1. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 1 1999 CAS Seminar on Health and Managed Care Hilton Head Island, SC October 18-19, 1999

2. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 2 Intro - Shevlin Benchmarking Measures and Quality Control Hilton Head Island, SC October 18-19, 1999

3. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 3 Overview on Healthcare Benchmarks What? Why? Examples Sources Classifications Planning Limitations Analysis Application Discussion

4. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 4 - What are they? - Healthcare Benchmarks - What are they? - “Gold standards”; target results Easily and reproducibly measured Pertaining to Financial or Clinical Outcomes Typically involve ratios

5. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 5 Used for Comparison and Quality Improvement “If you cannot measure, you cannot improve” To provide objective measures that will drive performance to a new level of excellence - Why Do We Need Them? - Healthcare Benchmarks - Why Do We Need Them? -

6. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 6 History of Efforts in Healthcare Quality Early years - physician esteem/ethics/peers 1980s - Utilization Management (UM) 1990s - Case/Care Management Now - Disease/Health Management - Why Do We Need Them Today? - Healthcare Benchmarks - Why Do We Need Them Today? -

7. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 7 Apply evidence-based medicine Establish “Best Practice” Monitoring results: “Report Cards” Target “Intervention Strategies” Establish Value - Why Do We Need Them? - Healthcare Benchmarks - Why Do We Need Them? -

8. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 8 Improving healthcare: Services Process Outcomes Resources - Why Do We Need Them? - Healthcare Benchmarks - Why Do We Need Them? -

9. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 9 - Clinical Examples - Healthcare Benchmarks - Clinical Examples - Mortality - Unequivocal? - Clinical v.s. cost implication - Certain diseases and surgeries - Must be severity risk adjusted Morbidity - Tests (lab) - Vitals signs - Physical findings (disease classes) - Trends - Manual records extraction is expensive

10. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 10 - Clinical Examples - Healthcare Benchmarks - Clinical Examples - Prevention Primary - Screenings/Immunizations Secondary - Drugs/Services Clinical Guidelines - Diagnostics/Therapeutics - Inappropriate Complications - Medical/Surgical

11. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 11 - Other Examples - Healthcare Benchmarks - Other Examples - Financials - Dollars - Resources Perception / Satisfaction / Patient Self-Assessment - Functional status - Access to care - Waiting times, time to return calls - Quality of life - In areas of concern to the patient Proxy Measures - Length of stay - Number of visits/services/readmissions

12. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 12 Intro - Shevlin Asthma

13. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 13 Medical & pharmacy claims data Laboratory data Electronic medical records Hospital information systems Utilization review & incident reports Surveys & direct observation Proxy Measures: LOS, visits (billing) - Sources: for Data - Healthcare Benchmarks - Sources: for Data -

14. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 14 - Sources: Market Characteristics - Healthcare Benchmarks - Sources: Market Characteristics -

15. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 15 Drivers – Purchasers – Comparatives among suppliers – Financial and quality objectives – Lacking knowledge and/or resource for measures and outcomes - Sources: Accreditation/Measurements - Healthcare Benchmarks - Sources: Accreditation/Measurements -

16. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 16 - Sources: The Accreditation Industry - Healthcare Benchmarks - Sources: The Accreditation Industry - Organizations The “Joint Commission” on Accreditation of Healthcare Organizations (JCAHO) National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) Utilization Review Accreditation Commission (URAC)

17. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 17 Organizations Foundation for Accountability (FACCT) University of Wisconsin University of California Association for Healthcare and Policy Research (AHCPR) - Sources: The Measurement Industry - Healthcare Benchmarks - Sources: The Measurement Industry -

18. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 18 Review – Customers care about “value” – Suppliers care about customers – Third parties make it happen - Sources - Healthcare Benchmarks - Sources -

19. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 19 CodesCodes –ICD –CPT –DRG - Classifications - Healthcare Benchmarks - Classifications - GroupersGroupers –MDCs –ACGs –DCGs

20. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 20 Relevant Outcomes (desirable or not) Measurable (reproducibly) Impact Sensitive Achievable Return on Investment - Planning: Choosing the Right Ones - Healthcare Benchmarks - Planning: Choosing the Right Ones -

21. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 21 Time Requirements Volume Requirements Scope Management Buy-In Realistic, Incremental Goals - Planning: Achievability - Healthcare Benchmarks - Planning: Achievability -

22. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 22 General –Case matched –Temporal issues Internal –Most similar –Randomized - Planning: Controls - Healthcare Benchmarks - Planning: Controls - External –Availability/Quality –Industry ‘Best Practice’ –Improvement priorities –Historical perspective

23. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 23 Intro - Shevlin Don’t Forget to Plan Don’t Forget to Update

24. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 24 Regularly (annually) New measurement or coding procedures New technology or diagnostics New therapeutic modalities or interventions - Planning: Reevaluation - Healthcare Benchmarks - Planning: Reevaluation -

25. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 25 Population drift/differences Environmental issues Collection process/irregularity Storage process/irregularity Integrity indicators - Data Limitations - Healthcare Benchmarks - Data Limitations -

26. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 26 Data limitations Barriers Be suspicious –Skewed or broken axes –Missing data –Sub-populations –Undisclosed methods - Analysis - Healthcare Benchmarks - Analysis -

27. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 27 Physicians do not need more medical school Practice Guidelines and Outcomes Data Benchmarks and Peer Profiling Physicians do not like to be outliers Physicians are uncomfortable with change - Application: How to make it work - Healthcare Benchmarks - Application: How to make it work -

28. CAS Seminar on Health and Managed Care Benchmarking Measures and Quality Control October 18-19, 1999 page 28 Intro - Shevlin “If You Can Not Measure, You Can Not Improve”