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Questions and answers

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Questions for the future

RON DAVIS: Now that we have heard from each of the speakers, we will offer you some “questions for the future”. Those questions will set the stage for the question-and-answer session.

Here are my questions:

  • Is the HEDIS advice-to-quit measure, determined by patient self-report, a valid performance indicator?

  • Would it make more sense to evaluate screening and intervention (for example, advice to quit) through the traditional HEDIS method of assessing computerised medical records and medical charts? (Would this be affordable?)

  • Should our goal be the development and use of moreoutcome-oriented measures, such as quitting and prevalence?

  • Will purchasers and the public discriminate among health plans, at least in part, on the basis of this measure?

  • Will health plans build quality improvement initiatives around a tobacco measure?

  • Can we include a tobacco measure in other “report cards”, such as those in development for medical group practices and individual physicians (American Medical Accreditation Program (AMAP))?

I would like to show you two charts that were put together by Rick Ward, a former colleague of mine at the Henry Ford Health System. Figure 1 depicts what he describes as the current reality of the complex accountabilities in the American healthcare system. There are multiple and complex accountabilities. HEDIS only addresses the accountability from the health plan to the employer. All of the other accountabilities shown in the figure can be described by other performance indicators or “report cards”, some of which are currently under development. For example, AMAP, a program sponsored by the American Medical Association to accredit individual physicians, can address the accountability of physicians to hospitals, medical group practices, and health plans.

Figure 1

The complex accountabilities in the American healthcare system. IPA = independent practice association. Source: Dr Rick Ward, Oceania Inc., Redwood City, California.

Figure 2 shows the different performance measurement efforts that are in operation or in development at the level of the doctor, the medical group practice, the hospital, the healthcare system, and the health plan. As shown along the vertical axis, some of these measurement initiatives address the structure of the institution, others are process or outcome oriented, and some span more than one of these areas of focus. The Foundation for Accountability (FACCT) measures, for example, are more outcome oriented (as I noted earlier) and are meant to apply to all of the institutions shown horizontally. Tobacco can be addressed in each one of these measurement efforts, and I am sure people in this audience would agree that it should be addressed within each. But the question is how?

Figure 2

Performance measurement efforts in the United States, their areas of focus (vertical axis), and the institutions they cover (horizontal axis). AMA AMAP = American Medical Association’s American Medical Accreditation Program; FACCT = Foundation for Accountability; AMGA = American Medical Group Association; SCORE = Spinal Surgery Consortium for Outcomes REsearch; JCAHO = Joint Commission on Accreditation of Healthcare Organizations; IMS = JCAHO’S Indicator measurement system; MHA = Michigan Health and Hospital Association; GDAHC = Greater Detroit Area Health Council; CRISP = Consortium for Research on Indicators of System Performance; NCQA = National Committee for Quality Assurance. Source: Dr Rick Ward, Oceania Inc., Redwood City, California.

TIM MCAFEE: I would like all of you to go home believing that the HEDIS question, the FACCT question, etc., are very important. It will drive our behaviour. People involved in managed care plans and people working in tobacco must become involved in that process. We need to have something measurable around what we actually offer on a population level. We need leadership in managed care to “bite the bullet” to look at ways to remove barriers. I am somewhat sceptical about our internal capacity to accomplish that in the current marketplace without a HEDIS-type indicator that measures something like participation in organised cessation support or documentation.

Another big issue is going to be automation. In the next five years, most health plans are going to move to automated records. Another challenge is network improvement measurements. It is harder to measure performance in the IPA [independent practice association] models than it is in staff models. Figuring out how to do that right is an important challenge.

This type of work in our organisations requires leadership. We all can help provide leadership. It is not just a question of going back and taking the pulse of your organisation. It is moving it forward to the next stage. It is not your fault if the chief executive officer thinks it is stupid, but it is our responsibility to work with them and the other parts of the organisation. We have to provide leadership ourselves to guide how things unfold within our organisations. We do not want to just follow where the current leadership is taking us; we need to provide leadership.

JODI JESSEN: I will just speak to some basic implementation issues. As an implementation coordinator for “smoking as a vital sign”, I would pose the question: Is the stamp that we are planning to use going to be helpful in the future? It looks as though the answer is “yes”. Even if we do not change anything, the “smoking as a vital sign” stamp is going to work. There is some problem with short-term implementation. Once we implement smoking as a vital sign, we do not have a big enough capacity to handle all the people in the smoking cessation programme. So for those of you who are associated with training smoking cessation instructors and giving classes, we need to increase the capacity for those courses.

The other shortcoming is in the number and variety of options we have available for quitting smoking. Not everybody wants to take these courses. We are looking at the “Free & Clear” programme and telephone-based counselling, but are there good self-help programmes? What about techniques through the internet or on computer games? Many different tactics and options exist for our members, and we are looking at many of them.

General discussion

SKIP YOUNG (AMC Cancer Research Center): Tim, you mentioned experimenting with cash incentives in your plan. I should like to hear more about that.

TIM MCAFEE: We are experimenting with using incentives in practice teams at the level of several key performance indicators. Higher levels, such as an entire regional medical team, might be offered incentives as well. Whether the plans received a bonus at the end of the year, from the health plan side, would depend on whether they met certain targets. In some areas, these targets might include something relating to advice to quit or tobacco status identification. So far, in the area of advice to quit, there has been wide variation. We have three different large regions. The region that made the most improvement, the most rapidly, was our southern region, which did have incentives at the team level. Teams agreed to performance targets over the next year, for which they will receive a modest financial token of recognition.

JODI JESSEN: Kaiser Permanente National recently chose “advice to quit” as a national performance indicator. So, it will be a measure upon which all Kaiser Permanentes across the nation are measured. Administrators at top levels in each region will have some of their pay and incentive bonus based on outcomes. There will be a lot of creativity in deciding how to increase compliance in each region.

NANCY RIGOTTI: Jodi, in regard to your “30-second” message, what do the medical assistants actually say in that 30 seconds?

JODI JESSEN: We are experimenting with medical assistants giving the advice at this point. The advice to quit is: “As your healthcare provider, and healthcare team member, we strongly urge you to quit”. Or: “Quitting smoking is the single most important thing you can do to protect your health or improve your health.” If the person is farther along, in terms of the stages of change, and ready to quit, he/she may get counselling assistance.

BOB MERBERG (Health Plan of the Redwoods): Since the National Committee on Quality Assurance survey and the HEDIS measure reflect advice to quit smoking for adults 18 and over, it seems that a big piece of the picture is missing—that of adolescents. If we wanted to measure the effectiveness of our interventions, some of these other methods of data collection, such as chart review, may be more appropriate. Then we could collect data on prevalence among adolescent smokers and whether they are receiving advice to quit smoking. The HEDIS measure reflects the number of smokers who have been advised once or more during a year-long period to quit smoking. The Agency for Health Care Policy and Research guideline recommends that smokers be advised during every office visit. In that sense, it seems like the HEDIS measure is unambitious. In the case of childhood immunisation, we are not instructed to have one immunisation by the age of two. I realise that this is an exaggeration, but I should like clarification on this seemingly apparent conflict.

RON DAVIS: It would be difficult to use every office visit; then you would have a complex denominator of people who saw a healthcare provider once or twice, or several times during the past year. HEDIS measures cannot evaluate all aspects of performance. They are meant to be proxy measures, which reflect overall performance; that is the theory. For example, for diabetic care, the measure is screening for diabetic retinopathy. That is one small part of diabetic care, but the assumption is that if you are doing well in screening for diabetic retinopathy, then your overall diabetes care is good. And so, similarly for the tobacco measure, if you perform well on the “advice to quit” measure for adults, it is to be hoped that you are doing well in talking to adolescents about prevention or quitting. Obviously, one could quarrel with whether that assumption is correct. That is the rationale, however, and there are serious implementation problems with having broader complex measures for all of the items we would like to measure.

TIM MCAFEE: We would really kick and scream at Group Health if an adolescent measure was required. This may contradict the focus on young people, but we feel as a health plan that we need to be held firmly accountable for interventions for which there is evidence of effectiveness. There is no evidence yet regarding effectiveness in adolescents in our type of setting. The evidence thus far is for earlier intervention through media and school interventions. There is no evidence for adolescent cessation interventions. Our job as a health plan is to work to help build a database of evidence regarding effective programmes for adolescents. We should not be required to measure in an area where there is not clear evidence regarding what is effective.

BOB HARMON (United Healthcare): What effect is Zyban [bupropion] having on your physicians’ enthusiasm, and advice to quit? Is there any impact yet on success rates for quitting?

TIM MCAFEE: We are in the process of integrating Zyban into our formula in the same manner as nicotine replacement therapy (NRT). If it is integrated into our programme, it is covered. At this point, we are determining how to integrate it, in terms of when it would be suggested—NRT versus Zyban. Patients’ choice will probably play a role. We are also just about to begin a large, randomised control trial that compares 150 mg with 300 mg in the “Free & Clear” programme to the Zyban advantage plan at different levels of behavioural intervention.

JODI JESSEN: Enthusiasm is not how I would characterise the response to Zyban and Wellbutrin. At Kaiser Permanente, our drug benefit states that Zyban would be allowed because it has been approved by the [United States] Food and Drug Administration; it is one of the annual co-pay-based drug benefits for smoking cessation. Currently each facility deals with it a little differently. Regional plans are investigating how to integrate some sort of provider chart review into the process. Zyban is a more serious medication and has serious side effects. At the health education level, we developed a patient information handout so that members could make informed decisions about using this medication.