1. April 15, 2015 HCAW Pre-conference Using Information to Drive Improvement in Health Care Value: Trends in Quality and Cost Reporting Susie Dade, Deputy Director, Washington Health Alliance

2. Presentation Outline Overview of the Alliance Understanding Value in Health Care – Six Key Variables Alliance Reporting and Recent Results Plans for Future Reports 2 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

3. The Alliance: Who We Are Multi-stakeholder. More than 185 member organizations representing purchasers, plans, providers and patients. Purchaser-led. The majority of our governing members represent employers and labor union trusts. A convenver. A place where those who give care, get care and pay for care come together to lead health system change. Data-driven. We have claims data on approximately 3.9 million lives in Washington (commercially insured and Medicaid) dating back to 2004. The Alliance’s database includes well over 1.2B claim lines, comparing favorably to some of the largest health databases in the country. Currently recognized as state’s “voluntary APCD.” Non-profit. We are a designated 501(c)3. Non-partisan. We engage in lobbying efforts on a very limited basis and only on topics that are directly related to our mission and core work. 3 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

4. Examples of the Alliance’s Broad Membership 4 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

5. Our Mission and Vision Mission The Alliance’s mission is to build and maintain a strong alliance among purchasers, providers, health plans, consumers and others to promote health and improve the quality and affordability of the health care system by reducing overuse, underuse and misuse of health care services. Vision Our vision is that physicians, other providers and hospitals in Washington will achieve top 10% performance in the nation in the delivery of equitable, high quality, evidence-based care and in the reduction of unwarranted variation, resulting in significant reduction in the rate of medical cost trend. 5 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

6. Three Overarching Goals 1.Reduce the price of health care services 2.Reduce the overuse of health care services 3.Reduce underuse of effective health care services The Alliance’s principal strategies: We bring together organizations and individuals who share our cause, to design and drive collective action to improve the value of health care. We share information and insights that guide how health care gets delivered, used and paid for. 6 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

7. Why we do what we do? The status quo in health care is financially unsustainable and results in a level of health that fails to meet our collective expectations. – We do too few of the things that can help improve health. – We do too many things that do not add value, and may cause harm. – We spend way too much, impeding our ability to invest in other areas of our economy and infrastructure. The system of health care delivery is big and complex. No one organization is powerful enough to drive lasting and systematic change. We are building a coalition of the willing and the impacted. The debate about improving the value of health care, including quality, needs to be a public one with transparent data about performance to identify opportunities, celebrate successes and drive change. 7 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

8. Understanding VALUE in Health Care - Six Key Variables 8 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

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10. Understanding VALUE in Health Care - Six Key Variables 10 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

11. Different Regions, Different Health Care: Where You Live Matters A Report on Variation in Procedure Rates in Puget Sound © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

12. Sample of the Report Findings Women ages 45–54 living in Olympia were 192% more likely to have spine fusion surgery than their counterparts in Seattle. Residents of Monroe were almost twice as likely to receive an extremity MRI scan as people living in other Puget Sound communities. Women living in Arlington were 234% more likely to have a sleep test performed in a medical setting than their Bellingham counterparts. In Tacoma, children received upper GI endoscopies at higher rates than the rest of the region. 12 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

13. Overall patterns for the tests and procedures examined in this report: 13 Everett, Tacoma, Puyallup and Olympia tend to have higher use rates. Seattle, Bellingham and Bellevue tend to have lower use rates. © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

14. Understanding VALUE in Health Care - Six Key Variables 14 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

15. Community Checkup 15 The report includes 31 measures of care in the following areas: Access to preventive care for adults, adolescents and children Prevention (effectively screening for diseases) Care for patients with chronic disease: diabetes, heart disease, asthma, depression, and Chronic Obstructive Pulmonary Disease (COPD) Appropriate use of services (when antibiotics and imaging are called for) Use of generic prescription drugs © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

16. Community Checkup Alliance’s annual report to the public comparing the performance of medical groups, clinics and hospitals for basic measures of quality care 8 th annual report 120 medical groups, 440+ clinics Started in five-county Puget Sound area Expanding to new areas of the state with this report: Bellingham, Mt. Vernon and Spokane Next report will expand further to include: Ellensburg, Tri-Cities, Wenatchee and Yakima We will align our measures with the new Statewide Common Measure Set on Health Care Quality and Cost starting in 2015 16 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

17. Community Checkup Results Common and Persistent Themes: Significant variation exists across counties and medical groups and even within medical groups. No single medical group or clinic is good at everything. Everyone has room for improvement. The same holds true for the counties around the state. High-performing medical groups demonstrate that outstanding quality care is achievable in our state. Nonetheless, too many patients are still not receiving recommended, evidence-based care. 17 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

18. 2014 Community Checkup Medical Group Results 18 Results stratified by: Commercial Medicaid Medical Groups with: 15 or more results 5-14 results Fewer than 5 results © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

19. 19 2014 Community Checkup County Results Results stratified by: Commercial Medicaid © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

20. Community Checkup: Results Show Improvement Over Time 20 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

21. Understanding VALUE in Health Care - Six Key Variables 21 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

22. Patient Experience Report 22 Publicly available comparable results for 46 medical groups with clinics in 185 locations across a five-county Puget Sound region (King, Kitsap, Pierce, Snohomish, and Thurston counties). This is the only report of its kind in the Puget Sound area. Both medical group and clinic results are available on the Alliance’s Community Checkup website: www.WAcommunitycheckup.org www.WAcommunitycheckup.org We will repeat the survey in 2015-2016. © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

23. Puget Sound Regional Summary of Patient Experience Results, 2013-2014 (“Top Box” Responses) 23 *Based on 2012 Data, most recent available for comparison © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

24. There is wide variation in performance among medical groups. 24 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

25. Understanding VALUE in Health Care - Six Key Variables 25 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

26. Potentially Avoidable 30-day All Cause Readmissions © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

27. About the Report NCQA HEDIS 30-day All Cause Readmissions (NQF-endorsed) Measure included in new statewide common measure set Measure counts the # of inpatient stays for patients ages 18-64 that were followed by a readmission (for any reason) within 30 days Compares actual rate of readmission to risk-adjusted “expected rate” 27 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

28. 28 Summary of Findings © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

29. What are the most common diagnosis categories for patients who have been readmitted? The following four diagnosis groups account for about 1/3 of all readmissions in this analysis: Readmission Diagnosis Categories% of Total Complications14.2% Diseases of the Heart10.4% Lower GI Disorders5.8% Bacterial Infection4.4% 29 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

30. Readmissions and Outpatient Follow-up 30 Range of Performance for Hospitals Outpatient follow-up w/in 7 days 15% - 65% Outpatient follow-up w/in 30 days 24% - 70% Range of Performance for Medical Groups Outpatient follow-up w/in 7 days 11% - 52% Outpatient follow-up w/in 30 days 11% - 64% © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

31. Hospital and Medical Group Results 31 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

32. Understanding VALUE in Health Care - Six Key Variables 32 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

33. Potentially Avoidable ER Visits DON’T WAIT! The ER at St. Mary’s Hospital is Ready for You. © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

34. About the Report Medi-Cal Measure on Potentially Avoidable ER Visits Measure included in new statewide common measure set Very conservative measure of avoidable ER Visits Results based on 3.3 million Medicaid and commercially insured lives Hospital AND medical group results Results stratified by payer type and age group 34 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

35. Overall Results Rate of Potentially Avoidable ER Visits Age RangeCommercially-InsuredMedicaid Ages 1 – 98.8%15.7% Ages 10 - 197.4%11.2% Ages 20 - 449.2%11.2% Ages 45+7.7%10.6% Overall Puget Sound Average Rate 8.4%11.8% 35 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance. Close to 10,000 Avoidable ER Visits in 5-county area for: Headache, Eye Infection, Ear Ache, Common Cold, Back Pain, Urinary Tract Infection

36. Key Messages Patients contribute to the problem of avoidable ER visits. Many patients, including those with health insurance, don’t have an established relationship with a primary care provider or simply choose to go the ER for convenience. Hospitals and primary care groups compound the problem. – Unprecedented expansion of ER capacity – Heavy marketing of ER availability (“why wait?”) – Lack of access to primary care advice or appointments – PCPs suggest that patients “just go to the ER” There are good reasons why patients should think twice before visiting the ER for a non-emergency. – High cost – Increased risk – Less personal care/lack of continuity of care – Longer waiting times, more stress 36 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

37. Understanding VALUE in Health Care - Six Key Variables 37 VARIABLEIs the Health Care Service... AppropriatenessReally Needed? Process Quality Provided in the most effective and safe manner? ExperienceProvided in a patient-centered way? Outcomes Producing the best possible results for the patient? Intensity/ Utilization Provided in the most efficient manner? PriceProduced at a fair price for the buyer? © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

38. Different Region, Different Health Care Report Includes Estimated Commercial Price Ranges Based on Healthcare Bluebook estimates of “fair value” and price variation* Service-level estimates for each test or minor procedure Episode-level estimates for surgeries (hospital + surgeon + anesthesia) Ranges are estimates; actual prices could be higher No ability to identify lower/higher priced provider organizations in this market 38 healthcarebluebook.com © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

39. Hospital Sticker Shock: Hospital Price Variation in Washington 39 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

40. Future Quality and Cost Reporting Continue many of our past reports, e.g., Community Checkup, Patient Experience, Choosing Wisely – Expand medical group measurement and reporting statewide Structure of Regional Health Costs Identifying High Performing Systems Cost of Potentially Avoidable Care and Complications Cost of Potentially Avoidable ER Visits Multi-payer data for Cost Information Targeted at Uninsured Consumers and Employers 40 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

41. So, again, why does this matter? The status quo in health care is financially unsustainable and results in a level of health that fails to meet our collective expectations. There is tremendous variation in the delivery of evidence-based care, signaling a big opportunity for improvement. The system of health care delivery is big and complex. No one organization is powerful enough to drive lasting and systematic change. We have to work together and align our efforts. Transparent data about performance is essential to identify opportunities, celebrate successes and drive change. 41 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

42. Home Health Care is an important part of the solution. Home health care helps to improve patient outcomes in terms of wound improvement, healing, breathing, bathing, and less pain and anxiety. Home health care helps people to remain independent and potentially avoids further complication or hospitalization. Home health care can be more efficient and less costly than care delivered in other settings. More patients prefer in-home care to alternatives. 42 TRIPLE AIM Improving the patient experience of care (including quality and satisfaction); Improving the health of populations; and Reducing the per capita cost of health care. © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.

43. Thank you! Susie Dade sdade@wahealthalliance.org 43 © 2015 Washington Health Alliance. All rights reserved. This material may not be reproduced or modified without the prior permission of the Alliance.