April 30, 2012

Health Care By The Numbers

Quality Counts

Massachusetts Health Quality Partners keeps performance 
measurements that help determine quality of care. For example, here's how three Central Massachusetts providers stacked up in how much of their target populations of diabetics received tests 
to monitor kidney disease:

Reliant Medical Group at Worcester Medical Center 92.2%
UMass Memorial Medical Center-Based Practices 86.1%
Acton Medical Associates 85.6%

When Joan Vines, director of clinical services at Acton Medical Associates P.C., began working there in 1998, part of her job was to determine whether women who were supposed to get mammograms were actually getting them. At the time, that was the only quality metric the practice looked at. Now, it compiles more than 50 different reports on different quality measures, from well-child visits to blood sugar tests for diabetics.

When Massachusetts Health Quality Partners released its eighth annual report on quality measures in the state's physicians' practices earlier this month, the practices took notice. "MHQP kind of sets the bar," Vines said.

But while doctors' offices clearly see value in the MHQP reports, they also sometimes question how valid particular findings are. And, in some cases, they say the whole process of making sure the right data gets counted can have unintended consequences.

MHQP compiles claims data from the state's private insurers to develop its reports. Executive Director Barbra Rabson said the organization has become influential because using information from a number of different sources means it's more statistically valid, and because the group's process in developing the reports is recognized as rigorous. Among the findings of this year's report are that Massachusetts doctors are improving the quality of care they deliver, that the state is well above the national average on most measures and that there's a great deal of variation from one practice to another.

Rabson said making the data public offers the chance for patients to look at the quality of care their doctor's practice is providing and, if it's not great, ask questions about why not. But she said there's also another reason to publish it.

"When you publicly release data, the providers who are being measured are more motivated by it," she said.

Frances Anthes, president and CEO of Family Health Center of Worcester, agreed that simply having the measurements out there can be a good thing for doctors' performance.

"Anything you measure is something you're going to pay attention to," she said. "So all of this is good in terms of moving us to a place where we're going to pay attention to these things."

But the logistics of making sure the numbers are accurate can be complicated. Family Health Center is a clinic that caters largely to underserved populations. Most of its patients are on some form of government-supported insurance, Anthes said, which makes the private-insurer-based MHQP numbers "not the perfect measurement for us."

Anthes said another issue is that the clinic has only had an electronic medical records system for a year, and staff members are still getting accustomed to clicking the right boxes so that the care being delivered is recorded correctly, which could mean some care isn't getting measured correctly.

Vines said she's seen data slip through the cracks between practices and insurance companies too. In some cases, she said, her office uses different standards than MHQP's, determining how often to perform a test based on a different professional organization's recommendations, for example.

Communication And Culture

Other gaps are harder to explain. Vines said she got letters from an insurance company two years in a row saying a particular patient was overdue for a gynecological exam. The problem? "The patient was a male," she said.

Beyond the details of data-gathering there are more substantive issues. For Family Health Center, one big issue goes back to the patients it serves. Chief Medical Officer Gregory Culley said patients at the clinic are largely poor, and many don't speak English as their first language. At times, he said, there are communication problems or cultural resistance against having certain types of exams.

Culley said it might make sense to look at individual offices' progress in reaching quality standards rather than just how they stack up against other practices in absolute terms.

Rabson thinks it's important to hold all practices to the same standards, but she said it's clear that some have a more difficult job in trying to reach them. She said patients at different locations vary widely in their level of medical knowledge and ability to advocate for themselves.

"We have practices where people come in demanding their mammograms," she said, "And practices where there's no patient knowledge of guidelines."

Even without the challenges of a low-income patient base, making data-based standards of care work is complicated. Vines said one issue is that multiple institutions—practices, insurance companies and hospitals—are all collecting information and communicating with patients, but their systems don't always work together. That means a patient may get letters from three different sources telling her she's due for a mammogram. Or an insurer may believe a patient is overdue for an exam because he switched from a different insurance company six months ago but the records didn't transfer with him. Sometimes insurers give the doctors' offices a chance to review and correct data, Vines said, but that means even more work for someone in the practice—someone who may already be overwhelmed with other duties around data collection.

"I worry sometimes that the manpower we're using to meet these measures could be better spent doing the patient care," she said.

Still, Vines said she sees a lot of value in the quality measures too. She said physicians are more likely than they once were to notice that a patient visiting them for a sore throat is diabetic and squeeze in a blood sugar test while she's in the office.

"It's always kind of in the back of your mind now," she said.


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