The Institute of Medicine in its recent publication Best Care at Lower Cost encourages healthcare providers and healthcare organizations to adopt the attitude of setting goals for continually improving the quality of care of patients and to do so at lower cost. It suggests that providers and organizations write out goals to achieve and then use proven methods, such as Plan-Do-Check-Act, to achieve the goals. You may think that it is impossible to achieve better outcomes without higher cost, but my own experience has shown that it can be done with hard work.
What are the ways healthcare providers learn what it will take to improve the outcomes for their patients? Most providers rely on the standard approaches such as reading journal articles, going to conferences and talking to colleagues, often times earning continuing education credit. One way not often considered is to use data to drive process improvement and quality improvement. In fact, many do not understand how data can be used to improve the quality of patient outcomes. It is my goal to help you see how this can be done in this month’s newsletter.
For some of my clients I help them to use data that they have collected. Generally, the data is used in two ways: (1) see the level of outcomes achieved on the goals that the client has set and (2) to find ways to improve the outcomes in the future—improve the quality of outcomes. For instance, one of my present clients is involved in getting its clients to be better at paying their bills, to be more consistent in managing their financial resources, which in turn will generally improve the quality of life for the clients. Effectively managing one’s financial resources helps clients avoid crisis situations in their lives, as Dave Ramsey so effectively preaches. I take the payment data provided to me as well as assessments of the clients and determine what percentage of the clients are managing their resources. Then, I investigate the assessment data along with the payment data to find ways that my client can help its clients be more effective in achieving financial stability. The providers then use the suggested processes in their client encounters to improve the financial stability of the clients. My client and I are seeing improvements as more clients are avoiding financial crises.
As a healthcare provider you can do the same. You can examine the provider performance data from your payers, such as Aetna, and from your Electronic Health Records, if you have one, to find data to improve the quality of patient outcomes. Not all providers have EHR’s but all should be able to access performance data from its payers through web portals. The American Medical Association in its white paper “A Physician Guide to Reviewing and Using Claims Data to Improve Your Profile, Practice and Payment” describes in detail how to do so. I will share what I think are some of the more important points of the white paper.
First, payers use the claims data for each physician to measure the quality of the services and the cost of the services of the physician. These are then benchmarked against peers in the same region and against the goals of the payer. Payers are beginning to share physician quality data online to the public and will be expanding this reporting in the future. Also, payers will use the data to reward or penalize physicians as value based purchasing becomes more important; the data will drive the size of bonuses for physician and physician groups based upon quality data. These are two good reasons that providers should be knowledgeable of payers’ ratings.
Second, physicians and staff should review these documents regularly to see if there are any inaccuracies and to find ways to drive improvements. It is not necessary for a physician to examine the data initially; rather, staff members and administrators can review the data and then involve physicians and other clinicians in reviewing areas of success and in areas that need improvement.
Third, what can you find in the payers’ claim data reports? Generally, there are two sections: (1) provider quality score overall as benchmarked against regional peers in the same areas of practice and against the payers’ goals and (2) the provider cost score benchmarked the same way. After looking at the overall quality score, the provider or staff can examine more detailed information in the report. One could find, for instance, a report on the care of patients with chronic diseases, such as diabetes. In the report the physician or clinician would be compared to peers in monitoring the stability of the patients’ glucose through A1c tests. This would also be compared to the payer’s goals. Physicians and clinicians who do not measure favorably against peers are flagged in some manner. The claims data report also highlight where the clinician is exceeding his peers or exceeding the payer’s goals for patient outcomes.
A physician and her staff can use the flagged procedures, tests, prescriptions, etc. to identify areas for improvement. The physician and staff can then work together using standard process improvement techniques such as PDCA or Lean Six Sigma to reach the goals they have set for themselves based upon the data claims reports. Using this approach the outcomes for patients should improve and the cost of care per patient should decrease while income for the practice rises.
Once goals are achieved the provider should be careful to continue to monitor its processes of patient care so that the identified best processes do not deteriorate and patient outcomes fall to previous levels. I believe that each day providers should have in mind how they can deliver better care based upon the data that they have examined and based upon the improved processes that they have designed.
As mentioned earlier, payer claims data reports are not the only source of data for identifying processes that need improvement. EHR’s are another good source. Good EHR’s have registries that are much like the patient specific data found in claims reports. Providers can use these to gain insights into the quality of service that they are providing to their patients. Using a data evaluator can help providers gain even more insights.
In conclusion, the analysis of data to inform payers and providers of the quality of the work of the providers is becoming more important and more prevalent. This information is being used to inform the public in online reporting of the quality of care of healthcare providers and by payers to reward physicians and staff. I believe that it is very important that providers continually monitor this data so that they can continually improve the care that they provide and to sustain their reputations. It is better to be prepared for and act on value based outcomes now rather than trying to recover from negative outcomes later.