Health care reform: people, processes, data, oh my!
The Massachusetts Health Data Consortium's spring workshop on Analytics, Data and Accountability  centered on how data and analytics must change as the U.S. health care system moves from paying for volume to paying for value. Nevertheless, the ultimate message may have been, that as always, it takes people, process, and data to effect dramatic change.
Clearly, the devil will be in the details of the integration of these three elements. The conference was rich with case studies of what works and warnings about where the challenges lie.
Employers seek health care value vs. volume
Dr. Allan Gorroll, MD gave a great overview of the issues from the perspective of practicing primary care physicians to set the context for the day. He pointed out that employers, as the entities that foot the bill, are driving the change.
Clinical data trumps transactional data
Dr. Gorroll noted that we will require clinical data to measure performance and outcomes, rather than the claims-based transactional data we are gathering today. Moreover, it must be reliable, available at the point of care in real time, and risk-adjusted by patients' health status.
Need transparent, meaningful, actionable metrics
The metrics must be based on evidence and clinically meaningful to doctors and patients-and agreed to by all stakeholders. Metrics need to measure the percentage improvement, adhere to rules of statistical significance, be transparent and actionable, and measure the full spectrum of care.
Admirable goal, much work remains
In addition to holding providers accountable for health outcomes, Dr. Gorroll said we will need to match risk and reward and reform liability. My conclusions: the goals are admirable; success depends on strong data; obtaining the necessary data will be challenging-and require substantive change by all stakeholders.
It takes time to enact improvements
Dana Gelb Safran, up next, spoke about Blue Cross Blue Shield of MA's Alternative Quality Contract. This 5-year contract holds providers accountable for health status across the continuum regardless of where patients actually receive their care.
Must pay for managing quality as well as cost
Providers receive a global payment for care that BCBS ties to performance and performance improvement. Rather than growing by the health care inflation rate, increases depending on the much slower growth of the Consumer Price Index. Providers benefit financially when they reduce the cost of the care they deliver, follow certain evidence-based processes, and achieve specific outcomes.
Providers amenable to pay for performance
Building on Dr. Gorroll's talk, she noted that providers are anxious to receive pay for performance. In fact, she said that the physicians that piloted her organization's programs asked that outcomes measures get triple weight.
Few reliable health care measures exist
One of the difficulties is that few totally reliable measures exist. BCBS, therefore, uses an approach developed by Dr. Beckman that looks at performance variation for very narrow episodes of care where guidelines do exist.
Change begins with awareness
What BCBS has found is that providers were previously unaware of the degree of variation of their practice with their peers. Receiving this information starts a conversation that ultimately leads to change.
Safran reports that the approach is working. Providers with AQC contracts are outperforming the organization's other providers.
Commitment and access to data essential
While initial improvements came from actions such as choosing less expensive sites of care, they are now beginning to see changes in the actual practice of medicine. Safran attributes success to leadership, use of reliable measures known to create value, and monthly access to health status data.
Data must be useful and compelling
Dr. David Goodman, MD MS from the Dartmouth Institute shared data to show how his organization reaches conclusions about the source of variation across regions. In so doing, he described its use of small area data sets to minimize regional variations and data sets from multiple sources to mitigate weaknesses in each one.
In a compelling talk, using a number of case studies, he demonstrated that:
- Utilization varies by region even after controlling for health status.
- Differences in utilization account for most of the differences in per capital spending
- Utilization depends on provider supply
Nevertheless, like Gorroll and Safran before him, he noted change will depend on the availability of better data. Key steps in overcoming resistance to findings include adjusting data for population differences and precisely attributing measures to particular providers.
All Payer Claims Data will provide the big picture
Seena Perumal Carrington from the Division of Health Care Finance and Policy provided an update on the Massachusetts All Claims Payer Database. This and other regional databases will begin to address some of the data problems the previous speakers referenced. In particular, these databases will address the whole population and the whole patient. Achieving this goal will depend on collecting data from a number of sources and scrubbing it for accuracy and completeness.
Right care in right place: provide care at the community level
John Donlan of Steward Network Services described the initiatives his organization is taking to deliver the right care in the right place. In most cases, this means serving more people in the community through health coaching, home care, and community hospitals.
Achieving results depends on credibility depends on data
Nevertheless, he told us success will depend on convincing stakeholders that they will receive high quality care in a community setting-and raising purchasers' awareness of the premium they pay when their employees seek care outside the community. Key parts of his strategy have been engaging physician leaders, attracting primary care providers, putting in place infrastructure to support care measurement and accountability, entering into risk-based contracts such as the AQC to get providers' attention, and posting relative quality scores to show patients that local care is better.
Achieving results depends on closing the loop
At the same time, his organization is playing catch up on initiatives that support profitability under a fee for service structure. Chief among these is reducing leakage by identifying sources of the problem and making it easier for providers to make referrals within the system.
Collaboration is key
Francois deBrantes of Health Care Incentives Improvement Institute summarized lessons learned from the Prometheus Pilots. His message: there are a lot of moving parts to coordinate as organizations shift from health care volume to value.
Here are some of his main points:
- Payment reform requires massive change
- You need to have a strategic plan and stick to it.
- Step one is CEO engagement since business models must change first
- You can't change what you can't measure
- You need clean and complete claims and eligibility data to get a whole patient view
- Clinicians need actionable data in real time
- A comprehensive medical record is a must
- Feedback and comparative reporting assures practice improvement
- Profitability depends on quickly shifting entire organization from high volume to high margin
Perhaps his largest point was that providers and payers need to work together to effect change-as each needs data and services from the other. Although it initially makes sense for them to upgrade their systems in parallel, he noted that eventually the two systems will need to merge.
The last presentations of the day brought in the pharmaceutical perspective. Unfortunately, I was unable to stay for them.
Ultimately, we're all in this together
Together, the presentations did a great job of stating the goals for health care reform, the critical success factors, and the challenges from all perspectives. It also gave listeners a sense of the importance of greater collaboration among providers and between payers and providers. It's this type of integrated, evidence-based thinking that will accelerate the progress of health care reform.
Barbara Bix is a health care marketing consultant  in the Boston area. She specializes in working at the nexus of health care and technology.