Transcript

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”ENRIQUE MARTINEZ-VIDAL: Good afternoon, everyone. This is Enrique Martinez-Vidalfrom AcademyHealth. Right now we’re waiting for a few others. We will start in short order,thank you.Good afternoon, everyone. I’m Enrique Martinez-Vidal. I’m the project director for the StateQuality Improvement Institute. I think I probably met you most of you participating on this calleither at the Kick-off Meeting back in June or if you participated in the first cyber seminar. Ifthere are any new folks joining in, welcome. I’m also joined in our office by several otherQuality Institute team members. From AcademyHealth, Alison Rein, Shelly Ten Napel, HilaryKennedy, and Caroline Pang from AcademyHealth. And from the Commonwealth Fund, AnneGauthier and Allison Frey.So first let me welcome you to the State Quality Improvement Institute’s second cyber seminar,focusing on examining the state’s role in Using Information to Help Providers Improve. This isthe second of a series of four cyber seminars scheduled this fall and winter, aimed to assist youin your quality improvement efforts by providing the latest information on quality improvementand health reform topics of interest.But before we get started, I wanted to thank everyone who has completed the survey that wassent to them a couple of weeks ago for the first cyber seminar – the team here is looking overthem to think about ways to further help you. If you haven’t completed the survey yet, it’s nottoo late to send it on. We really do appreciate the feedback, and it will, of course, beanonymous.The goal of today’s cyber seminar is to give states a better sense of the role that a state can playin the process of designing a data collection and reporting framework, as well as the potentialbenefits to a state from partnering with other stakeholders. This cyber seminar will also explorethe improvements in the quality of care that can occur when providers collaborate and learn fromeach other.Today’s cyber seminar will have three speakers, followed by an open question and answerperiod, during which we encourage you to dive in and ask the panelists as many questions as youhave. Last week you received the bios of each of our speakers, which you hopefully have hadsome time to review. In order to allow as much time as possible for the content of today’s event,I will only briefly introduce the three panelists.Susie Dade will be our first presenter. Susie is the Director of Quality Improvement andAdministration for the Puget Sound Health Alliance in Washington state. She works with othersin the community to identify quality improvement opportunities and to stimulate and encouragesystem and practice changes that will result in improved delivery of care for patients withchronic diseases and increased participation in prevention-related activities. Susie will talk aboutsome of the work that the Puget Sound Health Alliance is involved in.

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”Dr. Vahé Kazandjian will be our second presenter. Vahé is the President of the Maryland-basedoutcomes research center, The Center for Performance Sciences (CPS). Among the activities ofthe Center is the development of quality measurement and evaluation strategies in The Americas,Europe, and Asia.Vahé is also the Senior Vice President for The Maryland Hospital Association (MHA). Amonghis research and policy responsibilities is the Quality Indicator Project, the largest national andinternational effort to measure and compare indicators of hospital performance.He is also on the Board of Directors of the Maryland Patient Safety Center, a collaborationbetween the Maryland Hospital Association and the Delmarva Foundation, which Maryland’sQIO. He will talk about some of the activities currently underway in Maryland.Our third presenter will be Scott Leitz. Scott was appointed assistant commissioner of health inJanuary 2007. In his role as assistant commissioner, Scott oversees and directs the department’sefforts on health care policy development, and he is spearheading the Pawlenty Administration’sefforts on health policy and reform. Scott will talk about Minnesota’s new health reform bill thatwas enacted in May of this year.Each of the speakers will give a 15-minute presentation. After we hear all three, we will moveinto the question and answer session for the remainder of our time. There are two ways to ask aquestion. You may submit a question at any time throughout this cyber seminar by typing yourinquiry into the chat box located on the right-hand tool bar on your screen, beneath theparticipant list. Or, during the question and answer period, we encourage you to ask livequestions, which you may do by clicking on the ‘raise hand’ button located at the bottom of thebox containing the participant list. That will place you in the queue of questions. We will tryour best to get to all questions. I will repeat these instructions when we begin the question andanswer session.One other thing is that this cyber-seminar will be audio taped so that others who couldn’t join ustoday will have a chance to listen to it on the Quality Institute Web site. Without further delay Iwill now turn it over to Susie Dade.SUSIE DADE: Thank you. Good morning, or afternoon, depending on where you are calling infrom. I’m in Olympia, Washington, so it’s morning here. I’ve been asked to talk about a coupleof things, including an overview of the Puget Sound Health Alliance and our role in dataaggregation and reporting. I will frame this information with an overview of our convener roleand the Alliances’ overarching goals. Then I will talk about potential roles for state governmentin using information and advancing the quality value agenda. I will finish up with lessonslearned. I have 25 slides and 15 minutes. I will move through them quickly. I’m happy to takeyour questions later.The Alliance got started in earnest in mid-2005 when our first executive director was hired.Since then we’ve grown to about 170 member organizations. We’re a multi-stakeholder2

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”coalition in which our public and private purchaser members play a significant role in guidingand funding our work. Also key to our efforts are our other stakeholders, health plans, otherhealth related organizations and consumer advocacy groups. The Alliance is one of the RobertWood Johnson Aligning Forces for Quality Pilot sites. We were among the first in the country tobe designated a Chartered Value Exchange by Secretary Mike Leavitt. We enjoy the support ofGovernor Gregoire and numerous Washington state legislators.A central role for the Alliance is to serve as a convener for our multiple stakeholders. Animportant starting point for all of our discussions is basically: what is your perspective? What dowe have in common? And how can we work together? We strive to create forums in whichdifferent interests can come together and build a common agenda and collaborate on stimulatingimprovement one step at a time. As you might imagine this is rarely easy, given the variousagendas and differing goals, many of which are not freely shared with one another. For example,the health plans in our area, three of them are highly competitive, none of whom have dominantmarket share. We all get along and play nicely together, but I would not say we’re particularlycollaborative in real ways yet, so that’s something we’re working on. The framing for our workis really around advancing transparency. One of the main topics for today, promoting valuethrough recognition and incentives and activating consumerism.This slide is busy. But it visually demonstrates the outcomes, goals and strategies that drive theAlliance’s work. At the bottom are examples of our methods and tactics. And I’m not going togo through in detail, but feel free to ask questions if something in particular catches your eye, interms of an activity.When you think about improving quality the work differs significantly depending on whetheryou are thinking about improving quality across a community or specifically within a practice.In this slide I have included examples of activities that are essential to transforming care across acommunity of healthcare providers. If you look closely you will be able to see there’s a role forpurchasers and plans, providers and consumers. The work is really here more at a macro-level,but represents the underpinning of the culture and system that drives practice at a micro-level.On this slide I’ve shown important elements of improving quality within a practice. As youknow, it’s extremely challenging, it requires a physician champion, an engaged team, support ofleadership, an understanding of the chronic care model, and the time and resources to redesignsystems of care to anticipate the patients’ needs and effectively use all members of the team.Sustaining improved quality in a practice is, I think, dependent upon improving the communityculture and system that frames and drives that practice, thinking back to the previous slide. It’simportant to point out this does include financial incentives that reward quality rather thanquantity without regard to quality.At the Alliance we recognize that although we don’t purchase insurance or provide healthcare wehave an essential role in stimulating change and improvement. Our central goal is to help othersthrough our role as a convener and to align their efforts. Our current healthcare system is sort of3

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”like a row boat with lots of rowers and multiple paddles and everybody pulling in a differentdirection. If we can get key stakeholders pulling together in the same direction, our concept isthat the community can make headway.I’m going to switch gears to talk a bit about the Alliance’s data collection and reporting work. InJanuary of 2008 we published our first community checkup report. I invite you to take sometime after today’s meeting to visit our website which is noted there at the top of the slide.Our initial effort is one of the largest of its kind in the country and has data aggregated from 14health plans and self-funded purchaser, covering 1.6 million covered lives. Our first reportincluded results from 14 volunteer medical groups that have 60 clinic locations. We includeresults on 21 quality process of care measures in the areas of diabetes, heart disease, depression,low back pain, use of generic drugs, appropriate use of anti-biotics and preventive care. In aboutone month we will be publishing our second community check up report. This time it willinclude results for about 50 medical groups, all of whom have six or more providers and whopractice in over 150 clinic locations around the greater Puget Sound area. We’ve added datasuppliers, including fee for service Medicaid and we’ve increased the data span formeasurement. Results will be posted to our new interactive website, which will also includeresults for hospital quality drawn from other publicly available sources of data, such as HospitalCompare and Leapfrog.Here is a list of the types or categories of measures that you will find on our CommunityCheckup website. I have also included some that we are planning for the future when databecomes publicly available. We are starting our second round of Evaluate, which is a health planassessment. We’re working with the state around including measures around healthcare,acquired infection and never events.The next two slides are simply snapshots of our website. I have included them to make the pointthat it’s not enough to aggregate and report data, you really have to continually look for ways tomake the information user friendly and relevant to various stakeholders, each with differentlevels of understanding and different goals in using the information.On this slide I have picked the area of depression to show how the data is shown at a summarylevel. If you look down the left-hand side you’ll see the names of medical groups at specificclinic sites and the measures across the top. There are various places to click that will take youto subsequent pages with drill down detail.Overall we know from our first report that we have significant variation and performance withlots of room for improvement really across the board. This slide shows how many of the 14volunteer clinic systems in our first report performed above, at, or below the regional average onthe 21 ambulatory measures. You will see on the very far left side is Group Health Cooperativewith a number – performing on a number of measures above the regional average and on the farright side is the UW Medicine Neighborhood Clinic with a little more room for improvement.4

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”We’re also able to look at each disease area. For example, here is diabetes and see how we’redoing across our five county area. The overall slide shows the regional average along with thehighest performing clinical system there across the top. These results would suggest there’sroom to improve across the board, and that we do a better job overall in some areas, for exampletesting HBA-1C, than we do we do, for example, in ensuring that routine eye exams take place.The detailed results, if you drill down, will tell you which clinic systems do a better job. Theclinics themselves get provider-level data privately to help them target QI activities within theirown practice.The importance of the process for creating our Community Checkup and for performancereporting generally can not be overemphasized. Doing this work correctly takes a long time. It’simportant to take steps to foster inclusion and opportunities for input. You can’t do this byconsensus, but seeking agreement from the majority of participants is extremely important. Weworked with a number of clinical improvement teams to get to our first set of metrics. Eachimprovement team had a specific focus area, like diabetes or depression. We held a number ofpublic meetings to try and get input on the approach. We tested different approaches forattribution and for formatting the results. We spent time with each of the provider groups beforemaking the results public to allow them to review the results and work with us to get them asaccurate as possible. We put in place a process with our data suppliers and select clinics to tryand verify patients and services that they were meeting the specifications.For the first two reporting periods our organization put in place rules for use that made it so thatthe results could only be used for establishing baseline quality of care, comparing results fromdifferent performance reports, and basically quality improvement. The results cannot be used forestablishing networks, designing employee benefits packages, negotiating contracts, publicrelations, advertising or other marketing. These rules for use have been important in setting thetone and context for the work. I would say they de-charge the atmosphere for us. It also helpedto start with volunteers. I would say that the process for our first report was extremely smooth.In our future reports, starting in 2009, we have plans to expand the content, as well as the rulesfor use. Our purchasers and plans are interested in lifting some of the restrictions on use in orderto leverage them for more improvement faster. That’s a discussion we will be having with themin the coming couple of months. We plan to expand the types of measures we include to movebeyond process of care and include other elements such as efficiency, resource use, patientexperience and potentially unit cost, although that’s a big hurdle to get over with both ourproviders and our payers. We want to find national best performance and compare ourselves tothat rather than simply comparing ourself to ourself with our own regional average. And we’realso interested in moving towards using clinical data, but those of you that have worked on thisknow this is challenging. We know using encounter data from claims to measure quality is astarting point. But it’s not our ending point. We also know that neither administrative nor chartdata offer a panacea for measurement and reporting. Both create large and complex challengesin the path to reliable and valid reporting. We believe we have to start from where we can start,which for us in this region is really using claims data. Our uptake of EMRs, particularly EMRs5

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”with the ability to report out results is quite low, probably somewhere in the neighborhood of20% of practices.I’m going to switch gears again really quickly looking at the time. I would like to talk aboutsome ideas for how state government can be involved in improving quality and value. Our ownstate serves as a template for these ideas so I want to give credit to our governor’s office, theHealth Care Authority, and our division of Medicaid. I will talk briefly about each of theseareas. There are examples here of states doing the work, as well as examples of stategovernments helping with the work.The first is really to support transparency in real and tangible ways. Aggregating data frommultiple resources and reporting results is controversial, time-consuming, and is expensive.There’s a role for state government in potentially funding the work, at least partially, and inleveraging data suppliers to share data either through influence or legislation. Here in our statethe Alliance is doing this work. We’re the aggregator of the data but in other places the state isdoing it. My own view is that this work is best done by multiple-stakeholders with very strongsupport from the state. I have listed several examples here where the state can influence and beinstrumental in helping an organization such as ours to move forward. In Washington state wehave legislation that requires reporting of health care associated infection and never events. Idon’t think we would have gotten access to these performance results without this legislation.The same may be true for other areas, for example, unit price.The second area is in contracting. Contracting is a powerful tool. I would say generallyspeaking purchasers under-use it to drive system change. To be most effective we need to get amajority of other large purchasers to join with state government to build similar expectations andto plan contracts. It will get their attention. In turn we want to drive health plans, both publicand commercial payers, to use provider contracting to drive towards similar goals. For exampleusing evidence based medicine, adoption of health IT and so on. Again, all of the rowers pullingin the same direction is really the concept here, and using contracting to make that happen.Here’s a topic around payment reform. I’m not sure state government can drive payment reformalone. But as a large purchaser and a policy leader the state has a significant role to play inpayment reform efforts. And in bringing together our other large purchasers. In a number ofstates the governor’s office has been instrumental in influencing the dominant commercialinsurers to come to the table to develop a critical mass of payers and work through antitrustconcerns with their AGs’ offices. Leading this work really requires active sponsorship, frequentdiscussion, and in-depth or real tackling of areas of concern or disagreement. There are lots ofelephants in the room, we have to be able to call them out and talk about them.And then fourth, state government can play a key role in driving IT adoption. Here inWashington state, for example, our state has been a central participant in the Washington StateHealth Information Collaborative, which makes grants available for EMR adoption in practicesand critical access hospitals. Washington state, through our Healthcare Authority, is also leading6

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”the work to drive the creation of health information data banks through pilots in threecommunities. I realize after I sent in my slides that I should have a fifth slide, which is reallythat the state can play an important role in coordinating collaborative learning opportunities forcommunities and practices. Here in Washington, our Department of Health, under the leadershipof Jan Norman has hosted an excellent collaborative focused on practice redesign to implementthe Chronic Care Model. This collaborative has involved 175 practices since 1999.And finally, advice, very quickly. On collecting and reporting data, I think, what we have foundis getting to an all payer database is extremely important. Probably essential to get the interestand attention of providers. We need to choose measures for which there’s strong evidence. It’sok to have quality measures as a stand alone but you don’t want to ever start with cost or price,or efficiency. You need to start with quality. Aggregating data and reporting is extremely timeintensive and expensive. It’s harder than you think, it takes a lot more time than you think itwill. It’s significant to develop the provider crosswalk, meaning which providers practice whereand when? Attributing patients to those providers is extremely challenging but key to thecredibility of reported results. In terms of involving stakeholders, I think the key points here arethat purchasers are absolutely key to moving payers and reimbursement is key to movingproviders. You have to do those things to get traction. Consensus is hard to get on challengingissues. We don’t strive for consensus. We strive for developing a majority that will move thework. And then finally, just on pace, I think it’s important to strike a balance between doingthings that are bold and innovative and fast and being thorough, “perfect,” and slow. It’s a toughbalance to strike but it’s one that we work on continually.And I think that’s it for me. I don’t know how I did on time but happy to either take a couplequestions now or at the very end.ENRIQUE MARTINEZ-VIDAL: That was great. You were just on time. Right now, we willmove right in to Dr. Vahé Kazandjian.VAHÉ KAZANDJIAN: Thanks, Enrique. I am trying to see where my slides are.All right. Thank you. I am going to build on some of Susie’s points as I go along. It’s going tobe a description of the Maryland health care system in this area, focusing primarily on theaccountability issue. I chose to discuss some distinct experiences that some of you may knowabout because they’ve been national and international in focus, but also on others becausethey’ve been relatively recent that will cover a lot of territory in the role of government and therole of stakeholders at the local level to show accountability.Back in 1985, Maryland Hospital Association started a project called the Quality IndicatorProject that has become very large and also the oldest project in the field of performancemeasurement via indicators. The reason I am presenting this first is that it was an activity towhich a lot of the stakeholders, including the State Government, contributed to over the years inpromoting data collection that would be kept confidential through legislative protection as a peer7

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”review information and that has tremendously helped in hospitals and non-hospitals direct careproviders to actually submit data. So the two questions, are we doing the right thing and how dowe know? And how do we know has been the question of accountability. How can we showthat it works?The next phase in this and building on the experience of almost 15 or 20 years of trust betweenthose who promote quality and accountability and provide protection of the data, and those whosubmit the data and those who analyze the data and provide feedback was the issue of: are wedoing things in a safe way? And this was as you can see in 1999. And this was before the IOMReport on errors that created world wide attention on this topic. Actually in Maryland we starteda project called Med Safe that has been going on for almost a decade now. That looks veryspecifically to medication use practices in hospitals and it is still the only statewide project thatcollects information and we work with ISMP, which is one of the most respected folks in thefield.As you can see, there is this concept of building trust, then the goodness and the quality of thedata submitted gets better because they trust that the information being submitted will not beused in an adverse way. And then going from performance measurement to actually addressingthe questions of safety which are much more sensitive because they have to boil down toindividual patients or provider or floor service level. Which is much more sensitive than hospitalwide aggregate statistic.And then we have the Maryland Patient Safety Center that actually started with the stateDepartment. Basically promoting the creation of a Patient Safety Center and if I may say, at thatpoint, Enrique was in the Maryland Health Care Commission and he was involved andinstrumental in putting together this historical action for the state of Maryland. The PatientSafety Center was created in 2003 and as you can see in the second bullet, in 2005 we receivedthe John Eisenberg Award for Excellence by NQF and Joint Commission. As you can see wereceived that national award without ever collecting a piece of data! There was very strangebecause most organizations and state activities were based on data. And people were saying nowwe are collecting 10 thousand records, 12 thousand records or what ever. And we said, well thatis important to collect records but for what reason and what are we going to do with it? How dowe prepare people for what is coming with that question of data collection? So we spent twoyears building an infrastructure to the Patient Safety Center that was seen by NQF and JointCommission as very innovative without collecting data. Now we are collecting data. I will showyou some results. When we got the award, it was primarily on the design and philosophy of theCenter, which was to build collaborative work with the state, department and office of healthcare quality within the state that was looking at type one errors that need to be reported on amandatory basis. Working with the hospital is to create the new level of trust which was verysimilar to what we started doing in the mid ‘80s. This one would be trust regarding informationabout safety.8

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”Susie mentioned that can the state be involved in the payment system? Interesting enough,Maryland is the last of the Mohicans when it comes to a non DRG state. It’s an all-payer system,which means that we are paid on an algorithm that applies to all payers regardless of how theypay for otherwise nationally when they are involved in other states. We have a centralorganization which is called the Health Services Cost Review Commission that is the keeper ofthe goods regarding the funding as well as the algorithm that goes with allocating funding forhospitals based on previous utilization and projected utilization.So the Commission started a statewide activity called the Quality Based reimbursement – whichis another acronym for pay for performance which is very interesting. Also very unique becauseit is not an award based system. It does not say like the Premier System or any other system, thetop 10% get something. It basically says that it has rewards as well as incentives. The incentivesare interesting because it says that if the hospital is not at the level of what we expect the state tobe in certain indicators of performance then we have to figure out why and how we can providesupport. So that hospitals can get to that level within a time period. You can imagine that raiseda lot of eyebrows. Are you going to pay more, perhaps, for a hospital that is not doing as well asother? Perhaps yes. Pay more in the short-run to get them up to the level, at least to theminimum level that we expect of everybody. And then pay more for those who exceed that. It isgoing on now for 3 plus years and I think it is going to create a lot of interesting findings for thefield. It is called quality based reimbursement and in that sense quality is an integral part of thatmodel. So then, going back, those are some of the major activities I wanted to mention becausethey cover specific major dimensions, dimensions of payments and performance, dimensions ofsafety and accountability. And dimensions of indicators used for primarily internal processimprovement by organizations.What I would like to do, in the next 10 minutes, is to take you through some of the veryimportant findings that have also shaped policy in a very short period of time. The MarylandPatient Safety Center could be a good example for that. The data is very important for us, but welook at is as a data facilitator rather than the goal of what to do. And we are identifying commonareas as you may imagine for improving performance but also for accountability. I want tomention to you, what we think accountability means, in a very practical way. I would like toshow you some findings from a tool that we developed.We call the tool the Web Based Incident Reporting System, which is very generic description ofa tool. The reason why I think the tool is interesting and it has raised already a lot of interestnationally by other state associations and Department of Health, they have actually adopted thistool in their goals especially if they’re trying to become PSO, to be designated by the federalgovernment. The tool does not really focus on reporting what has happened, incident reporting,but also has a huge component of looking at potential for errors or near misses. So in that senseit is not only reporting what happens, but a reporting what could happen if nothing is done. Andthat seems to be quite useful in strategic planning.9

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”As you can see, on that slide, in Maryland we have a voluntary and mandatory system. Thevoluntary is the Patient Safety Center, although voluntary is a kind of funny thing because ofpeer pressure. If every hospital is reporting except one, that one hospital will be forced to reportbecause everybody would know that they are not. So basically it is voluntary by law but in a reallife, peer pressure plays an important role. Then we have the mandatory, which is level oneevents that need to be reported to the state as it is the case in many other states.Basically, the reporting system is designed for looking at near misses or for risk or for potentialfor errors as much as it is to report on what has happened. We can discuss this later if anybody isinterested. The logic behind it is putting different dimensions of the care together to build animage and profile of risk rather than just saying somebody fell, reporting five different thingsthat interfered with the patient’s falling. And I will show you one of the examples in a minute.As you can see, 32 out of 47 hospitals are reporting data already in Maryland. We have morethan 15,000 records of errors or near misses reported to us and eight hospitals actually adoptedthe tool as their internal on going risk-management safety tool, which is quite significant. If youthink about vendors that are out there that have very expensive tools, organization wide, theyactually prefer the tool we developed to the tools from the vendor and are very proud about that.As I said, the Med Safe in the past decade, we have been looking at clinical, organizational, andstatistical changes that have been seen and documented in medication use safety. Putting twothings together, as you can see from this slide over the years, and this is quite unique. You willnot see this graph in many places because even ISMP cannot do this nationally. Because theyhave done surveys on this only twice nationally, in 2000 and 2004. Whereas here we have beencontinuing to measure in the state of Maryland our trends and we have significant understandingas to why the trends are increasing so well. We do have a publication coming up in a majormedical journal on this hopefully in the next few months, reporting some of the actual changes,but it is a very practical project. That can cut across, in a way dealing with other aspects ofmedication safety.Here is how we did that. This year, what we did, we focused on two things at the same time.We looked at patient falls, which were collected through the adverse event reporting collected bythe Patient Safety Center, which are transformed into indicators, very similar to other indicatorwork in the state. And then we looked at medication use data from Med Safe. And we put ittogether. We said, instead of just looking at patient falls, or looking at medication errors, can welook at patient falls that were promoted or actually maybe even caused by medication errors. Sothere you go in multiple dimensions coming together and showing how it can be synthesizedacross projects within the state.Those are the pie charts, you can look at it if they want, but as you can see, 22% or so of ouractivities reported were due to medication errors, and about 11% of the incidents were related topatient falls. Those were big categories for us. If you look at harm versus no harm, you still seethat there is significant harm associated with patient falls. Therefore, it makes it quite asignificant area to focus on.10

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”Here are some, and sorry, on my screen it looks like the letters have been jumbled. Here’s whatwe looked at. 753 falls in 2008. Many of them were caused by many things that not manypeople pay attention to. Diuretics, patients were given diuretics at 9:00, before going to bed.Why do you do that? You know they have to get up and they are at the same time with polypharmacyand narcotics and sedatives, especially anti-hypertensive. You know that when theyget out of bed, they need to go to the bathroom where they are going to fall. It was veryinteresting to find those medications and this is the first time ever for the state of Maryland thatthis has been reported. And the state presented this at a conference so now we are going totackle this in tandem.Very quickly to finish up, accountability, we consider accountability a contract which means thatpeople have a contract in some ways between those who get our services and those who provideservices. Trust is important but data collection and demonstration is very important. Also, it isimportant to realize that accountability cannot be only on trust. It cannot be “Trust me, I knowwhat I am doing” which seems to be the old model, but it has to be quantifiable, and theactivities that need to be part of that deal with the issue of how do you measure it and when themeasure? Finally one of the new developments in the state and also other places, is that whenwe are talking about outcomes, outcomes cannot be measured during the 3.3 or 3.6 days of inpatientlength of stay, because most of the chronic disease or surgeries, or orthopedic proceduresor obstetrical, the outcomes are seen post discharge in the community, so looking at thecontinuum of care is going to be very important. And finally, human nature needs incentives andthe incentives are going to be financial and also the image of the institution.My last one is the summary that describes the way we look at it is safety, issues with work force,nursing and physician, among them incentives, operational, financial, and image wise, allinteract in this prism and the interaction is basically a picture of quality when you deal with that.We believe that all the three dimensions have to be built at the same time in order to deal withthe concept of quality. Where as accountability is actually a demonstration of the result of thatinteraction. Once you have the three dimensions that interact, we also believe that thecommunity and clinical medicine have to be on a continuum. And that if you are looking ataccountability, safety and quality, just looking at hospitals without looking at communities andwithout looking at community of care is not the way to look at the picture.I think I took 16 minutes. And I hope that was okay.ENRIQUE MARTINEZ-VIDAL: That is fine. Thanks. Let’s move directly into Scott.SCOTT LEITZ: Thank you. Good afternoon everyone. I would like to thank you for theopportunity to talk with you this afternoon. None of my slides will be as fancy as that last onethat Vahé just showed. I want to thank the Quality Improvement Institute and theCommonwealth Fund for sponsoring the Quality Institute.11

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”I am Scott Leitz, the assistant commissioner for health in Minnesota. What I am going to do thisafternoon is to give you a context about Minnesota. All state start from a slightly different place,so I wanted to give you some context about Minnesota and our health care system. I hope tohelp you all understand why we focused on certain things in our health reform bill that waspassed this May.I will talk about the components of the bill with primary emphasis on the elements of the bill thatrelate to quality improvement, quality measurement and transparency in the health care system.And will close by talking about the process that we are following for implementation and howwe think that is going to aid us in successful implementation of the bill.A little bit of context about Minnesota. Minnesota starts from a reasonably good place. Wehave among the nation’s lowest un-insured rate. We used to be able to say it was the lowest uninsurancerate in the country but that darned individual mandate in Massachusetts has bumped usto second I believe. But about 7% of Minnesotans lack health insurance coverage. We have hadthe Minnesota-Care subsidized health insurance program in place since 1992, which actuallypredates the S-CHIP program. We have done a lot of things to try to lower our un-insurancerates and generally speaking we rank among the healthiest states in the country and contextuallyin the state we have a history of collaboration, and innovation in the health care system.Minnesota operates in a largely nonprofit environment. Nearly all the hospitals save for one arenonprofit hospitals. The HMOs in Minnesota by law are non-profit. The environment does nothave the for-profit feel to it. We have traditionally built up a fairly high concentration of large,integrated, multi-specialty group medical practices. Both in the metropolitan areas in the stateand also in greater Minnesota, outside the Minneapolis St. Paul area, there tend to be largeregional hubs of integrated multi specialty group practices which has helped to disseminateevidence based medicine.The next two things listed on the slide are the Institute for Clinical System Improvement andMinnesota Community Measurement. These are two community resources that have been builtover time, ICSI has been built and funded by the health plan, but actually driven by physicians.About 70% of the state physicians participate in ICSI and their focus is to try to disseminate andencourage the adoption of evidence based best practices in clinical setting. MinnesotaCommunity Measurement then uses some of those best practice information that comes out tomeasure at a clinic level how well providers are doing on various measure of care. Finally, wehave an environment where we have a large amount of active large purchasers that have shown agreat deal of interest in improving the quality and value of the health care system.We’re one of those states that has a relatively does relatively well in the ranking of quality andcost and because of some of the factors listed earlier we’re in a relatively good spot because ofthat. But like most states, we are starting from an okay place, but most states are struggling withthings that are occurring in the health care system. We have rising health care costs, we have anerosion of our private insurance market that’s leading to rising number of the uninsured.12

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”This issue of health care quality, we know that is low, relative to the amount that is spent,although we also know that it is still not broadly measured. And that the issue of healthcarevalue is not well understood. What are we getting for the dollars that we are spending? Finally,and this was referred to earlier by Susie, this issue of healthcare reform, and payment reform,and the way that we pay for health care services, leads to distortions in the type of healthcare thatgets delivered. We probably under invest in things like prevention and primary care and overinvest in high-tech interventions.This then gets translated into data that shows we are not doing as well as we could be doing.Many of you have seen this slide before; it’s from Beth McGlynn’s study about four years ago inNew England Journal that looked at the percentage of adults that get care that’s recommendedfor them, and found that about half of the adults in the country were receiving the care that’srecommended for them. When we bring it down to a Minnesota level, if you look, for example,at the diabetes care in our state, we know that it is improving. In 2004 only about one in 25diabetics were receiving the care that’s recommended for them. And today it’s one in seven.But that means that six out of seven diabetics are not receiving optimal care for their condition,which means that there is a lot of room for improvement in that area. And if you look at theissue of disparities, in how well we’re doing across racial and ethnic groups, or by income, whenwe compare things like breast cancer screening between our Medicaid population andcommercially paid population, you see a disparity there. The Medicaid population is less likelyto be receiving mammogram every two years within a certain age group as opposed to othercommercial payers. Finally, like all states, we’re seeing an increase in risk factors. Percentageof Minnesotans that are obese has more than doubled, and nearly tripled in the course of 17years.So all this led up to a lot of discussion that occurred over the course of the last couple of years,with our legislators and with our Governor around the issue of health reform. And it resulted ina bill that was signed by Governor Pawlenty in May 2008. The bill itself is a comprehensivepackage that makes some significant advances in the health care delivery system forMinnesotans and importantly, the reform really anticipate building on existing efforts in someareas, and then building on and using a collaborative public process to implement initiatives inother areas. I think the state’s role here, there is a lot of interest, a lot of recognition thatcommunity work has been done through organizations such as Minnesota CommunityMeasurement, around measuring quality of providers and that really fed the legislative interest inseeking out and getting more information in those areas. And then using the state as a leveragepoint and a catalyst to find areas where new work needed to be done and to collaborate andcoordinate that work.Let me talk for a couple minutes the about the key elements of our health care reform initiative.It was a comprehensive package that included things like public health improvement, we didexpansions in our Minnesota Care program, we, like a lot of states, looked at the issue of healthcare home and chronic care management; a lot of the bill was devoted to the issues of paymentreform, and quality pricing transparency. We built on some existing initiatives around13

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”administrative efficiency and tried to drive those even further. And then we also have somethings on health care cost measurement. I’m going to focus most of my comments to chroniccare management and payment reform and transparency portions of the bill. And then I’ll alsoallude a little bit to the cost measurement piece of this and how we are planning to do someevaluation and tracking on whether or not our reforms are succeeding.On the chronic care management side, again I allude to the fact that a number of states arelooking to the use of health care homes, or medical homes, to help coordinate care for peoplewith complex and chronic conditions. We do know that a majority of health care spending is aresult of people who have either one or multiple chronic conditions, so there is probably rightlyan amount of focus to coordinate and better manage the care of those individuals. The way ourlegislature asked us to do that is to have my department and the Medicaid department, theDepartment of Human Services, jointly develop standards of certification for health care homesthat will encompass things like the achievement of certain outcomes and having certain pieces ofinfrastructures in place. And then based on that certification, care coordination payments beingmade to those healthcare homes for the coordination of care for people with chronic and complexconditions. The way we approach this work, while the work is assigned jointly to our twoadministrative agencies, we are envisioning a fair amount of collaboration with the privatesector, so we plan to issue or have issued request for proposal around helping us define whatoutcomes health care homes should achieve, to help assess the capacity in the system aroundhealth care homes, and to facilitate some of the development of certification standards in certainareas.The bill also does a lot to forward price and quality transparency in Minnesota’s health caresystem as well as to start down the road of reforming the way that we pay for health care. I willtalk about three specific areas and talk about how we are using request for proposal process tofacilitate the work in this areas. The first area of transparency really is the establishment ofstatewide quality of care measures and the establishment of quality incentive payment system.We heard a lot of the legislative session the frustration of providers being measured by multipledifferent ways by multiple different health plans, Medicare measures a different way, Medicaid adifferent way and private insurers a different way for quality of care. So the bill envisionsdriving to a common statewide measure of quality of care that will be established and thendeveloping a payment incentive system that would reward providers who are meeting certainthreshold showing substantial improvement in the quality of care that they’re receiving orproviding. And then we would actually the bill prohibits them to collect information unless itwas voluntary agreed to between providers and plans on additional quality measures.The second quality element that relates to transparency is the transparent ranking or grouping ofproviders based on their relative cost, quality and resource use. This has been called tiering ofproviders, ranking, grouping, in any case, it is basically a way to try to get at this notion of valuein the health-care system by combining cost and quality information in a transparent ranking ofproviders. This will be done via the collection and use of all-payer encounter data system, which14

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”is built, I’ll talk a little bit about the RFP for that, and contracted prices between health careproviders to determine the issue of health care costs and how much – what cost is in the system.Finally, an issue of payment reform, the bill calls for the establishment of at least sevencommonly defined what are called “baskets of care.” You can think of these as episodes of care,of baskets of care; there’s a variety of different words that have been used to describe it. Butbasically these are a commonly defined set of services that would be priced by providers, definedcommonly by the system itself and then transparently reported. So that a provider could in asense price a hip replacement, that price would then be what the provider would be accepting forpayment and that information would then be made available to the market.In terms of implementation of the bill, the Minnesota Department of Health was given a primaryresponsibility and all authority for implementing the law. But the law also envisions a strongrole for private sector involvement. The way that we’re really doing that is a variety of differentways of involving the private sector. We’re certainly including them in a number ofworkgroups, and in consultations early on, but we’re also using an explicit request for proposalprocess to identify and work with vendors and contractors who have specific expertise in thevarious areas of the bill. So that we’re really reaching out and trying to find the best of the bestof the private sector to help us implement this law, rather than doing it all internally in terms ofadministrative agencies. Although the oversight clearly lies there.With regards to the request for proposal process, what we have done has been to go through thebill, identify and then group parts of the bill that seem to make sense as explicit RFPs to themarket. Most of the components of the bill have deadlines of July 1st, 2009. Some havesomewhat longer deadlines, but a lot of the work needs to occur within the next year to twoyears, so there’s a relatively short timeline to actually accomplish much of what we’re trying todo. The bill does require coordination and oversight by the Health department, but uses theexpertise of private sector to accomplish a lot of the substantive work in the bill. What we reallyanticipate is about nine to ten RFPs in total to implement the bill.Let me talk more specifically about a couple of those as examples to get a sense of what we aredoing and how we hope to further the complex work that is in the bill. The first example that Iwill use is the common quality measure. I mentioned earlier that we are driving to a commonquality measurement in Minnesota and the then building of an incentive payments system. Thiswas an RFP that we released on September 2 of this year. It encompasses three tasks. The firstone is sort of an identification, documentation and global look at quality measures in general.There’s any number of quality measures that are being built by a number of groups, so this is anidentification of what those might be, and a recommendation around what are the right ones tostart with. Again, some of this work is already being done in Minnesota so we would certainlytry to build on that work.The second is the development of a quality incentive payment system. This could be voluntarilyadopted by the private health plans in the state. It’s required to be adopted by the state employee15

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”group in Minnesota so there is a requirement that we actually take a look at that and develop thatsystem. The third task is actually the implementation of the reporting and payment system itself.So getting information on quality, the publishing of that information on web sites and throughother publications. We anticipate this about $3 million contract over four years to implement thecommon quality measure portion of the bill.The second example I will use is around the issue of provider cost and efficiency. The rankingof providers based on the use of resources and quality. We envision several pieces to this workand a separate RFP for things like the collection of the all-payer encounter data, that might lookslightly different than the collection of pricing data, or contracted pricing data. We haveconsidered those things as being potentially separate RFPs although it is conceivable in theencounter data that you could actually collect contractor pricing information. But then separatefrom that is the analytical and the rather challenging analytical work of ranking providers basedon the quality and outcome data from the common quality measure that I just talked about. Theresources they used to achieve those outcomes and then the price of the resources that were used.And that analytical work might come from a group that might look different than a group thatmight be involved in the collection of the all-payer encounter data.But those are the key components that relate to price quality and transparency in the system butthe bill also envisions that we would be looking to see whether or not we are achieving costsavings as a result of the reform. We will be using CMS projections of health care spending.We’re going to modify those based on Minnesota’s demographics and other factors. And projectout what health care spending is expected to be. We will also be measuring our aggregatespending through some health spending account work that we currently do and comparing thatagainst projected spending and seeing whether or not we are achieving the cost containment thatwe’re hoping for in the bill. The quality measures will help us know whether or not we’reacheving some of the quality improvement we’re hoping for as a result of the legislation.Finally, in summary, the legislation that we passed is heavily focused on increasing thetransparency, quality and value in our health care system. And while the bill gives responsibilityto an administrative agency, the Minnesota Department of Health, to administer the bill, it reallyenvisions a highly collaborative approach of working in an environment fortunately in Minnesotathat we have as being faily highly collaborative already. We’re already working with thosecommunity assets and the private sector to implement the bill. And the way that we’re goingabout doing that in addition to some of the more traditional methods is using an RFP process totry to draw out the best expertise possible in the implementation of the bill.This is my contact information and link to our health reform web site for the people who areinterested. With that I will close and thank you for your attention.ENRIQUE MARTINEZ-VIDAL: Thanks, Scott. Thank you all of you. Thanks Susie, Vahé,and Scott for your presentations. There is a lot of information about the programs you areworking on in your states. Now we are ready to move into the question and answer session. We16

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”will be taking new questions and previously submitted questions. If you would like to ask a livequestion, press the raise hand button. That’s located at the bottom of the box containing theparticipant list in the toolbar on the right side of your screen. If you want to submit a questionelectronically, which we will read out on your behalf, type it into the chat box located beneaththe participant list. We have a couple of questions already and I will start with one directed toSusie, but could be directed to all of you.QUESTION: How much the account on the consumer use of the community checkupinformation to drive providers to improve?SUSIE DADE: It is a great question. I think that if I were to rank and order the importance interms of use of the information, I think we are very interested in having providers use theinformation to drive improvement in their institutions or practices and we are interested inhaving payers and purchasers use the information to leverage improvement in the providercommunity. And I think third in terms of level of importance would be consumers, and webelieve it is important but we believe that as a whole the consumerism movement aroundhealthcare and use of information around performances is really in its infancy. It is an importantgoal. I would say we bank less on it now than we do some of the other stakeholders using theinformation. That said, it’s one of three important goals for us, we spent quite a bit of time withconsumer engagement and trying to find ways to make the information useful to the average Joe.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thanks Susie. Here is another question andthis is for Vahé. What do you see as the relationship between the data collection that’sgoing on both in the Maryland Patient Safety Center and by the state and thecollaboratives and the educational activities that are being undertaken?VAHÉ KAZANDJIAN: I think, by design, those multiple activities have to be synchronized inorder to yield the best findings. I think, from the Patient Safety Center, the collaboratives arealso part of the Patient Center. There are other activities in the state in the area of participationin national collaboratives, like IHI or others, that are also important to keep in mind. I think thatthe question of synchronizing or harmonizing was really the idea behind my last slide. That iswhat we’re trying to do. To a certain extent, we have succeeded already. Just an example, apatient falls and medication errors, there are other examples regarding those different activities inthe different groups of the states are being synchronized.The department, and MHCC, the Health Care Commission, as I mentioned, those also have apublic website for making information available to the general public and all these are sort ofexisting within the philosophy that might be slightly different than what Susie was mentioning inthe sense that the primary approach is to help organizations improve their processes and second,other stakeholders to understand how their organization can change their processes. And then atthe third level, to take the information from those two levels and trickle down to the communitiesor patients. There may be situations where that’s very successful but in many situations thattakes a long time. And during that period of time there is the question of accountability that is17

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”important. Do people feel they are being accountable if for five years you have not shown tothem how you improve safety or whatever, and my final thought on that one is that this is not alocal issue. Even on a national level, as you know, after the IOM put a report on safety, anumber of studies were done without giving being able to demonstrate significant changes insafety nationally. So I think what is important is Patients Safety Center in Maryland and otheractivities with the state is that those activities go in parallel as much as possible and thecommittees and patients are not necessarily waiting for us to know what is happening in theorganization before we tell them what we have done.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thank you. Do either Scott for Susie want torespond to that question as well? Should we move on? Okay. How about for Scott? Did youhave any remaining resistance to your collection of pricing information? How did youminimize resistance in the legislative process?SCOTT LEITZ: I think how we implement that will be important as to what the resistanceactually is. There has been a lot of interest in getting beyond charge information and getting toactual cost or pricing information. I think where the nervousness lies, and it’s probably quiteanticipated and reasonable nervousness, is around the collection of actual contract and pricinginformation that might somehow give out trade secret type of information where we could causeone either the payer or the providers to lose some negotiating leverage one way or another. Theway we are dealing with that is the data that comes in on the pricing will actually obviously beaggregated up to a much higher level and aggregated across payers so that you can’t identifyeither within individual services or between payers what the negotiated rate actually is. Ratherthan aggregated level. I think it was, we passed a law in the context of trying to get at whatinefficiency to a provider might look like. And that has to be the nexus of the quality of care thatthat provider is giving, as well as the cost and price of that provider. I think legislators andpolicy-makers understood that that information was necessary. There’s obviously going to be alittle nervousness about the collection of information but I think how we use the information andthe quality of the analysis that gets done is going to be the piece that over time should, if it’sdone correctly and done in a way that is methodologically solid, should lessen that nervousness.But I think until that occurs and up to that point there will be some natural nervousness amongstakeholders because of that. The way it is overcome was really due to the strong desire of thepolicy maker to try to get at this value issue.QUESTION / ENRIQUE MARTINEZ-VIDAL : Thanks, Scott. I should add as well that ifthere are other people who are participating on the call, if they have any observations orcomments on any of these questions or topics, if you want to raise your hand and just make acomment or general observation about what is going on in your state, we welcome that as well.So here is a question for Susie. Can you talk a little more about the distinction of what ittakes to improve quality at the community level versus practice level?SUSIE DADE: Sure. I spent a number of years prior to coming to work that the Alliance Iworked actually in the delivery system and a lot of the work I was focused on was practice18

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”improvement at the individual practice level. It was a consultated specialty, not primary-care,but really the principles are the same. The reason I use these slides is to really talk about thedifference between working at a community level versus working at a practice level. Both areessential is really the point I am making. But the work involved is different.At the practice level, it is around having the providers in that practice working with other teammembers with their front and back office staff to really in place systems in their practice thatenable them to implement evidence based on guidelines at a point of care, that they can use plansand counters to enable them to use proactive planning to work with patients with chronic diseaseor even well patients, to make sure that they get the preventive care they need in a timelyfashion. That they use tools like electronic medical records or registries to try and put in placeprovider and patient reminders about care. All of these various elements are things that happenat an individual practice level or the group level within one clinic site.These things are quite different than a community coming together through purchasers, payersand providers to really work around, for example, building policy support within your state forprimary care, these things related to medical education in your state, they can be related toscholarship and loan repayment. They can be related to the use of financial incentive andpayment reform. You can come together with the purchasers and payers to assemble a pot ofmoney to help practices move forward in their adoption of EMR. Performance reporting, Italked a lot about that but it’s this idea that it kind of takes a village to pull together an all-payerdata set. It’s something where a community has to decide that it’s important and work toward ittogether. And all of these things, this concept of resources and transparency of information, andperformance reporting, and payment reform and improvement practices that are either superiorperformers or demonstrate significant improvement over time. All those things really create theculture that surrounds an individual practice that either makes it easier for them to move towardsquality improvement or harder if those things are not in place. Simply trying to say both areimportant but the work involved in each quite different. Does that answer the question?ENRIQUE MARTINEZ-VIDAL: I think so. You had lots of answers there, so that was reallygreat.QUESTION / ENRIQUE MARTINEZ-VIDAL: Here is a question, it’s actually a kind of atechnical follow-up to what Scott was talking about. Are you going to be providing more thanjust average values of price or are there going to be some measure of variation? Do youknow that yet? Scott, I think you muted yourself.SCOTT LEITZ: Sorry Enrique. That is a good question and I think that’s right. It’s somethingthat we’re still . . . that’ll be something via the RFP process and the analytical tool development,we will determine the best way to go about implementing that particular portion of the bill. So Idon't think we have a preconceived way of doing that yet. It’s a good question, but one wouldthat will have to work through.19

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”QUESTION / ENRIQUE MARTINEZ-VIDAL: Thanks, Scott. I think this is for all three ofyou. You all had multi-year stake holder practices in your activities. Do you haverecommendations for those states where those collaborative relationships and institutionsdo not exist at this point? Let's start with Vahé.VAHÉ KAZANDJIAN: Obviously, the whole discussion today was to show that thosecollaboratives are essential for successful carrying out of the issues that were discussing,accountability, performance improvement and reaching out to communities among other things.Any new starting system that does not have a sort of a model for building collaboratives, needsto seriously rethink it. But it is not the issue of the concept. We all agree that collaboration is agood thing. The issue is, what are the reasons for collaborating? And what are the incentives forcollaborating? I think those two questions need to be addressed.Obviously, different stakeholders have different expectations. Are those expectationsreasonable? If so, can they be met? The state can play a significant role in promoting certainapproaches, providing incentives, not only financial but also of community visibility whichcounts much more to a lot of groups to be seen as a leader, to be seen as caring for thecommunity and looking beyond fixing things when they are broken, as Susie was talking about.But dealing with prevention, dealing with public care issues, and domestic violence comes tomind as one of the very sensitive issues that get immediate attention, for example, when it isdealt with by care provider organizations for example. And the last point, there has to be anincentive system. There has to be a win-win situation for the stakeholders, but we should notforget, what is the win-win situation for communities and patients? One of the challenges thatwe have, everybody talks about patients safety organizations and very few organizations dealwith patients. They primarily deal with hospitals and helping them improve processes towardssafety, but that is not any different from traditional “quality improvement” models where peoplehelp hospitals improve internal processes towards quality. I think we need to be very clear as to,if we call ourself something, or start a collaboration that we deliver what it is promising.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thank you. How about any thoughts fromSusie about the whole idea of states that might not have these collaborative relationships.SUSIE DADE: Well, in the case of Washington and the Puget Sound Health Alliance, the thingthat really got our coalition off the ground was a very . . . you need a champion and you needsomebody who is passionate and charismatic, and who is an opinion leader. In that case it wasKing County Executive Ron Sims, who really initiated the plans for the Alliance. He represents avery large purchaser for King County, and he’s the one that really began the process literally, ofgoing out and meeting with the CEOs of hospitals and health plans and other large purchasers tosay will you join me in this effort? And it’s that work that laid the groundwork for the 170organizations that belong to the coalition today. That is how we got started.But what I would say is that you need to have that on a continuing basis because the work getsharder, as you go, it does not actually get easier. You tend to pick off the low hanging fruit, as a20

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”group, to get some early wins. And then as Scott was talking about moving into this whole areaof price transparency, and we’re just, ourselves, in the front end of that conversation and it’s verycontroversial. So you need to continue to have strong voices at the table, people who arechampion and opinion leaders, and I think it really helps when those people come from thepurchaser community because these are the people who are paying the bills. They are a keycustomer of the system, and so for them to have a strong voice in the discussion is a pretty itessential.SUSIE DADE: The only other comment I would make is that, purchasers by themselves, haveof long history in this country of focusing somewhat exclusively on cost containment. So, partof the balancing act here in a multi-stakeholder coalition is to keep the focus on value. Meaningthe intersection of quality and affordability. Rather than on letting the agenda just drift towardcost containment. To me, that is what the multi-stakeholder approach is so essential in this workbecause if you just work with any one stakeholder in this work, their agenda tends to dominate.COMMENT / ENRIQUE MARTINEZ-VIDAL: Thanks, Susie. Scott, unless you have aburning desire to add to that, I am actually going to move on to another thing and then we have aquestion for Scott that has to do with stakeholders. But right now, if Karen Nelson who sent in acomment from Massachusetts would like to say something on the phone I think it would bereally helpful. Karen, are you there?KAREN NELSON: Yes, I am. I’m just resonating with a lot of Scott’s comments. Here inMassachusetts we have a very similar model of healthcare reform and thank you foracknowledging that we jumped ahead of you on the lowest amount of un-insured; we hope thatlasts through the cuts that are coming through our government tomorrow. Nonetheless, we’refacing the same issues in terms of public reporting of cost and quality. We’ve been very engagedwith the Health Care Cost Quality Council here in Massachusetts, which is part of the executiveoffice of Human Services, and includes Department of Health. And we’re struggling with issuesaround what is cost versus charges and how much information to post publicly. And veryawkwardly, the quality data will be all-inclusive of all payers and patients but the cost data willonly cover two-thirds of the private payers, not self-insured, and then the . So we’re a littleconcerned that it’s going to be a misleading picture that will be posted for Massachusetts forpeople thinking that “wow, look how much hospitals are getting paid by these payers,” when infact small numbers of private payers are what’s off-setting the low payment by the public payer.So it’s really challenging to do it right.ENRIQUE MARTINEZ-VIDAL: Thanks, Karen. I don’t know whether anybody else has anycomments to what Karen just raised.SUSIE DADE: This is Susie. The only thing I would say is that, just, once again, reiterates theneed for an all-payer data set. Or as close to an all-payer data set as you can get. That theme tome as pervasive and it’s not just on the price transparency, it’s really on everything.21

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”SCOTT LEITZ: Enrique, this is Scott. Karen, thanks for you comments and I fully agree that itis challenging to do and we are undoubtedly going to hit some bumps in the road as we moveforward trying to implement some things. And I would also agree with Susie that it does point totrying to get as inclusive and broad a data set as possible. And recognizing that that too may takeincremental steps to get there. I would further that comment as well.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thanks, Scott. Here is a pretty specificquestion for Susie. Do you anticipate using HEDIS Relative Resource Use to report onresource use or some other measures?SUSIE DADE: I don’t know the answer to that yet. Like we did with our quality of caremeasures, we have assembled a team of opinion leaders and experts from our communities whoare working to either select or develop measures to recommend to our organization about theresource use measurement. That is still just under way and so I it cannot answer that question,but I do know that they’re looking at basically every available measure that is out there. We tendto have a tendency to have want to stick with nationally developed and vetted measures, butunfortunately, there just aren’t as many in this arena to really draw upon as there are in areas likeheart disease and diabetes and so forth. So, it’s a little bit more developmental for us.ENRIQUE MARTINEZ-VIDAL: Thanks, Susie. That actually came from Pat Jones. Pat, didthat answer your question? Just wanted to make sure, since that was kind of a detailed question.PAT JONES: Yes, it did. Thank you.SUSIE DADE: I guess I would just say stay tuned. Hopefully we will have this resolved byprobably about February of 2009.PAT JONES: Great. I will stay tuned. Thanks.QUESTION / ENRIQUE MARTINEZ-VIDAL: OK. Here is a question for all of you. Inthe context of what is going on in your state, do you think that there will be impact of theNew York attorney general's ruling that happened around physician performancereporting and the patient charter that came out of New York? Does anybody know whatthat is?SUSIE DADE: This is Susie. I know what it is. We’ve reviewed the charter and we support itand are trying to live according to the rules and the guidelines that are set out on the charter. Ithink, it is generally good stuff and it was really designed more to focus on individual, forexample, health plans who are using their data to do measurement reporting. It applies slightlyless to groups like ours that are using all payers system, or, I guess, not all-payer but many payersystem. But I still think the guidelines are good and we’re trying to stick with them as much aspossible.22

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”If you don’t do things to engender trust with the provider community, then the information . . . Ifthe purpose of making information transparent is to try and drive system improvement, and theproviders have no trust in the data, then you’ve really defeated your purpose.VAHÉ KAZANDJIAN: Enrique, this is Vahé. To follow-up on that, I think it is very importantto realize at what starting point every state is in this area of trust with the physicians, let’s say.There are states where the medical association is very strong, there are states where it is not.There are activities of already putting up some of the performance at the individual providerlevel and in other places it’s purely at an organizational level. I think what is important, theCharter, it makes the necessity for that kind of an activity. Clearly, sort of obvious that it shouldbe part of the overall model. When it can be achieved, at what stage, it could be achieved at thesame time as performance measurement at the provider level or at the community level, or itdepends on the state. But I think it is more raising the awareness about the importance of thatactivity than anything else.SCOTT LEITZ: Enrique, This is Scott, I would just briefly add that I would second or third thenotion of trust and how important that is to getting provider by in to the measurement system. Iknow it has taken a number of years and it relates to the earlier question about building thecoalitions or multi-stakeholder kind of collaborative work. That work, in some ways, needs tooccur before we can actually get to the points of being able to do some of the qualitymeasurement stuff in a way the providers trust because I think they have to have that trust toknow that the information that is being done is being done in a reasonable and methodologicallysound and non-punitive kind of way.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thank you. I am going to ask the threepresenters to respond to a question I have that’s going to be out of the blue for you; thatyou will have no idea is coming. We are facing an election shortly, we’re going to have anew President and a new Congress. Is there anything that you have on your wish list forthe federal government to do in order to help you with your activities out there? Howabout Susie, we’ll start with you?SUSIE DADE: I wish we could hold the election tomorrow because I am personally really readyto move on. In terms of what the federal government can do to do for us, two very importantthings. One is to give as Medicare data. We are a chartered value exchange, but the federalgovernment has placed, I would say, a pretty restricted approach to providing Medicare data forthe purposes of performance reporting. What we really need is the data because we want to beable to aggregate it to create an actual all pay your data set in our region. The very first thing isto access the data rather than just the numerator and denominator, or rates. Because obviouslythen you can’t aggregate. The second thing as a charter value exchange, would be funding. Thiswork, as I’ve said, probably several times in my talk, is time-consuming and expensive to do. Itis important to do, but finding somebody to pay for it on a sustained basis over time particularlyas it loses kind of loses its sexiness, is hard to do in a community. Particularly in this economy,23

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”where employers are really facing a lot of challenges. So my second thing would be funding tothe charter value exchange program.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thanks, Susie. What about Vahé?VAHÉ KAZANDJIAN: I have three things actually that will be on my wish list. The first onewould be to help with mental health access for mental health patients within the system. It is oneof the unnoticed areas that attention is not paid enough and it is a really creating a lot ofdifficulty into the system. Not only from caring for patients but also an understanding the trueburden of the disease in the community. So, mental health, access to mental health andclassification of mental health would be very important as one area.The second one would be more technical. Which would be provide guidance and maybeincentives for information technology in hospitals. I think there is a lot of discussion which iswonderful but it remains academic. If hospitals do not have the means to actually collectinformation, report information, have any sense of the quality of that information throughvalidation, all that is going to be requiring some IT that is strong enough to collect informationthat the patient level. Therefore serve for reasons of understanding practice as well as becomingepidemiological in nature.And the third area would be, as I mentioned, increase attention to the whole continuum of caremodel, rather than focusing on acute-care hospitals in payment or in their measurement or intheir incentive systems, but realizing that healthcare is a continuum. Unless we link acute-careto home care to long-term care, to sub-acute or whatever it is, and eventually to the communityhealth centers, we are not going to be able to achieve efficiency and therefore be accountable tothe stakeholders. Which goes back if you put all the three dimensions together, which is whatSusie was talking about. Which is the issue of value. Value cannot be achieved unless those areput together. What can be achieved is just to show that in some areas, you did better or savemoney, but you cannot tell if you improved the health of patients or communities.QUESTION / ENRIQUE MARTINEZ-VIDAL: Thanks, Vahé. Scott, how about you?SCOTT LEITZ: There’s probably a number of them, Enrique, but I will just focus on one.Regardless of who gets elected president, the issue of delivery system reform is going to be acritical issue that will need to be faced and, for example, as we move towards trying to get asystem where everybody has health insurance coverage, however we do that it is going to need tobe sustainable. Right now we have a system where the costs are way too high and quality waytoo low. And that’s largely driven by the incentives that are put in place at the payment level.And so, I would say that the one thing that the federal government could work with states onwould be on the issue of payment reform. And I know our reform that we passed this year werelargely intended to start to reform the delivery system, it did not go fully there, in able to geteverything, and a large piece of that would be working with states on how do we put in place24

State Quality Improvement InstituteCyber Seminar Two TranscriptOctober 14, 20081:00 p.m. – 2:45 p.m. ET“Using Information to Help ProvidersImprove: What is the State’s Role?”payment systems that don’t cause us to over invest in certain areas and cause us to under investin other areas and how can we start to turn that ship around in a unified way. Because I think thething that we struggle with is that we have the tools of the Medicaid program, we have the toolsof the state employee groups, we have hopefully some coalitions that can get built from a payerperspective to get them to drive some of this. But without systems that are uniformly applied,across the board, if Medicare goes a different route than private payers, for example, than selfinsuredsdo, it is going to be hard to send that unified message to the market around paymentreform. So, a willingness of the federal government to work with states and with payercoalitions to really put together streamlined and unified purchasing strategies and paymentstrategies, I think that would be the one thing that I would ask for.SUSIE DADE: I couldn’t agree with that more. I wish had thought to say that.SCOTT LEITZ: I got to go third.ENRIQUE MARTINEZ-VIDAL: Hopefully we are all on the same page with many of theissues. I would like to think again Susie, Vahé and Scott for their presentations, and also to theQuality Institute team members, thank you for your thoughtful questions and participation in thiscyber seminar. Since we would like to make this series of cyber seminars as valuable as possiblein your quality improvement efforts, we would appreciate any suggestions from you for thetopics you would like to see addressed. Please take a couple of minutes, I promise you no morethan five, to complete a short evaluation that is on your screen. It should pop-up. It will help ourefforts to plan the remaining two cyber seminars in the series as well as to think about additionaltechnical assistance offerings. Also, please don’t forget that the Quality Institute has a Web site.That is showing on the slide. That Web site also has most of the materials in electronic formfrom the Kick-off Meeting binder as well as updated information about what each state isworking on, as well as some newly posted resources. Please feel free to contact us and eachother with particular questions that might arise in your state as you work with the process.Thanks again and we look forward your participating in the upcoming seminars. Good bye now.25