9

QUALITY RATINGS ELUSIVE, BUT ESSENTIAL

UNLIKE MOST of his industry, Dr. Fernando Riveron competes on quality. The numbers for his twelve-doctor team for cardiac care in Wausau, Wisconsin, speak for themselves.

His team scored a perfect 100 on a quality scale for three different heart procedures. The track record of his cardiac unit at Aspirus Health, part of a health system in central Wisconsin, allows it to advertise as “the best heart care for 60,000 miles.” That’s the length of the arteries, veins, and capillaries in the human circulatory system. How refreshing: ads based on quality statistics.

Most heart centers use an external heart-lung machine four out of five times for bypass surgery, a process that causes all kinds of nasty complications. Dr. Riveron and his unit at Aspirus Health pioneered bypass operations “off pump,” which they employ 94 percent of the time. They graft their bypass repairs directly on the beating heart. Instead of lifting a patient’s heart out of their chest and temporarily replacing it with a mechanical contraption, the heart continues to pump during the operation. Riveron picked up that best practice from innovative surgeons in Brazil.

Though questioned for effectiveness in one study, that kind of breakthrough, coupled with Six Sigma-level analysis of all defects in the delivery of its cardiac treatments, has yielded some impressive results compared to national averages:

• a lower mortality rate by 40 percent;

• a 5.5 day hospital stay versus 7.9 nationally;

• half as many pneumonia cases;

• zero incidents of sterna infection from 2004 to 2007; and

• 8.8 percent of heart patients readmitted within thirty days versus 9.4 percent nationally.

When one of Aspirus’ metrics goes in the wrong direction, immediate analysis and corrective actions are undertaken.

Dr. Riveron’s rankings come from a thirty-year-old quality database maintained by the Society of Thoracic Surgeons (STS). Of the one thousand major heart centers in the country, about 75 percent send in their data voluntarily, so these are solid numbers.

Curiously, that data and other internal quality measures are seldom released by most medical providers. Why not? What are they afraid of showing?

Clearly, the fear of not looking good against competitors and the possibility of giving ammunition to trial lawyers in malpractice cases override the needs, even rights, of customers to know the facts about quality outcomes.

Does the doctor or hospital do a good job or a bad job on categories of procedures? Those of us who pay the bills should collectively demand transparency of quality data. That happens in most parts of the business world. Why not in health care?

The Cleveland Clinic, one of the most innovative health care systems, deploys advanced quality methods, and it makes its outcome data available to inquiring patients and payers. Aspirus and Cleveland prove transparency is possible.

STEER TOWARD QUALITY

Not surprisingly, then, Serigraph is steering its co-workers and their families to Aspirus for heart operations.

Another approach for buyers of health care would be quality audits, which are routine in manufacturing. Almost every month, a major customer descends on Serigraph to perform a quality audit. The auditors dig deep into our processes to see if we are good enough to be their supplier. They look at everything from plant cleanliness to scrap rates and from corrective action protocols to training regimens.

You pass the audit, you get the business. You fail, you don’t.

Often, vendors are given a list of non-conformances to fix. The end result of repeated audits and an unrelenting demand for accountability and corrective actions is much improved vendor performance.

Some interest by payers has developed in quality audits of health care vendors. But CEOs have been mostly silent. They have not yet found the collective voice to make it happen. You would think they would order their buying agents, the health insurers, to demand quality information.

Common sense tells us to ferret out which are the best and worst providers. To passively give our health care dollars to providers with poor outcomes amounts to dereliction of our duty as leaders of companies.

“The health care delivery system is fundamentally flawed because of the uncoupling of costs and outcomes,” said Dr. Riveron.

There is a bell-shaped curve of quality among doctors, doctor-nurse teams, clinics, and hospitals, just as there is in any field of human activity. How then can we justify a blind selection process that sends our people to the care-givers on the poor performance end of the spectrum?

Serigraph uses a variety of sources to try to judge quality.

First, our home-grown transparency system shows volumes of procedures. We want to know whether a surgery team, for example, performs six hundred hip replacements a year or six. Evidence supports a correlation between volume and quality.

It makes sense that the more times a doctor and a team perform a procedure, the better they get.

As I mentioned earlier, my hip replacement doctor does five hips each Monday and Tuesday morning. His outcomes are excellent. He has become very good at what he does.

Further, the best doctors attract the most patients, hence they do more volume. It is a virtuous circle. So volume is quality indicator number one but hardly sufficient.

Second, our health care specialists also dig into available quality information that comes from Medicare databases. We use two Web sites that glean consequential information from claims data, such as mortality and infection rates. They are Health Grades and Subimo, both for-profit companies. Aspirus, for example, ranks in the top 5 percent for heart hospitals in the Health Grade annual rankings.

Our HR department has a list of such high-value providers—those who give the best quality, price, and service—for many treatments. With help from Anthem, our network administrator, we have given grades of A, B, or C to the providers on our transparency site. It guides our co-workers to the best providers for value and away from the worst.

Let’s be clear: there is no correlation between price and quality. It’s counterintuitive, but, put simply, high price does not mean high quality, or vice versa. In fact, there is some evidence to suggest that good quality results in lower prices. (This is true in manufacturing and other sectors as well: companies with their acts together on quality often offer the best prices.)

MANDATE QUALITY DISCLOSURE

Our directory of best providers is helpful, but it could be a lot more complete and user-friendly. The problem could be solved for good if federal and state governments simply mandated transparency on quality and price.

Absent good quality information, patients are stuck with inadequate methods of finding the best doctor for procedures. They either talk to a nurse they know for guidance or they blindly follow their primary care doctor’s recommendation.

I have made the pitch to politicians in Wisconsin that they should be consumer advocates who put quality information into the hands of consumer-patients. My contention is that citizens have an inalienable right to critical information affecting their health. But it never happens, probably because of the heavy-handed political influence of health care providers.

Normally, I don’t like government mandates, but when it comes to consumer information, I favor them, much like those required in the markets for automobiles, houses, and mortgages.

In the interim, deep work is being done at several levels to use data mining to elicit quality results. For example, the Wisconsin Collaborative on Healthcare Quality (WCHQ) has been working with payers and most providers in the state on a voluntary basis to develop and publish usable statistics. WCHQ is a joint effort by providers, insurers, and payers in the private sector. So far, most of the findings deal with process inputs, such as whether an aspirin or beta blocker is delivered within thirty minutes of a heart attack after a patient arrives at a hospital. But WCHQ recently published three quality and cost comparisons on heart operation outcomes, which is where Aspirus and one other Wisconsin hospital scored at the top of a 100-point quality scale. Its ratings are available online at www.wchq.org.

The challenge for the collaborative is to collect more metrics on outcomes: Did the patient die? Did the patient need a repeat procedure? Did the new hip work?

Some additional outcomes are being added, such as blood test data for diabetics under care in a system. Both the A1c blood test and LDL cholesterol are tracked.

And it is displaying outcomes and charges across Wisconsin hospitals for treatment of pneumonia.

Next up should be inclusion of data from the Society of Thoracic Surgeons (STS) on heart procedures.

This is all excellent progress toward full transparency.

The collaborative’s work will be helped by the new Wisconsin Health Information Office, to which insurers are sending their common data. Similar initiatives need to happen all over the country, and they need to happen now. Consumers and businesses who are footing a large chunk of the bill need the information.

More quality data exists than is commonly thought or known. There are quality comparisons in specialty fields, such as the STS metrics. There are internal metrics at different health care systems that are used for continuous improvement and error reduction. There are “tissue committees” that do post-mortems on operations.

Unfortunately, almost none of this information is released to the public. In this void, Serigraph has been searching for Centers of Value that are willing to divulge their track records on quality.

Aspirus published its metrics from STS, though the society must not have been happy about the public use of the data for competitive comparisons. For instance, Aspirus rates higher than St. Luke’s, the high-profile Milwaukee heart hospital owned by Aurora Health. Aurora, the biggest health system in Wisconsin with twenty-five thousand employees, is one system that doesn’t submit its hospital data to WCHQ. It opts for opacity with the exception of its physician clinic data, proving it can be transparent where it wants to be.

Aspirus does a respectable five hundred heart procedures per year. And because the Aspirus team outshines its competitors with objective quality data, Serigraph recommends co-workers make the three-hour drive when medical circumstances allow.

As a bonus, its prices are about 40 percent lower than Milwaukee prices. Further, through BridgeHealth, the brokerage firm, Aspirus now offers fixed or bundled pricing for heart procedures. We now know what our costs will be up front. One reason that Aspirus can take the risk of fixed prices is that it has less variation and fewer negative outcomes. In quality lingo, it has fewer defects. In this case, a by-product of consistency in quality outcomes is better pricing and bundled pricing.

S.C. Johnson, the huge consumer products company with products like Raid and Pledge, has long used a center of excellence model for joint replacements, heart procedures, and back surgeries to steer its people. The company, based in Racine, Wisconsin, selects three nearby centers for each of the three types of procedures. Its selection has been based on quality alone.

The company sends its staff doctors to audit the candidate facilities and then steers Johnson employees to those high-quality centers. Quality, not price, determines Johnson’s choices. That company doubles the out-of-pocket maximum if employees choose to go elsewhere. Serigraph appropriated the concept of steering employees to centers of excellence from S.C. Johnson. We use the term Centers of Value, as we seek not only quality but price and service, too.

The important lesson is that you can dig out quality information if you are determined. The challenge for Serigraph and other payers is to insist on a more rigorous, user-friendly display of quality information. Consumers deserve to know this information so it can be used routinely in health care decisions.

Aspirus agrees. Its information package states: “We’re all about transparency. This message must get to the consumer.”

If businesses insisted that all health systems followed suit, better quality, better health outcomes, and better prices would surely follow. Their costs would drop.