The American Journal of Managed Care March 2011
Connecting Statewide Health Information Technology Strategy to Payment Reform
Objective: To develop an effective way to link statewide healthcare information technology strategy to payment reform.
Study Design: Investigation of what Wisconsin did to develop and publicly share provider performance data and then use those data to drive payment reform.
Methods: We examine 2 statewide organizations (Wisconsin Collaborative for Healthcare Quality and Wisconsin Health Information Organization) and 1 integrated health system (ThedaCare) to evaluate how they pool data and use those data to measure provider performance.
Results: When aggregated data regarding health outcomes are shared, a clearer picture emerges of provider performance baselines and improvements with which payment models can be developed.
Conclusions: Aggregating commercial and Medicare claims data will help states to better measure provider performance and to compare providers on quality and cost. The ability to compare performance using broad databases is necessary if the current payment system in the United States is to be reformed.
(Am J Manag Care. 2011;17(3):e80-e88)
Aggregating commercial and Medicare claims data will help states to better measure provider performance and to compare providers on quality and cost.
- The ability to compare performance using broad databases is necessary if the current payment system in the United States is to be reformed.
- Creation of multistakeholder statewide organizations to collect and analyze provider performance data is essential for effective payment reform.
- Up-to-date Medicare claims data should be available to the statewide initiatives to provide a complete view of provider performance.
WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY
In 2002, one of us (JST), then chief executive officer (CEO) of ThedaCare, initiated a series of phone calls with similar healthcare providers from around Wisconsin to discuss the crisis in healthcare quality and the growing drumbeat for reform. Along with Don Logan, MD (chief medical officer of Dean Health System), Jeff Thompson, MD (CEO of Gundersen Lutheran), Fred Wesbrook, MD (CEO of Marshfield Clinic), and George Kerwin (CEO of Bellin Health), Dr Toussaint invited purchasers (from 8 major employers throughout the state) to come together and explore the possibility of using quality reporting to improve healthcare. Together, the providers and employers decided on key performance metrics that needed to be publicly reported, and the WCHQ was created.
The business voice was critical in the early development of the WCHQ. When there was controversy regarding what to measure and why, the business leaders were clear. For example, one of the early controversies was whether to measure access to care. The business leaders reported that access to care was a big problem in many markets and was leading to lower worker productivity. Therefore, an access measure was created (time to the next third available appointment) and continues to be reported to this day. Business leaders also emphasized that “perfect data” should not be the focus. They pushed for reporting of the quality data on hand, realizing the data would improve with time. Perfect, they said, can be the enemy of the good. These business and provider leaders supported the WCHQ by lending their performance improvement staff to the committee that developed the performance measures and by attending the monthly WCHQ meetings starting in 2003.
Eight years later, the WCHQ has greatly expanded its membership. It also has built a statewide initiative with a broad group of stakeholders that has a common objective, language, and approach to improving the healthcare system.
The WCHQ has built an infrastructure and expertise focusing on the following 4 main aims: to develop performance measures to assess quality, to guide the collection and analysis of data to support measure creation, to publicly report measurement results, and to share best practices with providers. The WCHQ has translated evidence-based medicine into the reality of local practices to improve patient care and the health of the community. However, getting the WCHQ off the ground was not easy; it required political will and hard work from all the players involved.
During the early stages of development when the WCHQ was represented by just 8 providers and 8 businesses, other provider organizations claimed that these founding members were simply focused on marketing their own organizations. In fact, the goal of the collaborative was to prove the hypothesis that provider performance could be compared before inviting all in the state to participate. Members spent a year developing and testing measures before deciding to invite all healthcare providers to participate. The WCHQ now comprises 27 organizations, representing most of Wisconsin’s physicians (Table 1).
Although the WCHQ started with providers, it was the initial belief that a multistakeholder initiative was required. The WCHQ has partnered with other organizations, such as business coalitions, consumer advocates, governmental agencies, foundations, and healthcare associations, to gain a more balanced and complete understanding of what the current state of healthcare is and how it can be improved. The healthcare purchaser and other stakeholder partners benefit from having a voice at the table and a unique understanding of the provider perspective.
The value proposition of the WCHQ revolves around 2 interrelated core competencies. These are performance data, including development and public reporting of measures via its Web site (http://www.wchq.org/ [Figure 1]) and facilitation of collaborative sharing of best practices to improve care delivery and outcomes.
The WCHQ members, such as Dean Health System, Prevea Health, and ThedaCare, have shared presentations. These have included topics specific to patient care (eg, best practices for the treatment of patients with diabetes mellitus) and general topics relevant to healthcare systems (eg, creation of a culture of quality).
The WCHQ was formed before most health systems had implemented electronic medical records (EMRs). It was not the EMR that led to the formation of the WCHQ. In contrast, involvement with the collaborative may have spurred some organizations to move a bit quicker to invest in EMRs because they made data reporting easier. That being said, the opportunities for health information technology and health information exchange to affect our work are significant (Figure 2). While the architecture for health information exchange in the state is still being developed, it will likely rely on a “federated” model that obviates the need for a large static repository of data. Under this scenario, data reside within the provider organization but are accessed as necessary by the collaborative for purposes of quality measurement.
Since the WCHQ released its first public report in the fall of 2003, its portfolio has increased to include more than 60 measures, with 25 measures of physician performance reported at the group level. Some measures covered include glycated hemoglobin blood glucose testing for patients with diabetes mellitus, low-density lipoprotein cholesterol levels in cardiac patients, chronic kidney disease screenings, adult tobacco use, and cervical cancer screenings. A complete list can be found on the Web site at http://www.wchq.org.
The measurement method used by the WCHQ marries administrative data with more robust clinical results, allowing a physician group or health system to collect and report quality-of-care results on all patients under their care. Provider organizations submit patient-level data extracts to a secure data repository maintained by the WCHQ, allowing for efficient and accurate generation of the calculated measures. This repository is also an approved registry for submission of data to the CMS under the Physician Quality Reporting Initiative program.
AT THE FOREFRONT OF REGIONAL AND NATIONAL EFFORTS
The enactment of the American Reinvestment and Recovery Act and the Patient Protection and Affordable Care Act firmly established performance measurement, reporting, and improvement as an organizational imperative for every healthcare provider, regardless of delivery setting. In anticipation of this, the WCHQ is focusing its efforts on the following key strategic priorities: (1) Leveraging its expertise and track record in performance measurement to serve as a state and national model on a broad range of issues related to the adoption and use of measures in support of public reporting, quality improvement, payment reform, and consumer engagement. (2) Developing a “value metric” depicting the intersection of clinical quality and episode-based resource utilization at the physician group level. (3) Continuing expansion of the measures portfolio to specialty care, including chronic kidney disease, cardiac surgery, depression, and hip or knee readmissions, as well as patient experience of care and the physician group Consumer Assessment of Healthcare Providers and Systems provided by the CMS. (4) Introducing and developing a new Web site (http://www.wisconsinhealthreports.org) designed to report comparative information for consumers.
New Ways of Working Together
In 2005, the WCHQ leadership determined that, while the organization’s clinical information was robust, it lacked the data necessary to measure the efficiency of the care being delivered. At the time, the WCHQ leaders were busy expanding the clinical measures of the organization, so a separate group was formed to tackle the issue of efficiency. It was clear that, without a statewide administrative claims database, the WCHQ was not going to be able to measure resource utilization and ultimately cost of care. This realization by the WCHQ leaders led to a series of meetings called by the WCHQ chairman (JST), who was well known to most of the state insurance executives because his organization, ThedaCare, owned a health plan (TouchPoint) that was sold to one of the national carriers in 2004. This health plan had received the National Commission for Quality Assurance award for best Healthcare Effectiveness Data and Information Set scores in the country 2 years in a row. This experience, as well as the national reputation of the health plan, gave him the credibility to convene the insurers and explore a vision for the future that could only occur with collective action and cooperation of a broad group of insurers. He started by calling the CEOs of the major commercial insurers in Wisconsin to determine their interest in working together with the WCHQ to build a common claims database for Wisconsin. The initial idea was met with interest and with skepticism. Insurers are fiercely protective of the data they collect, viewing their information as the root of a company’s competitive advantage. A series of meetings between insurers and a few members of the collaborative was necessary before everyone agreed on a goal of creating a common claims database that all insurance companies could access.