Coming: Population health management evaluations
Coming: Population health management evaluations
This month, James B. Couch, MD, JD, FACPE, vice president of Health Care Strategy for the American Reinsurance Company in Princeton, NJ, an excess insurance organization, talks about quality-based population health management. In 1987, he created and developed the concept of health care value purchasing, which is now embraced by large companies in the private sector. From 1992 to 1994, he was only physician senior examiner of companies competing for the Malcolm Baldrige National Quality Award. He has taught health care policy, quality management, and clinical decision analysis at several universities, including Johns Hopkins and Yale. His books include The Health Care Professional’s Guide to Disease Management: Patient-Centered Care for the 21st Century and The Physician’s Guide to Disease Management: Patient-Centered Care for the 21st Century (Aspen, Gaithersburg, MD).
Q. Will you explain the basic principles of quality-based population health management?
A. It’s a stakeholder-driven approach to evaluating and improving the health status of a defined population, to the greatest extent possible, per dollar invested. Stakeholders are those who receive, purchase, evaluate, or manage health care delivery.
Q. How long has the idea been around?
A. I don’t know if it has always been named quality-based population health management, but certainly it’s been around since the 1960s when the whole community medicine revolution took place. The new features of quality-based population health management are the technologies becoming available to support evaluation and tell us whether this approach is actually working.
Q. Could you give us an example of a health care problem that a quality-based population health management model might address?
A. You can look at a number of potentially-catastrophic health events in a covered population that you would like to predict, prevent, or otherwise more cost effectively manage. Examples might be Parkinson’s disease, diabetes, stroke, and a whole range of cancers.
I think our whole perspective is really changing toward a much more preventive, early screening and detection approach. Clearly, if you notice what they are looking for at National Committee on Quality Assurance (NCQA) and in the Health Employer Data Information Set (HEDIS), most of it really has to do with early detection and screening at a population level.
Agencies ask, for example: "What’s the percentage of kids getting immunizations?" or "What’s the percentage of women above a certain age being screened for breast cancer?" or "How many men above a certain age are screened for prostate cancer?" or "What percentage of the population above a certain age is screened for colorectal cancer or diabetics?" The list goes on and on, and most measures, so far at least, have been process measures.
Going from concepts to results
At the present time, we just look at these things conceptually. The NCQA and the Joint Commission haven’t yet come back to the health systems responsible for a defined population. They haven’t said, "OK, so you did all these screenings. How many did you actually detect? What additional cases did you detect beyond what you would have by chance? What has been the actual impact on preventing stroke or heart attack? Or on detecting cancer early and saving a lot of mortality, morbidity, and cost?"
Q. Are you saying that we now have the tools to show us whether quality-based population health management works, but we still don’t know whether it works to reduce cancer or other catastrophic diseases?
A. I was involved in the early proceedings of NCQA, back in the late 1980s before it really got off the ground. We had lots of debates about whether we were going to put outcome measures into evaluations — and here we are 10 years later, still debating. And the 1999 HEDIS guidelines are going to come out and they’re still not going to really have hard core outcome measures.
The reason: Outcomes assessment measurement is still considered fundamentally controversial. It’s still very tentative whether or not you can link compliance with certain best practices or other processes with improved outcomes.
So even now, most of these accreditation groups like NCQA and the Joint Commission on Accreditation of Healthcare Organizations are still reluctant to evaluate health care organizations on their ability to implement effective screening, prevention, and early detection, as opposed to simply proving that they have implemented some kind of screening, early detection, and preventive program. That’s where we are at this time.
Health care quality measurement, as we know it in America right now, is still reluctant to evaluate the final product, the real reason for all these early detection, screening, and preventive programs. We still stop short of evaluating whether or not they actually have had their intended effect of preventing X number of cancers, heart attacks, or strokes.
Q. Why are we stopping short? Will you venture an opinion or a guess?
A. We are stopping short because there are justified reasons for it. It’s that nobody likes to be evaluated. And even fewer people like to be evaluated if they don’t really believe that the basis for their evaluation is medically accurate.
Are accreditation agencies falling short?
I think many of these organizations like NCQA and the Joint Commission have stopped short — fallen short. They intentionally stopped short. They don’t want to have a bigger backlash than they have already experienced from being in the evaluation business.
Efforts in the mid-1980s in Pennsylvania and to a lesser extent in New York, California, Florida, and Iowa, engendered major backlashes. The state legislatures set up agencies to evaluate hospital outcomes. A lot of people thought the agencies didn’t have many checks and balances. A lot of people also thought they were heavily weighted by purchasers and labor unions with little representation by the providers.
The evaluations might have been necessary though ill-conceived. State governments imposed the measures and the whole experience set outcomes evaluation back at least five to 10 years. So I think that that’s probably the reason we’re stopping short of hard core outcomes measurement. The ultimate goal is to link superior practices with improved outcomes. We’re finally getting the severity-adjusted measures in place to evaluate that.
There are other organizations, though, that do not necessarily share that reflection, although they’re perhaps in somewhat earlier stages of evolution. One would be the Foundation for Accountability. Its latest quality measure guide just came out, and I don’t think there’s any question that they are definitely trying to drop the issue of the ultimate impact of all these screening, early detection, prevention, and other health management programs on individual population health status.
My own personal bias gravitates toward any organization that is trying to evaluate the impact of these programs, though. I think we are ultimately headed to some kind of accommodation among the various organizations to get to some comprehensive evaluation of what these programs do at a population level.
Q. Would it make sense for a community hospital or a health care system to adopt a population-based health management approach for itself and use it for internal and community accountability?
A. Oh, yes. As long as you have a covered population — a population to which you are supposed to be clinically and financially accountable — a population health management approach has relevance.
It certainly makes sense in this day and age when we’re all trying to make the best use of our health dollars. We can’t do a shotgun approach to quality. We have to expend time and resources on those areas that are going to give the best returns.
The key is patience’
There is no question that the American health care system is heading toward a quality-based population health management type of model. The key is patience. For it to become dominant, it’s going to have to demonstrate its value. And we’re going to have to have appropriate technologies for that to happen.
In my 20 years of promoting this type of model, I’ve seen more hope for it in the last two years than in the previous 18.
I think we’re probably within a few years of beginning to measure and demonstrate that understanding a population, and allocating people, time, and resources literally leads to the desired outcomes. That’s really going to be the acid test of whether this becomes the model of the future.
To contact James Couch, MD, send e-mail to [email protected]. His books are available through http://www.amazon.com. For information about the Foundation for Accountability’s measurement guides, contact 520 S.W. Sixth Ave., Suite 700, Portland, OR 97204. Telephone: (503) 223-2228. Web: http://www.facct.org.
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