technology. Comprehensive legislation was enacted in 2007 based on these principles at the recommendation of a Washington Blue Ribbon Commission on Health Care Costs and Access (BRC). Washington’s legislation provides for insurance coverage of all Washington children by 2010 and links children to a medical home. The 2007 legislation also directs the state to use purchasing power to improve quality and directs the Medicaid agency to take action in promoting patient-centered medical homes to beneficiaries. The state has multiple initiatives designed to promote coordinated care consistent with the “Chronic Care Model” (developed in the state) and to align reimbursement and resources to promote the model. Washington has implemented a “learning collaborative” to encourage expansion of primary care practice capability to reflect the comprehensive “medical home” concept. The concept will align care delivery capabilities with reimbursement strategies and provider performance measures. Washington’s vision includes implementation of practice level information systems and data management strategies to enable ongoing measurement, improvement, and rewards related to performance. 2007 Commonwealth Fund State Scorecard Ranking Overall Rank: 17 Access: 27 Quality: 34 Avoidable Hospital Use and Costs: 6 Equity: 37 Healthy Lives: 13 State Agency Lead for SQII Department of Social and Health Services - Health and Recovery Services Administration – MaryAnne Lindeblad, Director, Division of Healthcare Services, Department of Social and Health Services (DSHS) Final Action Plan Targets For the SQII, Washington is working to define and improve access to medical homes, develop reimbursement approaches to incentivize improved care, and engage consumers and providers in participating in patient-centered medical homes. Continued on next page 30 SQII Profile - Washington (Continued) For the SQII, Washington’s action plan identifies specific steps and timeframes to: 1. Create an operational definition of medical home in order to measure and improve medical home capacity in Washington; 2. Develop reimbursement strategies to support providers in adopting a medical home model of patient- centered care; and 3. Engage consumers and providers in participating in patient-centered medical homes through information transparency and use of “navigators” to assist patients. Assets The state considers its health care reform activities for the past decade to have been an incremental approach to increase access and contain costs through contracting and reimbursement strategies. The state is expanding that scope to address quality of care. Washington has developed the Washington State Collaborative to Improve Health as a mechanism to define and implement patient centered medical homes. Other assets include the Puget Sound Health Alliance (the Alliance), a well-established regional partnership of employers, physicians, hospitals, patients, and health plans working together to improve quality and efficiency while reducing the rate of health care cost increases. The state has established a Children’s Healthcare Workgroup to develop payment and care coordination strategies to implement the medical home directive from the legislature. Washington will establish a Quality Forum to serve as a venue for promoting information to consumers and providers on best practices, quality data, and evidence based medicine. Washington is pilot testing medical home models in anticipation of expansion through reform and other initiatives. Challenges Washington recognizes the “challenge” of coordinating a wealth of programs and organizations involved in systems improvement. The state has embraced accountability for organizing and engaging public and private stakeholders. Stakeholder Engagement State agencies will be engaged in reform under the governor-designated leadership of DSHS. The state’s reform legislation and BRC are built on the platform of engaging patients and providers more fully. Participants include the Children’s Healthcare Workgroup, Washington State Collaborative to Improve Health, Medical Home Workgroup, Puget Sound Health Alliance, and a state “Quality Forum” technical advisory committee. The Group Health Cooperative is also committed to participating in testing and implementation of the program. 31 Appendix 4: State-Reported Policy Levers and Approaches Strategies Proposed By States for Health Care Reform These reflect some of the proposed approaches taken by states in health care reform initiative. These topic areas are reflected in technical assistance provided to states Chronic Disease Management/Medical Homes • Aggressive case management, education and care coordination • Focus on care of high-cost Medicaid patients provided through Medicaid contractors/plans • Create medical home/primary care home • Establish clinical guidelines for care of chronic conditions • Legislatively-mandate definition of Medical Home with outcome measures • Change payment policies to encourage medical homes/primary care (payment add-ons) • Measure avoidable hospital costs • Medical Homes pilots that include: – financial reform; – advanced clinical tracking; – evidence based practice improvement; – local Community Care Teams (CCTs) that provide an infrastructure for primary provider coordinated care support, self management, and prevention; – integration with broader community prevention efforts; and – systematic program evaluation at state and practice levels. Population Health/Wellness • Wellness initiative for state employees (health assessment, health coaches) • Partnerships with businesses, schools and others to ensure wellness and chronic disease prevention • Work with communities to promote healthy environments • Public education/awareness campaigns • Overall prevention focus • Interagency survey to determine all the state health initiatives that relate to prevention • Create wellness and prevention infrastructure in health care communities statewide Disparities Reduction/Consumer Engagement • Web-based portal for health consumers • Community Health Record that gives physicians access to claims information and e-prescribing • Use of personal, consumer-controlled electronic health records • Use of Patient Navigators to assist in care coordination • Medical homes/care coordination initiatives Continued on next page 32 Information Integration/Public Reporting • Build a statewide health information exchange network • Stakeholder group works to develop public reporting measures • Establish a multi-payer claims-based collaboration for evaluation of the health and cost impact of reform • Public-private collaboration on value-based purchasing, managing for quality and transparency • HIT Advisory Board with key stakeholder groups • Increase use of HEDIS measures or NCQA recognition in public and private programs • Physician engagement in measure development and reporting Payment Reform • Coordinate purchasing and contracting across payers • Adopt or pilot pay-for-performance with explicit payment for quality • Use payment systems to encourage care in the most cost-effective setting • Revise payment policies for payment of serious, reportable events • Tiered provider networks: establishing one to three levels for providers to encourage them to coordinate care and ultimately take responsibility for the total cost of care • Provide financial incentives to consumers to choose quality primary care providers. Enable patients to compare providers on cost and quality • Simplify and standardize payments to providers across payers • Establish community-wide “baskets” of care • Use contracts to incentivize improved electronic communication, reduced medical errors, and prevention • Share costs for local multidisciplinary community care teams across payers • Reduce administrative costs through technology and shared standards across public and private payers • Reduce provider-driven demand by aligning community needs with the development of new facilities, treatments, etc. Cost Reduction • Improve chronic care management in outpatient settings using strategies such as medical home and care coordination • Analyze root cause of re-hospitalization and avoidable hospitalization • Reduce unwarranted variations in service utilization through analysis, practice improvement 33