System Management Populations: An Analysis of the Quality Metrics for Managing Chronic Diseases

By 2001 it was brutally apparent that the U.S. Health Care system was in dire need of a reform in regards to quality and patient safety. Following two separate reports issued by The Institute of Medicine (IOM), To Err is Human (1999) and Crossing the Quality Chasm: A New Health Care System for the 21st Century(2001) the U.S. Congress requested the IOM review quality processes across multiple government funded health care programs. And understandably, “these reports described America’s healthcare system as a tangled, highly fragmented web that often wastes resources by duplicating efforts, leaving unaccountable gaps in coverage, and failing to build on the strengths of all health professionals” (Brown J., p. I – 15, 2013). Thus, the Committee on the Quality of Health Care in America released 6 aims to address key dimensions that require improvement in our health care system. These aims propose that our system needs to strive to be more Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable (STEEEP). All of which were created to help overhaul our current health care system and, more importantly, narrow the quality chasm.

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

A powerful force for change can be created by embracing transparency. According to the Department of Health and Human Services, “transparency is a broad-scale initiative enabling consumers to compare quality and the price of health care services so they can make their own informative choices among doctors and hospitals. This initiative is laying the foundation for pooling and analyzing information about procedures, hospitals and physicians services. In order to create value driven health care, there are four steps to turn raw data into

Quality Improvement Organizations (QIOs), work in partnership with the Centers for Medicare and Medicaid Services (CMS) to advocate for safe, efficient, and quality healthcare for Americans. Working at the community level, QIOs collaborate with providers and interact with beneficiaries to improve patient outcomes. Additionally, QIOs support new models of care and promote healthcare goals endorsed by the National Quality Strategy, and CMS Quality Strategy. CMS has strategically placed QIOs in several regions nationwide, and Mississippi is served by Information and Quality Healthcare (IQH). IQH founded in 1971 as a non-profit organization has strived to improve the quality of care received in Mississippi. IQH participates in a tobacco cessation helpline, behavioral health services, and diabetes education for Medicare beneficiaries.

Health care spending grew 3.7 percent in 2012 and the traditional way medicine was practiced had to change (Edlin, Goldman & Leive, 2014). The Affordable Care Act and Population Health was designed based on the concept of “The Triple Aim” to foster change in patient care by providing better care for individuals, better health for populations and decrease the cost of health through improved care (Perez, 2014). As a result, population management has moved to the front by linking services, reducing hospital admission, risk stratification, pursing preventive medicine, ensuring medication review and lowering health care cost. Several organizations have follow in the pursuit of population management by forming Accountable Care Organizations

The Accountable Care Organization (ACO) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients (McCarty, B., 2016). For example, Medicare Shared Savings Program was created by The Center for Medicare & Medicaid Services to monitor and establish that all ACO’s are meeting the quality performance benchmarks and reduce Medicare spending by certain percentages (H., 2017). The growth of ACO’s from 2011 to 2016 is astonishing, in 2011 there was 64 ACO’s and by 2016 they have risen to 838 in the U.S. (H., 2017).

Providing enhanced access to a better quality health care system is reliant upon the identification and modification of various barriers, which must be addressed. Complex health care systems and politics generate barriers to the delivery of high-quality access to care through knowledge deficits. Consumers are tasked with understanding what services are needed as well as their abilities comprehend their diagnoses are challenged. They must also over come barriers to communication to converse effectively with caregivers. Most importantly, they must understand their role in the process as patients and citizens when accessing health care services. (Ricketts, 2013) Comprehensive provisions built into the ACA help to energize endeavors aimed towards developing ways to ensured enhancements to the quality and access to health care provided in North Carolina. Accountable care organizations (ACO) were

Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (Eds.). (2008). The healthcare quality

There are three core principles to any ACOs. First, provider-led organizations with primary maintenance and a strong base are liable communally and total per capita costs for quality with full continuum for the population of care for patients. Second, excellent improvements will have linked to also have complete costs reduced, and third, progressively and reliable sophisticated measurement performance to improve, support, and provide the savings of confidence are achieved with improvements of care, , McClellan M, McKethan AN, Lewis JL, Roski J, Fisher ES (2010).

The American health care system has been victim to an escalation in the prices of health care services juxtaposed with inefficiency in delivery of care services. There has even been cases where State spending on the actual health care increased dramatically in the United States and one of the key components of curbing this problem which has been prevalent over the mass media and has been a major discussion among physicians is the advent of Accountable Care Organizations. Accountable Care Organizations (ACOs) is structured with the goal of trying to improve health care delivery and aid in the reduction of the overall cost of services (Weissert & Weissert, 2012). If there is insufficient coordination of high quality care delivery in the health care industry, this will have a negative impact on patient safety and diminish affordable care for patients. Hence, the development of ACOs is envisioned to be the savior of medical practices and can improve the overall fabric of the American society (Bresnick, 2013). ACOs serves as one of the answers for curbing the problem of high costs, low quality care and possible segmented delivery and as much as it serve as the major determinant for improvement in patient satisfaction, there are minor

Quality measures are strategies that gauge, evaluate or compute health care processes, results, discernments, patient insight, and administrative structure. In addition, quality measures are frameworks that are connected with the capacity to deliver first-class health care and/or that are able to identify with one or more quality objectives for medicinal services. These objectives include: compelling, protected, effective, quiet focused, impartial, and opportune consideration. Quality measures can be used to measure quality improvement, public reporting, and pay-for-reporting programs specific for health care providers (CMS.gov, 2016). There are an assortment of quality measures in which health care organizations can use to determine the status of the care they are delivering. Many are appropriate, but few are chosen for this research paper. Among them are: National Health Care Surveys, Hospital IQR Programs, Scorecards, and Political, Power, and Perception/Data for Decision-making tools.

Department of Health & Human Services. (2011). National Strategy for Quality Improvement in Healthcare. Washington, DC: U.S. Government Printing Office.

Examining planning for and effectively measuring the health care quality indicators make healthcare quality more transparent and provide information for quality improvement programs and initiatives in the healthcare system.

The Institute of Medicine (IOM) Committee to Design a Strategy for Quality Review and Assurance in Medicare defines quality of care to be “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Ransom, Joshi, Nash & Ransom, 2008). Making sure to have current knowledge on healthcare services is crucial to the quality of care provided, and health care professionals are expected to continuously stay updated on the changing trends. The IOM later released six aims for improvement, or also known as the six dimensions of quality, which are safe, effective, efficient, timely, patient-centered, and equitable.

The first quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is the national data warehouse. According to Brennan, Cafarella, Kocot, McKethan, Morrison, Nguyen, Shepard & Williams II (2009), “this type of quality analysis needs to be valuable to both payers and consumers. For payers, quality analysis helps them potentially understand payment mechanisms, quality providers, regional differences and medical management techniques. For consumers, there is a better understanding of practice and potentially cost differences of providers. So, the primary purpose for creating a national data warehouse will be to develop key quality measures that all parties can agree on.” The second quality initiative that could increase patient satisfaction and potentially reduce healthcare cost is creating one common contract between all health plans and providers (Brennan et al., 2009). According to Brennan et al., (2009), “to accomplish this, a national group comprised of government personnel and knowledgeable provider contractors from the health plans will set national guidelines. Regional contracting groups will be entirely made up of current health plan contractors and will do the local contracting under