‘We don’t have enough data, and we don’t have it at the right time’

Modern Healthcare - - Q & A -

For over a quar­ter cen­tury, the Na­tional Com­mit­tee for Qual­ity As­sur­ance has worked with

em­ploy­ers, health plans, providers and pa­tients to de­velop qual­ity per­for­mance mea­sures. But re­port­ing re­quired for its Health­care Ef­fec­tive­ness Data and In­for­ma­tion Set, or HEDIS, and other qual­ity re­port­ing has trig­gered a back­lash by providers. Mod­ern Health­care Ed­i­tor Mer­rill Goozner re­cently spoke with NCQA Pres­i­dent Mar­garet O’Kane about re­cent con­tro­ver­sies swirling around qual­ity mea­sure­ment. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: Tell us a lit­tle bit about the NCQA.

Mar­garet O’Kane: We started this whole move­ment about qual­ity 26 years ago by align­ing em­ploy­ers who wanted to con­tract with high-qual­ity health plans. We started an ac­cred­i­ta­tion pro­gram that was de­signed by em­ploy­ers sit­ting at the ta­ble with what they con­sid­ered the best health plans. We also had con­sumers. We use mul­ti­ple stake­hold­ers in all the things we do.

We came up with an ac­cred­i­ta­tion pro­gram. We used a sys­tem of qual­ity mea­sure­ment called HEDIS, and those two things ran in par­al­lel for a while. But now HEDIS re­ally drives a lot of the out­comes of our ac­cred­i­ta­tion pro­gram.

MH: HEDIS, the Health­care Ef­fec­tive­ness Data and In­for­ma­tion Set. What is that?

O’Kane: It’s a sys­tem of mea­sure­ment of things that we think plans can be ac­count­able for. Did peo­ple get the pre­ven­tive health ser­vices that they should get? For that, we fol­low the U.S. Pre­ven­tive Ser­vices Task Force. Did women get mam­mo­grams? Did peo­ple get colon can­cer screen­ing? Did chil­dren get their im­mu­niza­tions? Did adults get flu shots?

We look at chronic con­di­tions. Di­a­betes, which af­flicts so many Amer­i­cans, de­pres­sion, asthma, car­dio­vas­cu­lar dis­ease—if all these things are man­aged ap­pro­pri­ately, the out­comes are in­cred­i­bly dif­fer­ent than if they’re not man­aged right.

MH: What’s the trend on per­for­mance on the HEDIS mea­sures?

O’Kane: There are some that are stub­bornly not mov­ing up. Be­hav­ioral health in this coun­try is not work­ing. There are kind of shin­ing ar­eas where peo­ple are do­ing demon­stra­tion work that is very good, but in gen­eral we’ve carved out be­hav­ioral health­care from plans so no­body re­ally feels re­spon­si­ble for it.

MH: Are there some ar­eas where we’re do­ing bet­ter?

O’Kane: There are ar­eas where we can point to some tremen­dous im­prove­ment. Colon can­cer screen­ing, which re­ally af­fects out­comes, has had a very big im­prove­ment. Hy­per­ten­sion con­trol, car­dio­vas­cu­lar dis­ease con­trol, putting peo­ple on statins who are at high risk for re­cur­ring heart at­tacks—there are lots of suc­cess sto­ries. Asthma care is bet­ter. Im­mu­niza­tion rates have re­ally risen tremen­dously over the years.

MH: Col­lect­ing this data is a huge is­sue for physi­cians and physi­cian prac­tices across the coun­try and for hos­pi­tals. What are you do­ing to stream­line mea­sure­ment?

O’Kane: The plans worked around the prac­ti­tion­ers in many cases to col­lect HEDIS mea­sures. The com­plaint was much more, “I have to put up with these peo­ple com­ing into my of­fice to peek in my charts to make sure I did the things that they couldn’t find in the claims data.” HEDIS was heav­ily driven by claims data, and so the prac­ti­tion­ers weren’t af­fected that much un­less the plan was giv­ing them bonuses.

But now with Medi­care de­mand­ing qual­ity in­for­ma­tion with pretty big con­se­quences—start­ing at 4% of pay po­ten­tially and go­ing to 9% over five years (un­der MACRA)—there’s a kind of a shock to the sys­tem. They say, “Do we have too much data?”

(But) we don’t have enough data, and we don’t have it at the right time. It re­ally shouldn’t be that the first time I find out as a prac­ti­tioner, for ex­am­ple, that my he­mo­glo­bin A1c con­trol rate is lower than average is when I get my mea­sure re­sults. I should have the data at the point of care, and I should be able to

“Peo­ple are work­ing around the de­fi­cien­cies of elec­tronic health records. If the elec­tronic health record com­pa­nies are smart, they’ll fix their prod­ucts so that they work bet­ter.”

“Each or­ga­ni­za­tion seems to have to learn its own les­sons, which is a ridicu­lous waste of money and time and hu­man en­ergy.”

kind of get a re­port out of my med­i­cal record that says, “You’re at 70%” or “You’re at 60%” or wher­ever you are, “and here are the peo­ple that you need to work with or have your care man­ager in the prac­tice work with.”

MH: The govern­ment just spent $30 bil­lion on EHRs. Ev­ery­body has them. We have the claims data. Why don’t we have this clin­i­cal in­for­ma­tion in real time?

O’Kane: We will be able to one of these days, and some places are able to be­cause they have been scram­bling to ad­just by putting boltons on their EHRs that give them re­ports. Progress is slow (and) it’s way too ex­pen­sive. Each or­ga­ni­za­tion seems to have to learn its own les­sons, which is a ridicu­lous waste of money and time and hu­man en­ergy.

We have health in­for­ma­tion ex­changes in some parts of the coun­try that are do­ing an amaz­ing job of get­ting the data to the prac­ti­tion­ers at the time they need it. So peo­ple are work­ing around the de­fi­cien­cies of elec­tronic health records. If the elec­tronic health record com­pa­nies are smart, they’ll fix their prod­ucts so that they work bet­ter.

MH: Where are the good health in­for­ma­tion ex­changes at the state level?

O’Kane: My Health in Tulsa, Okla., which is now statewide. It’s got up-inthe-cloud claims data, EHR data, lab out­comes, drug in­for­ma­tion, and it all goes back to the prac­ti­tion­ers. CRISP in Mary­land is also do­ing a ter­rific job of giv­ing peo­ple the in­for­ma­tion they need to man­age their pop­u­la­tions and their sick peo­ple.

MH: Are hos­pi­tals, which have been buy­ing physi­cian prac­tices, do­ing a bet­ter job than in­di­vid­ual physi­cian prac­tices in mak­ing qual­ity data avail­able in real time?

O’Kane: The jury is out on hos­pi­tals. I have em­pa­thy. Peo­ple that have been ad­min­is­tra­tors of hos­pi­tals or even prac­ti­tion­ers in hos­pi­tals have been able to be suc­cess­ful with a model where heads in beds was a good thing, ER vis­its were a good thing, ex­pen­sive care was a good thing, whether or not it was bet­ter or cheaper care for the pa­tient.

Now we’re about to turn that model up­side down. And so how do they go about the jour­ney—to this kind of be­ing ac­count­able for qual­ity and costs and the pa­tient’s ex­pe­ri­ence—from where they were mostly ac­count­able for grow­ing their rev­enue and lately for qual­ity? It’s a huge change.

MH: How well are they do­ing on mak­ing this change?

O’Kane: There are al­ways points of light. In­ter­moun­tain Health­care. A lot of the Kaiser hos­pi­tals are do­ing in­cred­i­ble work. Mis­sion Health in North Carolina is a hos­pi­tal that does a re­ally good job. There’s great stuff hap­pen­ing in Bos­ton.

I’m hope­ful, but there are a lot of en­ti­ties to change, and it’s a big change. So it’s scary.

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