The reform of Oregon’s health care system has three main goals: To deliver higher-quality care, To have better outcomes and, to save money.
Governor John Kitzhaber calls it: “the triple aim.”
But a year from now, how will the state know if it’s succeeding?
The answer? By tracking a host of measures, and watching to see if they improve.
There are literally hundreds of ways to track the health of a population — you could measure their average blood pressure; rates of mental illness or their average weight. Lori Coyner of the Oregon Health Authority, says the agency has boiled the list down to 17 issues. Here are a some of them: the rate at which patients are re-admitted to hospital; the rate of chronic health issues like diabetes; the number of unnecessary tests ordered by health care providers. And here’s another one you might not expect: whether providers combine mental health, physical health and dental health together.
Lori Coyner explained, “So that patients don’t have to go to three different buildings or three different sites to get care. But to pull it all together so that a patient for example, that has depression, can meet with a counselor right in the doctor’s office.”
Deciding which measures to use has been a long and complicated process, says Sarah Bartelmann, a metrics coordinator with the Oregon Health Authority. To understand that, lets look at another measure on the list — whether doctors ask their patients if they’re abusing drugs or alcohol.
Bartelmann said, “So there are a couple of ways a practice could do this. They could start with a pre-screen, that would be just one question that a doctor would ask. It could be part of your vital stats., when they’re taking your blood pressure, weighing you in. They could also ask, do you use alcohol, do you use drugs, and that would be yes or now. And if the patient indicated that they did, to either one of those, that would then trigger a longer screening. That’s what we’re looking for.”
What the state is actually measuring is whether patients are referred to a service, when they admit to having a problem.
Just to be clear, they don’t have to go to the service, but they have to be referred. It’s an unusual measure that Oregon is creating on its own — so there’s no national standard.
So, to set a baseline, Oregon Health and Science University looked into how often doctors currently ask patients about drug or alcohol abuse — not just whether they smoke or drink, but whether they’re abusing substances.
The answer? Virtually never.
Bartelmann expained, “I think a lot of the hesitancy to add questions like this is because the provider would then, if they say ‘yes,’ the provider would then have to add an intervention. They then know this person is need and additional care is warranted.”
So the question is, where should the baseline be set?
Since doctors aren’t asking the question, the status quo is zero, so the state set the baseline at zero.
Now the state has to decide where to set the goal.
OHSU looked at a group of local doctors who started asking about substance abuse and found that after a couple of years, 44 percent had managed it. So, Oregon’s Metrics and Scoring Committee felt a goal of 44 percent was achievable.
Bartelmann said, “The committee wrestled with setting a benchmark that seemed so high, 44 percent compared to approximately zero percent right now. And whether that was truly achievable by CCOs (Coordinated Care Organizations) and if we were setting the bar too high.”
Not everyone is happy with the new measurement.
Rich Hangartner is a computer scientist in Corvallis. He’s starting a company that specializes in electronic health records and has participated in a citizens oversight board on health care issues.
He thinks the measure doesn’t go far enough to help people battling drug or alcohol addiction.
Hangartner said, “The big problem is finding a treatment program that can actually take them that works for them. So it’s got to be not only that we identify people with problems. That if the whole point is improving health, which is what the claim is about CCOs, we’ve got to show some follow through.”
It’s easy to see how setting up new measurements can quickly become controversial. For instance, let’s look look at another health care measure — hospital re-admissions. Under the current system, some argue that hospitals can benefit from a patient’s return visits.
The patient comes in, gets treated and pays the bill.
If that patient then returns a couple of weeks later, the hospital gets paid again. The U.S. Centers for Medicare and Medicaid Services wants to put a stop to re-admissions to cut costs. So it’s asked Oregon to track them.
It also wants to reduce so called “all-cause” re-admissions. Lori Coyner of the Oregon Health Authority, says that means a patient has to be treated for all their ailments in hospital — not just the one thing they’re admitted for.
Coyner said, “If it’s an all-cause readmission, you can come back for any reason. So you might go into the hospital with pneumonia, leave the hospital and then come back in for a different reason. And that would be an all-cause readmission.”
That’s if it’s within 30 days of the original case.
But Coyner says that’s where some see a problem.
She said, “The reason that some people do not like the all-cause measure, is because it does include what are called ‘scheduled readmissions.’ So for example if people have cancer, and come in on a regular basis for cancer treatment and they have to be admitted, then they get counted.”
Speaking at a recent Oregon Health Policy Board meeting, the president of Oregon Health and Science University, Doctor Joe Robertson, also expressed his doubts about health care providers’ ability to reduce the number of “all call” readmissions.
Robertson said, “It’s one of these trends that will swing too far before it comes back. And we will find people that were not readmitted one week later that are then readmitted three weeks later and they’re there for much longer of it’s much more complicated.”
One of the biggest issues the state has to wrestle with in setting up a new measurement system, is timing. Prevention efforts cost a lot of money in the short term and doesn’t start paying dividends for a long time.
For example, measuring how soon a woman comes in for a pre-natal visit after she finds out she’s pregnant.
The health benefits and the savings of early visits are enormous — a mother can avoid having a child with spina bifida by getting the pre-natal vitamin, folic acid.
But in the short term, having more women turn up for pre-natal visits, is likely to increase costs.
The feds have given Oregon $1.9 billion and five years to show it can reduce its rate of medical inflation by two percent.
If the state fails, it faces substantial fines.