Research Shows Wide Variation in Quality of Care Provided by Health Systems Across the Country
May 15, 2008
Research published today in The Joint Commission Journal on Quality and Patient Safety shows significant variation in the quality of care provided by health systems across the country.
Researchers Steve Hines, PhD, Principal at The Lewin Group and Maulik Joshi, DrPH, President and CEO of the Network for Regional Healthcare Improvement, analyzed data from over 70 health systems, representing more than 1,500 hospitals in the United States. Variation on quality scores in 19 publicly reported quality measures for health systems was substantial - ranging from 70% to 94% overall. Additionally, for-profit health systems and systems that are more decentralized were appreciably lower in the quality of care scores for pneumonia, heart failure, heart attack and surgical care.
In the findings, not-for-profit health systems had, on average, quality scores 7% higher than for-profit health systems and more centralized health systems had 5% higher overall quality scores than decentralized health systems.
"Although we are learning more every day about the quality of care individual hospitals provide, relatively little is known about how multiple-hospital health systems compare in quality," note Dr. Hines and Dr. Joshi. "This is the first study, that we know of, that examines how quality differs in the most commonly measured clinical areas for health systems, which is the most dominant hospital structure in our country," Dr. Hines and Dr. Joshi added.
"System leaders can use this information to compare their performance to that of other systems and to assess how well their processes and infrastructure are working to assure high quality patient care. While more research is needed to understand the best ways for systems to drive quality improvement, results suggest some systems have been far better at this than others."
The article lists the top 5 and bottom 5 performing health systems nationally. A full list, ranking the 73 largest health systems, is available here.
Also, the researchers have updated the data since the submission of the article with more recent clinical quality data and the addition of the HCAHPS data to develop a combined ranking of health systems. A list with the combined rankings is available here.
National Experts and Regional Coalitions Call for Healthcare Payment Reforms
October 4, 2007
Although healthcare reform is at the top of the national agenda, most of the current debate focuses on coverage for the uninsured when an equally serious problem is the high cost and unreliable quality of health care. A group of 100 healthcare leaders from across the nation convened by the Network for Regional Healthcare Improvement (NRHI) agreed that one major cause of cost and quality problems is that current healthcare payment methods penalize hospitals, physicians, and other healthcare providers who deliver the highest quality, most efficient care. They called for changes in the payment system.
NRHI convened experts at an invitation-only Summit on Creating Payment Systems to Accelerate Value-Driven Health Care to propose options for restructuring payment practices. The conferees proposed new payment methods and recommended that they be tested through regional demonstrations. They rejected marginal pay-for-performance bonuses that many insurers use to encourage practice improvements as insufficient to incentivize major care improvements in an inherently flawed payment system.
A summary of their conclusions and the new payment models they proposed have just been published in Roots, a special publication of the Jewish Healthcare Foundation (JHF) and the Pittsburgh Regional Health Initiative (PRHI), a founding member of NRHI. JHF, the Commonwealth Fund, and the California HealthCare Foundation funded the Summit. The full report on the Summit findings is available on NRHI's web site, http://www.nrhi.org.
"Our current payment system is one of the chief culprits behind the high cost of health care and it's also responsible for many of the quality problems," said NRHI President and Chief Executive Officer Maulik Joshi, DrPH. "As we move toward the presidential primaries, these findings should weigh heavily in any discussion of healthcare reform."
Under the current reimbursement system, physicians are paid fees for each service they provide and hospitals typically receive lump sums for every patient admitted or readmitted. As a result, the incentives of health care are weighted toward the number of services delivered, not the quality. Mishaps that result in additional need for treatment, such as infections contracted because of hospital stays, can even mean additional payments. Because of that, improvements in the quality of care often financially penalize doctors and hospitals by diminishing the number of services patients need or reducing the need for hospital care. Similarly, physicians often are not compensated adequately for the time-intensive care and counseling involved in preventive medicine or optimum treatment of patients with chronic illnesses, such as diabetes and high blood pressure.
"We need to improve the quality of care to control costs," said Karen Wolk Feinstein, PhD., who serves as Chairman of NRHI and is President and Chief Executive Officer of JHF and PRHI. "Without payment reform, quality improvements are doomed to be anecdotal in nature and glacial in pace."
Summit conferees proposed payment reforms for several broad categories of health care, including preventive care; care for patients with chronic illnesses such as diabetes, asthma, and high blood pressure; major, acute conditions such as heart attacks and strokes that come on suddenly and require hospitalization; and end-of-life care. The proposed payment methods were designed to shift the incentives of care toward the best, evidence-based practices of medicine and improved outcomes for patients. For example, instead of paying physicians for each office visit from a diabetic patient, reimbursements might be restructured to provide periodic (e.g. monthly) Comprehensive Care Payments to cover all of the care management, preventive care and minor, acute services associated with the patient's chronic illness. The payments would be based on specific diseases and on patient-specific factors, such as age, that are likely to affect the level of services required.
In addition to the conferees' conclusions and recommendations, the edition of Roots in which they are published provides firsthand accounts from physicians about ways the current system of incentives frustrates their efforts to provide the best care or prevents them from improving substandard care. For example, a Pittsburgh physician who implemented a new model for treating diabetic patients, which has both improved outcomes and efficiency at a government-funded VA Hospital clinic, lamented he would be unable to use the same model in his university hospital-based practice because of private payment restrictions.
Roots also describes some innovative payment approaches, including a warranty on open-heart surgery at Pennsylvania's Geisinger Health System and a change in reimbursement that helped Seattle-based Virginia Mason Health System implement a new, cost-saving protocol for treating patients with back pain.
The Geisinger and Virginia Mason experiments are examples of creative reform initiatives percolating around the country, including some under Medicare and Medicaid. Building on those, PRHI and other NRHI members plan regional demonstrations of payment reforms.
"Summit participants agreed that reforming payment systems will be challenging, but changes are essential in order to achieve efficient, effective, and sustainable improvements in the quality and costs of health care," said Harold Miller, the Summit Coordinator, who also authored the paper that framed the discussions at the Summit. "Summit participants agreed that the next step should be a variety of regional demonstration projects to test the real consequences of innovations," Miller added.
The Network for Regional Healthcare Improvement Appoints CEO
July 23, 2007
The Network for Regional Healthcare Improvement (NRHI) has tapped a senior advisor from the Agency for Healthcare Research and Quality (AHRQ) as its first President and Chief Executive Officer.
Maulik S. Joshi, Dr.P.H., will join NRHI effective July 24. Dr. Joshi, who will be based in Washington, D.C., has worked extensively in the areas of healthcare policy, patient safety and healthcare quality.
"Dr. Joshi’s experience and expertise are a perfect fit with NRHI’s needs and aspirations," said Karen Wolk Feinstein, PhD, President and Chief Executive Officer of the Pittsburgh Regional Health Initiative and Co-Chairman of NRHI. "He has a passion for healthcare-systems improvement; he shares the vision of the organizations that founded NRHI and he has the leadership skills to carry it to the next level."
"Local action will drive national healthcare transformation," said Dr. Joshi. "It is an honor to work with communities and leaders that are dedicated and bold in their shared missions of dramatically improving health care."
NRHI was founded in 2004 by five of the nation’s leading regional healthcare collaboratives: Pacific Business Group on Health; Pittsburgh Regional Health Initiative; Massachusetts Health Quality Partners; the Institute for Clinical Systems Improvement/Minnesota Community Measurement; and the Wisconsin Collaborative for Healthcare Quality. Formed originally as a loosely-knit working group focused on health-systems improvement, NRHI adopted a formal governance structure last year. NRHI’s members aim to accelerate improvement in the quality and value of healthcare delivery in the United States by building and strengthening regional, multi-stakeholder coalitions and influencing national policy. The Robert Wood Johnson Foundation, the Jewish Healthcare Foundation and the California HealthCare Foundation are providing financial support to NRHI.
Among NRHI’s first major initiatives was an invitation-only summit on reimbursement reform. Held in Pittsburgh in March, the summit drew more than 100 national and regional thought leaders from government, academia, and the healthcare and health insurance sectors. Together the attendees developed a slate of recommendations for new healthcare payment methods that would better align incentives with the best practices of health care. They agreed to meet again to continue their work. NRHI members committed themselves to organizing demonstrations of new payment methods at the regional level, with the hope of advancing viable models for national reimbursement reform. Dr. Joshi will assume responsibility for planning the summit follow-up.
As a senior advisor at AHRQ, Dr. Joshi has been involved in strategic planning, leadership initiatives and translating research into practice projects. Prior to joining AHRQ, he served as President and Chief Executive Officer of the Delmarva Foundation and as Vice President of the Institute for Healthcare Improvement. Dr. Joshi holds a Doctor of Public Health and a Masters in Health Services Administration from the University of Michigan. He earned his Bachelor of Science in Mathematics from Lafayette College. Dr. Joshi is Co-Editor of The Healthcare Quality Book: Vision, Strategy and Tools, a graduate-level textbook. Dr Joshi is also a member of several national Boards and Advisory Committees.