Healthcare Town Hall

Health Leaders looks at a recent report on avoidable medical errors and highlights the most costly such errors. Here are the top ten.

1. Pressure ulcers—374,964 errors, $10,288 per error and $3.858 billion total.
2. Postoperative infections—252,695 errors, $14,548 per error, $3.676 billion total.
3. Mechanical complication of a device, implant or graft—60,380 errors, $18,771 per error, $1.133 billion total.
4. Postlaminectomy syndrome—113,823 errors, $9,863 per error, $1.123 billion total.
5. Hemorrhage complicating a procedure—78,216 errors, $12,272 per error, $960 million total.
6. Infection following infusion, injection, transfusion, vaccination—8,855 errors, $78,083 per error, $691 million total.
7. Pneumothorax—25,559 errors, $24,132 per error, $617 million total.
8. Infection due to central venous catheter—7,062 errors, $83,365 per error, $589 million total.
9. Other complicaitons of internal (biological) (synthetic) prosthetic device, implant and graft—26,783 errors, $17,233 per error and $462 million total.
10. Ventral hernia without mention of obstruction or gangrene—53,810 errors, $8,178 per error and $440 million total.

Read the full article here and the full report here.

Cost, Quality of Care Jon Shreve, medical errors

A new study commissioned by Innovent Oncology looks at cancer-related utilization. The study, which was announced today, identifies both regional variation as well as ways to improve quality and efficiency in cancer treatment. Here is an excerpt from the press release:

Innovent Oncology commissioned Milliman’s [Kate] Fitch and co-authors in New York to evaluate 10 of the most common cancer types where chemotherapy is a key treatment modality. The utilization and cost metrics examined include: chemotherapy-related hospitalizations; chemotherapy-related emergency room visits; chemotherapy costs; and end-of-life care including hospice enrollment, death in a hospital and chemotherapy administration within 2 to 4 weeks of dying.

The study used a nationally representative claims database of 14 million commercially insured lives. The 10 cancers identified in the study account for 65% of cancer patients in a commercial population and approximately 25% of these cancer patients received chemotherapy treatment during the observation year. The members receiving chemotherapy and having one of the 10 cancers make up about 0.11% of commercial members, but account for about 4% of overall healthcare costs.

Regional variation is identified with respect to the first three metrics listed above. Chemotherapy-related inpatient admissions and emergency room visits show a two-to-three fold regional difference in rates and chemotherapy drug costs range from $17,000 to $27,000. These regional differences suggest opportunities for health plans and plan sponsors to improve quality, thereby reducing cost and utilization.

Proactive end-of-life care provides patients with higher quality care and both patients and payers with additional quality and cost savings opportunities. For chemotherapy patients with the 10 cancers that were identified as dying in an inpatient setting, 24% received chemotherapy within 14 days of dying and 51% received chemotherapy within 30 days of dying.

“This is a comprehensive commercial payer view of cancer patients receiving chemotherapy and various cost drivers,” says Kate Fitch, RN, MEd, Principal and Healthcare Management Consultant with Milliman. “We are very pleased that Innovent Oncology is publishing this report, especially because there is a growing concern over variation and waste in cancer care.”

Read more…

Cancer, Quality of Care Cancer, Kate Fitch, Utilization

A recent Kaiser Health News (KHN) article highlights a theme we’ve written about previously: the convergence of quality and efficiency in healthcare. Here is an excerpt from the KHN article:

Treating a pneumonia case at the Theda Clark Medical Center in Neenah averaged $10,435 in 2008. Sacred Heart Hospital in Eau Claire, on the other hand, charged the average pneumonia patient $20,419, nearly twice as much.

What shocked hospital administrators most were the results for quality. Instead of higher cost hospitals delivering better care, the evidence pointed to just the opposite: The higher cost hospitals were less likely to meet benchmarks for quality. Theda Clark attained 95.5 percent of the quality goals outlined for treating a pneumonia case in 2008. Sacred Heart met just 90.5 percent of the standards.

Publishing the cost and quality data has had a far-reaching impact on the state, whose health care system is now considered among the best in the country. It gave hospitals with low quality ratings objective feedback for improving their performance. And the rankings motivated high cost hospitals to begin looking for ways to eliminate expensive but medically questionable procedures that didn’t improve outcomes.

Most important of all, it created a constituency – informed consumers – who were now armed with data that allowed them to pressure local hospitals to improve their performance. “People make purchasing decisions for everything from banking to refrigerators based on cost and quality information, but that is not how it currently works in health care,” said Walter Rugland, chairman of ThedaCare, at a House Energy & Commerce subcommittee on health hearing held last Thursday. “In Wisconsin, we believe we have fixed that problem.”

At least three bills introduced in the House this session but not included in health care reform would make a start on replicating the Wisconsin system nationally. But they don’t go far enough because they focus exclusively on price, and not on the quality side of the ledger.

Rugland spent much of his career at Milliman and is volunteer chair of four nonprofit hospitals in the ThedaCare network.

Efficiency, Quality of Care Convergence, ThedaCare, Walter Rugland

While there is broad consensus over the importance of evidence-based medicine in healthcare delivery, it is not always entirely clear what it means for a provider to implement evidence-based medicine. A new case study, ”The compelling call for change is in patient outcome data,” tells the story of St. Jude Medical Center and how they adopted evidence-based practice care processes.

Quality of Care, evidence-based medicine Connie Hill, Kathy Zaharias, St. Jude Medical Center

The Wall Street Journal today looks at hospitals in Italy’s Lombardy region. In this region, competition between public and private hospitals has resulted not only in reduced costs but also in improved quality. Here is an excerpt from the article:

In much of the country, regions have continued to use the standards of care and reimbursement rates recommended by Rome. Some also give preferential treatment to public hospitals, making it more difficult for private hospitals to qualify for public funds.

Lombardy, by contrast, has increased its quality standards, set its own reimbursement rates and, most important, put public and private hospitals on an equal footing by making each equally eligible for public funds. If a hospital meets the quality standards and charges the accepted reimbursement rate, it qualifies. Patients are free to choose between state-run and publicly funded private hospitals at no extra cost. Their co-pay is the same in either case. As a result, public and many private hospitals in Lombardy compete directly for patients and funds.

There are also regions in the United States that have exhibited higher value than others. Recent Milliman analysis looks at this dynamic. While the Wall Street Journal has correlated hospital improvement in Lombardy to increased private/public competition, the causal drivers behind the most efficient regions in the United States are less clear.  Here is an excerpt from that study:

We were surprised to find that the 16 [highest-value] cities have little in common when it comes to what we thought were key drivers, such as:

• Hospital market concentration
• Commercial payer market concentration
• Wage index
• Ratio of primary care to specialty care
• Hospital Care Intensity index, a measure of the intensity of services provided in a locale

Prominent among our findings are the lack of consistent association of these characteristics among our set of high value cities. Our analysis was not designed to test for such associations for the entire nation. The authors hypothesize that hospitals can meet financial goals through controlling costs (strong management of resources) or by attempting to maximize revenue (high charges to private payers).

We note there may be some other factors common among the cities that are high value for hospital care, and finding those factors would be a great public service.

See the full analysis of high-value U.S. hospitals here.

Efficiency, Quality of Care Bruce Pyenson, Italy, NBGH

We have talked before about the newfound ability to gather community health data and mine if for new insight. A recent project for the Robert Wood Johnson Foundation and King County in Washington state looked to do just that by seeking information on health disparities in different ethnic groups. Here is a summary of their findings:

The pilot project revealed that King County employees generally experienced high quality of care on most  performance measures.  This made it difficult to observe relationships between quality of care and absenteeism and productivity.  The analysis did, however, reveal significant disparities in asthma medication use, with African-American patients less likely than other groups to receive adequate medication.

Indeed only 70.4% of African-American patients received appropriate medications for asthma, compared to 87% of Asians, 89.8% of whites, and 100% of Hispanics. See the full results here and in particular note Table 2 in the appendix.

Prevention, Quality of Care data pooling, disparities in care

Last night’s News Hour included an interview with doctor and essayist Atul Gawande.

He notes the disparities in American healthcare from one area to the next and calls for improvement in both quality and cost.

Cost, Quality of Care, Reform Atul Gawande, Convergence, geographic cost disparity

A new study looks at how health organizations are responding to the ICD-10 deadline of Oct. 1, 2013. In many cases, they don’t seem to be responding at all—70% indicated their organization has done  “little or nothing” to implement the new standard.

You can read the study here.

Electronic Health Records, Quality of Care Andrew Naugle, ICD-10, John Kasey, Patricia Zenner

Today’s Milwaukee Journal Sentinel reports that the community data pooling organization, Wisconsin Health Information Organization (WHIO), has launched a database that will now be available to large healthcare systems and, eventually, to consumers. The database will improve transparency and allow better understanding of healthcare quality and cost dynamics:

The database is drawn from the experiences of more than 1.6 million people and 72 million treatment services. In April, WHIO will add data from Dean HMO and Medicaid, which includes BadgerCare, the state health program for the working poor, adding the experiences of 1 million more insured people to the database.

“To us, the real opportunity is to look across all the claims aggregated here and get a picture of where we have cost-effective health care being delivered in Wisconsin, and where we have an opportunity to improve the cost-effectiveness of health care,” said Karen Timberlake, secretary of the state Department of Health Services and a WHIO board member.

“There isn’t a database like this that’s been available to providers to measure these sorts of things. And if you can’t measure it, you can’t improve it,” said Larry Rambo, chief executive of Humana’s Wisconsin, Michigan and Illinois markets.

Wisconsin is among a handful of states – including Minnesota, Massachusetts, Oregon and Washington – that have put infrastructures in place for pooling health data to improve quality and transparency, according to a briefing paper written this year by the consulting and actuarial company Milliman.

Click here for more information on these information exchanges.

Cost, Electronic Health Records, Quality of Care, Transparency chartered value exchanges, data pooling, Paul Leonardo, Rich Moyer

What follows is excerpted from “The convergence of quality and efficiency,” by Helen Blumen and Lynn Nemiccolo.

Unfortunately, even when guidelines score well using the AGREE instrument, providers may still view them negatively. One example of this is an examination of guidelines conducted by researchers at RAND. One of the questions within the AGREE rigor-of-development domain requires that experts in both clinical content and guideline methodology who are external to the organization that has developed the guidelines review them, but it does not provide detailed specifications for the review. RAND researchers examined a set of guidelines for common, expensive diagnostic testing and treatment for musculoskeletal disorders of the spine and extremities. The researchers gave these guidelines high scores using the AGREE instrument. Then they asked a panel of providers (recommended by their specialty societies as leaders in their clinical field) to rate the relevance of the guidelines to common clinical situations and consistency with clinical understanding of existing evidence and expert opinion. The expert panelists thought that the guidelines did not address common clinical situations, and reported that they often disagreed with the experts’ interpretation of published evidence and clinical experience. In the face of findings of this nature, it is not surprising that guideline adherence in real-world situations may be imperfect, or that implementation of guidelines in healthcare systems may be met with resistance.

  Read more…

Efficiency, Evidence-based Requirements, Quality of Care Convergence, Helen Blumen, Lynn Nemiccolo