MEDICARE QUALITY OF CARE BASELINE
Questions and Answers
(Draft 10/02/00)
Q. So what do these measures mean? Don’t they show that health care in the U.S. isn’t as good as everyone says it is?
A. No. High quality health care in the United States is still the norm. What these indicators mean is that in some areas, some best clinical practices are not being used across the country, either because providers are not aware of them or because systems of care either do not promote them or prevent them from being implemented.
You have to remember that this is the first time that anyone has comprehensively measured the quality of health care services in a fee-for-service setting. The data included in the report are the starting point for us to continue to improve already good quality health care.
Q. Why is HCFA doing this now (why hasn't this information been available before)?
A. HCFA implemented the Health Care Quality Improvement Program (HCQIP) in 1992. Prior to 1992, PROs focused on individual case review, where they looked at potential problems with care one case at a time, rather than looking at patterns of care among a number of cases. With the inception of the HCQIP, each PRO, through whom HCFA implements its quality improvement initiatives, focused primarily on quality concerns relevant to its individual state. Since efforts were state based, there really was no reason for HCFA to analyze the data on a national level; rather, each PRO analyzed its own state's data compared to clinically accepted standards of care. This national effort represents the first time that all PROs are working on the same clinical topics, and therefore provided the first real opportunity for HCFA to present the data in this manner.
Q. How can you run a health care program for 35 years and only now have this information?
A. HCFA implemented the Health Care Quality Improvement Program (HCQIP) in 1992. Prior to 1992, PROs focused on individual case review, where they looked at potential problems with care one case at a time, rather than looking at patterns of care among a number of cases. With the inception of the HCQIP, each PRO, through whom HCFA implements its quality improvement initiatives, focused primarily on quality concerns relevant to its individual state. Since efforts were state based, there really was no reason for HCFA to analyze the data on a national level; rather, each PRO analyzed its own state's data compared to clinically accepted standards of care. This national effort represents the first time that all PROs are working on the same clinical topics, and therefore provided the first real opportunity for HCFA to present the data in this manner.
Q. How much are these added services going to cost Medicare? Can we pay for
it?
A. These are not "added" services, but generally covered Medicare services. All these services should be provided to eligible patients because they are basic Medicare benefits. Poor quality of care ultimately costs more than good care, particularly when quality of life is considered.
The Challenge we face is to work together with all participants and stakeholders in the health care system to insure that every patients gets precisely the care they need.
Q. Whose fault is it that some beneficiaries are not getting the highest quality of care?
A. The question is not how to place blame, but how to achieve change through the points of leverage and control. Most doctors, nurses, hospitals and health plans want to deliver high quality health care services and patients expect that from them. Unfortunately, there are some concerns with the quality of care in the system. Everyone, from payer to health care practitioner to facility to patient, needs to recognize that the system needs improvement and then take responsibility for doing his or her part to improve it.
Q. What will HCFA do with providers who don't provide these services or even refuse to provide these services?
A. These measures have such a high degree of acceptance in the medical community that, once the results are disseminated, we expect that providers will voluntarily take steps to improve their performance. In the unlikely cases of providers who, after having been given an opportunity to improve, categorically fail to deliver proper care, HCFA does have the authority to impose sanctions or make referrals to state medical societies or licensing and accrediting bodies.
Q. Will HCFA reveal the identities of those providers who have been giving less than optimum care?
A. No. HCFA does not have provider-specific information for these data.
Q. Is it a medical error if a beneficiary didn't receive one of the specific treatments that you looked at, such as a beta-blocker?
A. The Institute of Medicine defines an error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." These indicators are not designed to be used as the basis for complaints about the care that a particular patient receives at a certain point in time, but to help us, and those who provide health care services to Medicare beneficiaries, continue to improve the health care system.
However, a beneficiary should also use this as an opportunity to strengthen his or her relationship with his or her doctors and asking questions, such as: Does my hospital or doctor's office have a Quality Improvement Plan? How does my hospital work to ensure that it delivers high quality care? Is my local hospital one of the many hospitals that, by working in partnership with our State Peer-Review Organization (PRO), has already made strides in improving care?
Q. How do you explain the regional variations in quality of care provided to Medicare beneficiaries?
A. We are still investigating why there are these variations from region to region. While the quality of care is good across the United States, some areas have more room for improvement than others. Even the regions with the highest measured performance have substantial opportunities to improve.
Q. What is HCFA doing to improve care in those States that ranked lowest?
A. In each state, HCFA has contracted with a Medicare peer review organization (PRO), whose job it is to work with the health care providers, practitioners, and plans in that state to promote improvement in the quality of the health care provided to Medicare beneficiaries. It is through the work of the PRO, in collaboration with partners in its state, that HCFA intends to improve care in all states in the nation.
Q. Where can I get information about what activities are taking place in my State?
A. Anyone interested in obtaining more information on the quality improvement activities taking place in his or her state should contact the PRO for that state. The name and phone number of every PRO is available on HCFA's website (www.hcfa.gov/quality) or by contacting a local HCFA regional office.
Q. When will we be able to find out if these improvement efforts have had beneficial results?
A. HCFA intends to conduct regular on-going assessments of the change in performance level on these quality indicators. The first large-scale re-measurement on these data for each of the 24 indicators will take place in 2002.
Q. How can I determine the ranking of specific hospitals and/or doctors?
A. HCFA does not have individual hospital or doctor rankings. Even if it did have this information, it is illegal for HCFA or the PROs to reveal that information. Instead of concentrating on the specific ranking of their doctors or hospitals, Medicare beneficiaries would be better served to talk to their providers about quality improvement and inquire about ways that they contribute to overall improvement in their own health status.
Q. Why is my state so much better (or worse) than other states?
A. We are still investigating why there are these variations from region to region and state to state. While the quality of care is good across the United States, some areas have more room for improvement than others. Even the regions with the highest measured performance have substantial opportunities to improve.
Q. Based on the rankings, our state should be declared a federal emergency zone and receive more funding. What is the government doing about this?
A. Concerns about performance should not be related to funding issues. Rather, those concerns should focus on the processes of care that should be taking place. Most of the indicators that these data represent are Medicare covered services for which providers are already eligible to receive reimbursement.
A little under 1 percent of all Medicare spending is earmarked to support the work of the Peer-Review Organizations, the state-based organizations who are responsible for working to improve the quality of care for Medicare. These organizations have adopted quality improvement principles and, working in partnership with doctors, hospitals, nurses, pharmacists and others, can help to improve care. While they can’t force the health care providers to change how they deliver care, they do help inform changes and recommend ways to help make sure that Medicare beneficiaries get the best, highest quality health care possible.
Q. Who has access to the data, when will they have access, and how can they get access?
A. The data on which these results are based are confidential. We are working on a process by which researchers could have access to these data in a format that makes them unable to identify specific individuals, but still allows them to conduct their analyses.
Q. What other types of analyses of the data will HCFA do, for example, by race, age, and gender?
A. This is the first in a series of assessments of the quality of care for Medicare, and we will measure our progress regularly. Many factors such as race, age, gender, and medical conditions could explain some of these results and, more importantly, help guide improvement efforts. We will continue to research the possible influence that these factors have.
Q. There are only 6 conditions here; does HCFA plan to cover additional clinical areas in the future?
A. HCFA intends to release re-measurement data for the 6th SOW indicators that are comparable to the data released for the baseline rates. Based on these results, HCFA will determine on which clinical areas it will concentrate, that is, whether to introduce new clinical areas, to continue to work on the original six areas, or some combination of the two. It is also anticipated that as individual PROs reach defined upper thresholds for the indicators on which they are working, they will move on to work on new indicators for the same clinical topic or to new clinical topics. PROs who have not yet reached those upper thresholds will continue to work on the original indicators.
Q. How does managed care compare? Hasn't similar information been available in managed care through such programs as HEDIS and CAHPS and NCQA studies?
A. Overall, we believe that care ought to be virtually identical for the hospital-based measures, whether in a fee-for-service or managed care setting. Preventive services, and indicators like eye exams, which are more patient-dependent, may be more difficult to compare. Again, though, we always need to work toward ways to improve the system. It is possible that both fee-for-service and managed care settings may provide lessons for each other.
Many managed care organizations do collect data under the aegis of HEDIS, CAHPS and others that is similar to that which was collected and analyzed by HCFA for this national effort. HCFA also has initiated such efforts for managed care; the Quality Improvement System in Managed Care (QISMC) requires managed care plans with Medicare contracts to implement quality improvement efforts in certain clinical areas, and as a result, requires them to collect data on these clinical topics.