Getting Better Value in Health Care

Public Employers Health Purchasing Committee

5-23 DRAFT

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Problem Statement

• Health care costs are unsustainable• Quality of care varies across the State• Access to care is decreasing for many

Oregonians

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The Oregon Vision:

• Improve the health of all Oregonians• Improve a patient’s experience of care• Control per capita costs over time

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Strategies

• Improving quality will reduce the rate of cost increases in costs

• Reducing the rate of cost increases will improve affordability and access

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What is “Quality Care?”

• The Institutes of Medicine defines Quality as:– Safe– Effective– Efficient– Patient Centered– Timely– Equitable

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Another Definition: Quality Health Care is…

• The Right Care • At the Right Time• At the Right Place

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3 things to remember about quality

• More care doesn’t mean better care.• New types of care aren’t necessarily better care.• Quality care doesn’t have to cost more.

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Where do we stand on quality?

• Although there are areas where Oregon is doing better than most other states, there are many areas where we could improve.– Oregon ranks 3rd in avoidable hospital use and costs – But is 46th in prevention and treatment

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Where do we stand on quality?

• Quality varies across the country.– In 2005, the percent of adult patients who received

antibiotics at the right time to prevent surgical infections varied from 90% in the best state to 50% in the worst state.

– 90,000 Americans die each year with conditions like high blood pressure, diabetes or heart disease because they don’t get the type of care that research and science shows works best.

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Where do we stand on quality?

• Quality varies across the state.– Some Oregon examples.

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How do we improve quality?

• Maximize the use of care that is known to work:– Effective care means services of proven value that have no

serious risks – all patients with a specific condition should receive the service

• For example: Diabetics should have annual blood screenings of blood sugar and lipid levels, but between 30-90% of Medicare patients with diabetes don’t get these tests.

Not using enough of the right care can be as costly as using too much of the wrong care

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How do we improve quality?

• Reduce the misuse of preference-sensitive care– Preference-sensitive care involves significant tradeoffs

affecting a patient’s quality and/or length of life, and should reflect an informed patient’s personal values and preferences.

• Surgical options for the treatment of early-stage breast cancer can include mastectomy or lumpectomy. Both have similar survival rates, but very different health consequences.

• In some areas, providers strongly influence treatment choices.

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How do we improve quality?

• Reduce the overuse of demand-sensitive care– Demand-sensitive care includes doctor visits,

diagnostic tests, hospitalizations, and admissions to intensive care.

• This type of care is used more where there is more capacity (for example, more people are admitted to hospitals where there are more hospital beds), whether or not science shows it is necessary.

• This higher spending doesn’t improve health outcomes.

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How can we make sure we get good quality care?

• As public purchasers, we can:– Promote evidenced-based care (research)– Use strong contracting standards with providers and

insurance companies (implementation)

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What are evidence-based, best practice guidelines?

• It’s what the best doctors do for their patients.• Guidelines help doctors know what current

medical science has found to be the most effective care.

These guidelines help make sure you get the right care and the right amount of care, no matter where you live.

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How are the best practice guidelines developed?

• Brought together by the State• Respected doctors from around Oregon• Open and transparent process

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How can I use best practice guidelines?

• Ask your doctor about your options:– Find out what the risks and side effects are– What are the chances for success with the

different options– Find out what it will cost

Knowing all of these things will help you and your doctor make the best decisions for your health

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How can I use best practice guidelines?

• Ask if there are evidence-based or best practice guidelines that show if one option is better or more effective than the others.– Ask yourself: Are you paying for care that works, or

for care that doesn’t work as well?

There are tools available that can help you know what questions to ask, find out how much things cost,

and learn about the quality and safety of your care.

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How can employers use the guidelines?

• Encourage wide-spread and consistent use of guidelines:– In contracts– In benefit designs– Through improved payment methods (starting paying for

quality, not just for procedures)• The more that employers use guidelines, the easier it

will be to change and improve local health systemsEvery dollar spent on unnecessary or inefficient care

raises the price for effective care for everyone

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Paying for quality – What happens now

• Our “fee-for-service” system encourages volume, not quality.

• Pays for more care, not the best or right care• Doesn’t reward efficiency

When we spend money on unnecessary or inefficient care, it increase premium

costs for everyone.

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Paying for quality – What we need to do

• Use payments to reward providers to improve quality and efficiency.

• Use “bottomline” pricing – instead of paying for everything piecemeal, pay one price– (Use the price tag metaphor)

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Paying for quality – What we need to do

• Look at variations in cost:– Why does the same procedure cost $15,000 at

Hospital A and $30,000 at Hospital B?– Why does the same procedure at the same hospital

cost different patients more?

Are these differences justified? Are they fair?