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Article Excerpt
Facilitator
* Eric Schneider, M.D., M.Sc., Associate Professor of Medicine and Associate Professor in the Department of Health Policy and Management, Harvard Medical School and Harvard School of Public Health.
Panel Members
* Elliott Fisher, M.D., M.P.H., Professor of Medicine and of Community and Family Medicine, Dartmouth Medical School.
* Helen Burstin, M.D., M.P.H., Senior Vice President for Performance Measures, National Quality Forum.
* David Hopkins, Ph.D., Director of Quality Measurement and Improvement, Pacific Business Group on Health.
Eric Schneider: I'm Eric Schneider from the Harvard School of Public Health in Boston. Like many of you, I began my trip to Orlando in the back of a taxicab. When I explained to the cab driver that I was going to a meeting of health services researchers to discuss quality and cost of medical care, she became very engaged and discussed all of the problems with American health care, including problems with access to primary care, and the lack of information for patients about the quality of doctors and hospitals and the prices they charge.
I took from our conversation that the public is beginning to get the message from the Institute of Medicine's (IOM) Crossing the Quality Chasm report. The public is also beginning to perceive some of the solutions regarding performance information and information on the cost of care.
Our session on national strategies for measurement and reporting is a nice conclusion to a meeting that has featured performance measurement and reporting as a fundamental arch in the bridge that will take us across the quality chasm. Almost every presentation during the Annual Research Meeting has referenced performance measurement and reporting as tools that will be employed in this enterprise of quality improvement.
Measuring and reporting on performance has been around since at least 1986, when HCFA started the hospital mortality reports. In the 20 years since then, there's been slow but steady progress in developing measures for hospital care, long-term care, health plans, and now, increasingly, physician groups. While many health plans and private entities are using measures to pay for care, and pay for performance, there are still skeptics about these efforts.
Some anxiety about performance measurement reporting has resurfaced among providers regarding Medicare's Physician Quality Reporting Initiative (PQRI), which expands the number of quality measures and starts paying providers based on performance. The question that intrigued me and prompted this session was whether this performance measurement reporting "arch" we're ready to step out onto is sufficiently solid. Will it bear our weight as we try to move across the bridge and across the quality chasm?
To address this question, we have three distinguished panelists. Elliott Fisher is Professor of Medicine and Community and Family Medicine at Dartmouth. He was also on the IOM Committee on Redesigning Health Insurance Performance Measures, Payment, and Performance Improvement Programs. Helen Burstin is Senior Vice President for Performance Measures at the National Quality Forum (NOF). And David Hopkins is Director of Quality Measurement for the Pacific Business Group on Health. He is also an affiliate at the Center for Primary Care and Outcomes Research and the Center for Health Policy at Stanford University.
Elliott Fisher: Let me start with a story. Two weeks ago my mother was hospitalized with chest pain. She was taken to a hospital without a catheterization lab and experienced a 6-hour delay between the onset of chest pain and receiving her coronary angiogram, which did show significant occlusions. Physicians inserted stents and eventually averted a major anterior myocardial infarction. Her ejection fraction is back to normal, but the initial technical quality of care she received was pathetic.
There was no real harm done, other than to my own sense of having failed to improve the health care system yet again.
She experienced four hospital transitions, moving back and forth between an acute care hospital and a rehab hospital. On three out of four transitions, her providers asked me to help with the medication reconciliation. The intern called me to ask, "What medications is your mother on?" And then called back to say, "I'm sorry, we don't have that medication in our hospital. Could you go to the other hospital and pick some up for us?" It was a remarkable portrait of a badly broken health care system, especially for patients suffering from chronic illness.
And so it is a good time for me, personally, to look back at the work of the IOM Committee, and for all of us together to look forward, and ask, "Are we getting where we need to go?" Our IOM Committee on Redesigning Health Insurance Performance Measures, Benefits, Payment Programs, and Public Reporting renamed itself, for simplicity, the Committee on Redesigning Health Insurance. The Committee convened at a time when we believed the gap between the current care and the vision of the IOM's Crossing the Quality Chasm report remained wide.
I would like to ask you as we go through these recommendations, which are now 2 years old, how much progress have we made in the last 2 years? We concluded that there is a huge gap between the current system's high costs and poor quality and the safe, timely, effective, efficient, equitable, and patient-centered care that the Quality Chasm report envisioned. We believed, as it seems almost everybody in this room believes, that performance measurement is actually the key to further progress. Performance improvement seems to depend upon good, reliable, robust performance measurement whether it's pay for performance, consumer engagement, or quality improvement initiatives that would help providers improve what they're doing.
We concluded at the time that recent public and private sector initiatives on performance measurement were very important but unlikely to achieve the national performance measurement system we need. We articulated concerns about a narrow--and the word I found when I reread the report--timid focus of measurement, largely around technical quality. In addition, duplicative and inconsistent measurement systems had proven burdensome to providers, who were expected to abstract data from medical records. We expressed concern about the independence and integrity of data and whether funding levels provided to achieve a robust measurement system were adequate to support the data's reliability and independence.
First and foremost, we...
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