Wisconsin Medical Journal
108 #3
108 #3
Wisconsin Health Information Organization (WHIO)
The following is a series of articles about the Wisconsin Health Information Organization (WHIO) and its role in health care transparency efforts underway in Wisconsin that have appeared in Medigram.
In a written response, Ingenix Consulting CEO Theodore Chien said, “The Prevailing Health Charges System (PHCS) and Medical Data Research (MDR) database products are not in the scope of the current or planned services provided to WHIO by Ingenix.”
New York Attorney General Andrew Cuomo’s investigation concerned allegations that the Ingenix database intentionally skewed “usual and customary” rates downward through faulty data collection, poor pooling procedures and lack of audits.
The intent of WHIO’s first quarter study period is to identify limitations, gaps and credibility of the data. In light of these recent actions, the Wisconsin Medical Society will continue to monitor and evaluate the WHIO database for any impact related to this situation.
Questions or concerns can be directed to QandE.
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Possible Advantage: USABILITY
The biggest asset of the Data Mart and its tools may be that it takes into consideration a multitude of metrics to ascertain standardized costs, utilization of services and quality of care. These metrics then can be used to assess the comprehensive performance of physician practices. In a positive way, the Data Mart can be likened to a labyrinth—they key is in learning how to navigate the data with the designated tools, thus determining the credibility of the reported findings.
The information appears to be useful in monitoring costs by condition, gauging compliance with the evidence based guidelines and tracking differences in health risks within the member and patient populations. Not only does the tool allow the user to get the numbers for all these different categories, it also provides the aptitude of mixing and matching these metrics for comparative study. The application can break this detail down to the level of encounters, episodes of disease, number of scripts, generic vs. brand name drugs prescribed, inpatient admits, outpatient services, specialties, lab and imaging services provided.
The application appears to be fairly facile and can be mastered in little time to generate these figures and comparisons by a trained user.
Possible Disadvantage: RELIABILITY AND VALIDITY
The biggest drawbacks relate to ascertaining the reliability and validity of the information obtained from the WHIO Data Mart. During the first quarter of 2009 WHIO stakeholders will be evaluating if the data accurately represent practice patterns and cost of care. The information offered, especially the performance measures, ratios and indices, is disconcerting and even confusing to the uninitiated viewer of the data. There is no way to ascertain the 'accuracy of representation' of the criteria mentioned, unless we fully understand the algorithms and formulae that constitute them.
Also, the comparisons in data may vary depending upon a plethora of factors like case mix, episode, size of facility, etc, and it is difficult to determine if all physicians/practices are being compared by the same touchstones. These intrinsic technicalities of the application may generate increased hesitancy by the physician community. The purpose of the study is to build an understanding of the breadth and depth of data and evaluate the limitations that may exist.
The Society will continue to work with WHIO and Ingenix to enhance the transparency of the application, as well as the flexibility of the reporting tools so physicians identify some perceptive and actionable value from the information. Currently, the reported data demands some amount of translation to make the final product more lucid and evident.
During the first quarter study period, the Society will continue to provide updates on both the potential uses and limitations of the WHIO Data Mart through Medigram. If you have any questions or concerns, please contact the Society's Quality & Efficiency department.
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So what happens next?
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So why do efforts like WHIO matter to the growing and real concerns regarding physician shortages in Wisconsin?
The Society provided additional data for the WCMEW report, which was gathered through a robust survey of Wisconsin physicians. The survey indicated over 40 percent of respondents are either “dissatisfied” or “very dissatisfied” with their quality of life in relation to the demands of the profession. Anecdotal responses from these physicians make a compelling case that non-clinical activities like excessive documentation, redundant and unnecessary administrative duties, pressure to implement costly electronic medical records software and required reporting to multiple entities with little to no standardization—which are mandated by various government and private constituencies—are key factors contributing to the declining supply of physicians and the rising cost of medical services.
The Wisconsin Medical Society’s mission is to improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment. Efforts like WHIO are important to the collaborative process of improving the current health care delivery system for all stakeholders. Yet thoughtful deliberation must be given to the impact—and possible unintended consequences—these efforts may have on patients and the physicians who provide their care. The Society is working to ensure that, at a minimum, initiatives like WHIO safeguard against adding pressure to the already known shortage of physicians in Wisconsin.
To learn more about WHIO, click here. If you have questions, e-mail QandE@wismed.org.
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Are we up for the tipping point?
I recently attended a conference on quality and safety, along with several hundred other smart, motivated and practical people affiliated in various ways to our health care delivery system. During the course of the presentations, one of the speakers posed the question, “Surely all of our physicians will quickly and willingly engage in opportunities to improve quality. Right?” To which the majority of the audience responded with knowing laughter. Although I was a bit stunned—and maybe embarrassed—by the response, I couldn’t help but ask myself, “Am I, and my physician colleagues, ready to proactively lead efforts that will improve the cost-efficiency and quality of health care we provide to our patients?”
Malcom Gladwell, author of the acclaimed best seller The Tipping Point, claims that the theory of the tipping point requires that we reframe the way we think about the world in which we operate. The stakeholders participating in the Wisconsin Health Information Organization (WHIO) have faced the difficult challenge of working together when individual goals and interests are not always aligned. Purchasers may use the WHIO data to identify better health care value; insurance companies may use the WHIO data to determine “high performing” provider networks. Hospitals and physicians may use the WHIO data to drive quality improvement initiatives, study geographic practice variation or reduce health care disparity in patient populations.
The WHIO Data Mart will be operational by the end of this year. During the first quarter of 2009, the credibility and value of the WHIO data will be tested by the participating organizations, including the Wisconsin Medical Society. The availability of WHIO data will create a “tipping point moment” for many physicians. Some of us may to decide to ignore the data and continue to practice status quo. Others of us will engage the information to improve our practice and the care we provide our patients.
As physicians, we have the choice to lead transparency initiatives in Wisconsin and nationally—or to follow. This may require us to look differently at how we respond to and use information from organizations like WHIO. Through a physician-led tipping point, we may find unexpected partners who share a mutually beneficial vision for improving our health care delivery system. Who could refuse a health care system that better aligns access, quality and cost? I, for one, am ready to lead this charge.
Note: Doctor Bartholow is a family practice physician from Sauk City, Wisconsin. Over the past year, he has served a Chair of the WHIO Physician Cabinet and as its representative on the WHIO Board of Directors. He recently joined the Wisconsin Medical Society staff as Senior Vice President of Member Services, Policy Planning and Physician Professional Development.
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This is not the first time the Society has addressed this issue. In 2004, the Society House of Delegates passed a policy regarding the use of data as it relates to performance measurement. The policy, (DHC-004: Characteristics of Ideal Performance Measures), established a set of criteria to guide a disciplined approach to transparency.
Over the last several years, initiatives by insurers, employers and the federal government have incorporated the use of data and performance measurement into their Pay for Performance strategies. The Society (as well as other provider stakeholders) has diligently represented the interests of the physician community regarding transparency—the ability to compare cost and quality information for improved health care decision-making—in national and state debates, including those occurring at the Wisconsin Health Information Organization (WHIO).
Over the past several months, WHIO’s Board of Directors has been deliberating over the terms and conditions in the organization’s Data Use Agreement. The Society has been actively involved in these challenging discussions and in efforts to reach compromising language to serve physicians’ best interests. The finalized Data Use Agreement will become a formal legal document and all WHIO participating organizations, who sign this portion of their WHIO contract, will be required to comply with its terms. WHIO anticipates Board approval of this document at its November meeting.
Society members are encouraged to review and reference the Board-approved transparency principles in discussions on transparency and use of data. These principles do not replace DHC-004; rather, they are intended to provide a more general, yet succinct description of the Society’s position on transparency.
It is likely the November elections will only enhance calls for reforming the health care system, including bipartisan calls for more transparency. The Board’s action allows the Society to continue its commitment to ensuring physicians have a say in how these issues evolve.
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The Study Period Process, approved by the WHIO Board, is composed of two large scale acceptance test functions that will run concurrently throughout the first quarter of 2009. The Pilot Program will exercise and evaluate the processes and outputs of the performance measurement program at a micro or provider group level. The Data Study will focus on analysis and evaluation of the accuracy and completeness of the data in the data mart at a macro or market level. Information from the Pilot Program and the Data Study will be collected and shared with WHIO participating organizations throughout the quarter. A final report of findings and recommendations will be issued to the WHIO Board of Directors at its April Board meeting.
“Hastily measuring doctors with data that does not accurately reflect the complexity of practices may ultimately damage the patients’ trust in their doctors and unfairly measure physicians,” said Tim Bartholow, MD, Chair of the Physician Cabinet. The Physician Cabinet, created by WHIO to provide real world focus on what data will be useful to both physicians and patients, advises the WHIO Board on practical physician measurement and reporting applications.
The Cabinet will also be reviewing a slate of physician practices identified to particiapte in the Pilot Program at its upcoming meeting. Practices were considered eligible for the pilot based on the volume of claims they have in the initial data mart and on several other criteria relating to their current use of data for quality improvement.
If you or your practice is interested in learning more about the WHIO Study Period Process, please send an e-mail or your questions to qande@wismed.org.
Also, the Physician Cabinet is interested in recruiting additional physicians to serve in an advisory capacity to WHIO. Members of WHIO’s Physician Cabinet currently include these physicians: Tim Bartholow, MD, Gregory Blommel, MD, Jay Gold, MD, JD, MPH, Rita Hanson, MD, Mark Kehrberg, MD, Lowell Keppel, MD, and David Smith, MD. Please e-mail qande@wismed.org if you are interested.
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By working with physicians in a pilot setting, WHIO expects to identify defects in the initial data mart, gain an understanding of the impact of data gaps and determine reasonable and viable methods for improving the data. WHIO CEO Julie Bartels commented, “It is important that we understand this is a 'test' and that the process will involve finding out what works and what doesn't work.”
Phyician practices (large, small, rural, urban, speciality, etc) will be considered for the pilot based on ranking a set of criteria that includes the following:
The initial pilot will include no more than six physician practices. WHIO will work very closely with these groups, delivering the first reports in person and providing a walk-through of the results. If your practice is interested in being considered for this, or any WHIO pilot activity, please provide your name, clinic location and contact information to qande@wismed.org.
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Elizabeth McGlynn, PhD, spoke about key considerations involving health care cost and performance measurement to nearly 100 attendees of last week’s “Efficiency Symposium: Methods, Measures and Policy Impact,” which was jointly sponsored by the Wisconsin Medical Society and the Wisconsin Collaborate for Healthcare Quality. Dr McGlynn is an associate director for RAND Health and holds its Distinguished Chair in Health Care Quality. She is currently leading the COMPARE initiative, which is developing a comprehensive method for evaluating options to improve the performance of the U.S. health care system.
Noting that the latest trend is consumer-directed health care, McGlynn emphasized patients will be the “engine of change.” It is critical that adequate information exist for patients to choose the right health care professional based upon quality and cost metrics. “Employers providing insurance coverage might be willing to give (patients) a Hyundai but they’re not going to pay for a Mercedes,” she said, but added that “just putting information out there does not appear to drive patients to do anything differently.”
From 2003 until 2005, a study was conducted using data from four Massachusetts health plans. The study focused on adults, 18-65. “Grouping” methodology bundled care into episodes (types of treatment). Then costs were assembled for each episode of care. “These actual costs are then compared to the average of that type of care,” McGlynn said. Ranking of physicians then was applied with the following considerations: aggregation, attribution, reliability, classification, metrics, level of analysis and standardized costs; McGlynn elaborated on the first four.
Aggregation is determining “if we are able to compile data across health plans, does it increase our opportunity to profile physicians through increased sample sizes?” The conclusion was that combining data did not provide as much of a “lift” as was hoped. “However, it was still a worthwhile consideration,” McGlynn added.
Attribution is determining how episodes of care are attached to particular doctors. McGlynn noted that more than half of all patients saw five or more physicians over the period of the study. Admitting that this was not an exact science, she pointed out that vital considerations are how the information is aligned with patient choices and that the information is adequate to making decisions combining quality and value.
Reliability measures how much variation in observed scores is explained by real differences in physician performance. The metrics must differentiate the performance of one physician from the other, however, “We may have to measure reliability beyond the individual physician level,” said McGlynn. She proposed that lower levels of reliability (70-80%) are acceptable for drawing conclusions at the group level. Psychometricians use a rule of thumb of 90% reliability for determining individual physician conclusions. Reliability can be increased by a larger number of observations and greater clarity in the measurement. Using low reliability information to drive physician change could have undesirable consequences. McGlynn also cautioned that reliability does not address validity.
Classification of physicians breaks down into two methods. First, the “bright line” test essentially categorizes doctors into quartiles with an emphasis on the comparison of performance above or below the halfway point. Second, the statistical classification is a measurement of performance that is statistically different from peers. The breakdown effectively mirrors a bell curve. McGlynn concluded that the most rigorous tests (statistical classification) must be used.
McGlynn concluded her comments by encouraging stakeholder involvement in efforts in cost-efficiency. She reminded the attendees that “getting something for nothing probably isn’t one of the options.”
A DVD of this presentation is available on a limited basis, please call the Society at 608.442.3800. For a copy of the slides from her presentation, click here.
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Doctor Rattray, president and executive consultant of CareVariance LLC, offered insights into physician practice measurement and examined the following key considerations for effective measurement:
“There must be critical stakeholder commitment to the process,” he said. Increasingly, physicians better understand the connection between measurement and positive patient outcomes, he noted and it is now widely accepted that “until you measure your performance, you can’t accurately assess the impact you are having on treating patients.” However, Dr. Rattray went on to explain that it is tough to realize that “the bell-shaped curve is alive and well in medicine and that there will be physicians at the lower end of the curve and the upper end regardless of the measurement device you use.”
In a 2004 study of 40 million claims, it became evident that the medical profession couldn’t use quality measurement to predict efficiency, and efficiency and cost of care measurements weren’t accurate predictors of quality. “Employers were disappointed because in their world quality and efficiency go hand in hand,” said Dr. Rattray. Consequently, it has been accepted that the involvement of clinicians as a “critical mass” is a primary driver in the accurate measurement process.
The measurement and improvement environment is evolving rapidly as national, state and regional groups enter the fray with more sophisticated approaches. “Accurately developed claims data that includes physician input and review can be quite reliable for assessing process quality,” Dr. Rattray offered. However, specialty practices have a unique challenge in that the number of measurements is more limited than primary practice physicians. “With narrow measurement parameters, are you really measuring the quality of that practice,” he added. This process of evaluation has led to three categories of care for measurement purposes:
Doctor Rattray went on to assess factors in improving measurement. “Measures should be meaningful to consumers and address a broad array of physician activities.” In addition, targets for measurement must be actively engaged in the process. Measures and methodology must be “transparent and valid” and measures must be based upon national standards whenever possible.
Finally, “improving improvement’ will be a dynamic process where accountability, payment reform and “more actionable” reporting are critical.
To access slides from Dr. Rattray’s presentation, click here.
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UHPD: In October 2008, Wisconsin physicians will receive their annual assessment report from UnitedHealthcare’s Premium Designation program. This is not a new program, nor does it currently use data provided by WHIO. Other insurers have similar programs or Pay for Performance initiatives either in development or operation.
WHIO: The WHIO Data Mart remains on schedule for a December 2008 production date. A proposed “study period” during the first quarter of 2009 is being proposed to the WHIO Board of Directors. The study period will allow participating WHIO organizations, including UnitedHealthcare, to test the data for defects and uses.
UHPD: In a letter to the Society, UnitedHealthcare commented, “The enhancements to the Premium program for 2008 incorporated recommendations from the physician community, medical specialty societies and physician advisory boards. “
WHIO: The endorsed provisions of the Patient Charter and NCQA Quality Reporting Guidelines will assist in the more credible and accountable use of physician measurement and reporting by insurers. Many national insurers have endorsed the Charter. The WHIO Board is prepared to approve a set of Data Use Guidelines that adopt these criteria at their September meeting.
UHPD: UnitedHealthcare’s annual assessment reports are based on refreshed paid claims data. The upcoming report will include claims paid through Feb. 19, 2008 with dates of service from Dec. 1, 2005 through Nov. 30, 2007.
WHIO: WHIO’s Data Mart will be comprised of historical administrative claims data currently submitted by five insurers doing business in Wisconsin. The Clinical Advisory Group of WHIO has also selected a starter set of measures that will be reported using the WHIO data. The Society is positioning itself to conduct a “validity study” to assess the variation between administrative claims data and clinical information when using it for quality improvement and/or measurement and reporting purposes.
UHPD: UnitedHealthcare will notify physicians of their individual designation status at least 45 days prior to any public disclosure of the results to give physicians the opportunity to seek clarification and, if necessary, to request reconsideration. New designations will be available on their consumer Web sites by the end of the year.
WHIO: The transparency requirement in the Patient Charter states that “reporting organizations must be prepared to identify and share patient data that was used to generate the provider performance measure.” At this time, WHIO data on patients will be de-identified, thus the WHIO data cannot be used by insurers like UnitedHealth in the development of their Premium Designation Program. WHIO does anticipate that when conflicting measures are produced from other sources, using different data or other measurement methods, physicians will be able to challenge the results by comparing it to WHIO data and methods. This has the potential to drive more open conversation about real practice patterns and real costs and lead to consistency in measurement methods across sources.
UHPD: Comprehensive information about the program is available on UnitedHealthcare’s physician Web site.
WHIO: The Wisconsin Medical Society has been publishing a series of articles about WHIO in Medigram. This series of articles can be found here.
“Programs like UnitedHealthcare’s are evidence that insurers are being pushed hard by their customers to give them information about their choice of physicians and to get costs under control,” said Julie Bartels, WHIO CEO. “Directionally it is good, but specifically (especially at the practicing physician level) we have a lot to learn.”
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What, from a payer perspective, would make health care data credible enough to be reported?
As a payer, we want health care cost and quality data to be available, so consumers are empowered to have the information they need to make decisions about their care. This means working with providers to make sure data is standardized, statistically valid and appropriately reflects a provider’s practice pattern.
Anthem Blue Cross and Blue Shield (Anthem), through our parent company, WellPoint, has taken the first step in collaborating with providers on behalf of consumers by adopting the patient charter initiated by Attorney General Andrew M. Cuomo in New York State.
In previous interviews, you’ve addressed “variations in health care.” How does payer involvement and WHIO’s upcoming Data Mart address variations in health care?
Price variation is one factor in why Wisconsin has been seen as a state with higher health care costs. Anthem believes making cost and quality data available is important if that is going to change.
The full disclosure of the cost and quality of an episode of care (meaning all the costs involved in a given procedure—doctor, anesthesia, facility, etc.) is a first step in controlling rising health care costs. The public needs to understand there is variation in health care costs and quality, and they have a choice in their health care professionals. Tools and reports from initiatives like WHIO will assist in reducing the variation in health care and empower consumers to make informed decisions. As cost and quality data is more widely available, we anticipate variation in costs between providers will narrow, thereby helping to control overall health care costs.
Why do you believe the WHIO endeavor is taking longer than previously expected?
WHIO is a landmark endeavor. Never before have a hospital association, a medical society, five payers, purchasers of health care, and state government come together to improve the quality and efficiencies of health care.
WHIO is breaking new ground, and everyone involved wants to make sure we get it right before the data hits the marketplace. We are learning how to work together, recognizing each other’s concerns and expectations, and building a strong working relationship to get the data right for the consumers.
How do you see payers benefiting from this collaboration of payers, providers and purchasers?
Payers will always be looking to differentiate themselves from one another, but we all understand that everyone – payers, providers and consumers – stand to benefit from the availability of health care data.
As health care cost and quality information becomes public, the WHIO data will create metrics and measurements the entire industry can use to find ways to improve how we do business, and contribute to the health of our communities.
What are the sources and extent of pressure for the creation and maintenance of this Data Mart?
The drive to undertake this project and get it right is coming from everyone involved with WHIO.
Employers are feeling cost pressures. Providers are seeking quality scores in an industry that does not have well-established quality measures. Physicians are high achievers looking to improve the quality of the health care they provide to help their patients get better faster and stay healthy.
For health care in Wisconsin to retain its high quality and become more affordable, we have to create a market in health care; that’s what the WHIO data is going to do for consumers. In an open and accountable marketplace, competition among providers will then focus on providing consumers with the best value proposition available, based off of quality scores. This is a desirable outcome for all who use and participate in our health care system.
In short, everyone wants to improve the customer’s health care experience. To do that, we need the data to know how we’re doing and what we can do better.
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What are the key issues slated for WHIO over the next 60 to 90 days?
Anthem BCBS, United Healthcare, WEA Trust, WPS and Humana are currently sending their Wisconsin-based administrative claims data to Ingenix, a health care information and research company, to import into the WHIO Data Mart. We are on schedule so far, and remaining on schedule is so critical to delivering a productive Data Mart at year’s end.
WHIO must finalize the Data Use Guidelines so that all current members and potential new members understand what data will be made available and how it can be used for member company business purposes. This is tricky, because we're looking to create consistency in reporting of the data across health plans, while supporting innovation and quality improvement at the same time.
WHIO is also preparing to test the data contained in the Data Mart. This will include establishing minimum parameters on sample size, assessing data credibility and determining effective data uses. The data must be accurate and actionable in order to support provider practice quality improvement activities.
How is WHIO navigating through these key decision-making areas?
WHIO is a multi-stakeholder organization that depends on the participation of its members and work groups established to consider these tough issues. Fortunately, our members have been willing to commit tremendous in kind staff resources to these efforts. At any point in time, there can be as many as 35 to 40 people working on WHIO projects from member health plans, employer purchasing groups or provider organizations.
Physician participation is especially critical in addressing issues of WHIO Data Use Guidelines and Reporting Parameters, as mentioned previously. Many physicians have dedicated a significant amount of time to this effort through the Physicians Cabinet and the Clinical Advisory Group—both are voluntary work groups. In addition, we have consulting expertise provided through our contract with Reden&Anders, the consulting arm of Ingenix.
Where do key stakeholder stand on these key issues?
All stakeholders agree on WHIO’s core objective—that is, aggregating administrative claims data for reporting purposes. It just makes sense that a more reliable result can be achieved by collecting data from multiple sources and producing reports on a more statistically significant base of data.
The difference among stakeholders occurs in how the data will be put to work. Some believe that the data should only be used be when there are valid and consistent outputs/measures. Others are concerned that too many restrictions on data use will stifle innovation that could lead to product or process breakthroughs and opportunities for quality improvement. These potential breakthroughs might have a significant, positive impact on future health care costs.
WHIO is breaking new ground, and, therefore, we have no specific model to follow. The best case scenario will be determined by bringing together the best minds with the best intentions and asking them to work collectively and collaboratively through the issues. Shared understanding of motivation and intention of the various stakeholders, and a willingness to compromise in order to make progress, will get us to where we need to go.
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1) Data Use Guidelines
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WHIO’s impending health care Data Mart presents numerous challenges and questions for physicians and other health care professionals including the credibility, validity and actionability of the WHIO data in regard to efficiency and effectiveness measurement. The symposium will feature two industry experts, Elizabeth McGlynn, PhD, and Mark Rattray, MD, whose research and experiences in this area promises to offer symposium participants the opportunity to gain new understanding and have a dialogue on critical issues that may influence the direction of Wisconsin’s effort through WHIO.
Dr. McGlynn, an international expert on methods for assessing and reporting on quality of health care delivery, is an associate director with RAND Health and is the RAND Corporate Chair in Health Care Quality. She is currently leading a project to examine the methodological and policy issues of implementing health care efficiency measures at the individual physician level.
Society CEO Susan Turney, MD, and Cindy Helstad, PhD, RN, the Society’s Director of Research, recently attended a meeting hosted by the Massachusetts Medical Society and Physicians Advocacy Institute to review McGlynn’s key findings to date. Following the meeting, Dr. Turney said, “This work will be a landmark study that provides evidence on the state of the science for individual physician-level performance measurement.”
Doctor Rattray worked directly with episode-based physician profiling as a former executive at Regence Blue Shield in Washington. He is currently president of his own health care consulting company, CareVariance LLC and has served as a technical advisor on health care efficiency measurement initiatives for several national organizations.
Medigram readers interested in attending the Symposium or in receiving further information about the Society’s Quality Forum may e-mail QandE@wismed.org. A formal invitation to the Efficiency and Effectiveness of Care Symposium will be sent to interested Society members in mid-August.
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Legislation passed in 2006 amended Wisconsin law related to the Physician Office Visit Data (POVD) initiative conducted by the former Wisconsin Department of Health and Family Services. The amendment established a sunset of POVD data collection activities, while allowing the State to directly contract with a data aggregation entity such as WHIO. The annual physician assessment, which funded POVD, remained in place and will be redirected to WHIO activities, as well as to other State-sponsored initiatives that support improvement in health care quality and efficiency. The annual assessment is currently $70 per physician.
Department of Health Services (DHS) Secretary Karen Timberlake recognizes the importance of the partnership between the State and other health care stakeholders in WHIO’s endeavor. “This is an extremely important initiative for Wisconsin to achieve transparency in health care and promote better health care outcomes for the people of Wisconsin,” Timberlake has said. “We are fully committed to working in partnership with the other health care stakeholders across the state through WHIO.”
Two individuals represent the State on the WHIO Board of Directors: Karen Timberlake, Secretary of the Department of Health Services (DHS), and David Stella, Secretary of the Department of Employee Trust Funds (ETF). Among its various efforts, DHS administers Wisconsin’s Medicaid program and its related programs: BadgerCare, SeniorCare and Family Care. In 2009, plans include integrating Medicaid data into the WHIO Data Mart. ETF manages the benefit programs for more than 250,000 active and retired State of Wisconsin employees through contracts with nearly 20 different health plans doing business in Wisconsin. WHIO is actively recruiting these health plans to participate and submit their data to the Data Mart.
“This is an extremely important initiative for Wisconsin to achieve transparency in health care and promote better health care outcomes for the people of Wisconsin,” said Timberlake said in this press release. “We are fully committed to working in partnership with the other health care stakeholders across the state through WHIO.”
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With the Wisconsin Health Information Organization (WHIO) currently building a statewide data mart from administrative claims information, health care quality and cost efficiency measurement is in the foremost of industry discussion. The Wisconsin Medical Society’s June 24 Quality Forum provided a venue for exploring both the potential and concerns that surround the complex endeavor of gathering, analyzing and publicly reporting health care data.
“It was a challenging three years, having to squeeze quality and cost scores from claims data,” said Kirshenbaum. “The problem was that not all physicians were measured on the same things; methodologies used by the insurers varied.” In May, the Massachusetts Medical Association filed legal action seeking to “correct the wrongs” of the physician ranking program implemented by the Massachusetts Group Insurance Commission, the purchaser of health insurance for most Massachusetts state employees and retirees (www.massmed.org).
Kirshenbaum stressed the need for physicians to be “deeply engaged” in cost and quality dialogues, along with investing in external expertise and resources. She says this may have lessened data errors, physician grievances and related injustices to patients and physicians in Massachusetts.
Julie Bartels, WHIO’s executive director, and the WHIO Board of Directors have been tracking and learning from similar national initiatives to best avoid errors in developing data marts and tiering physicians.
“We must have great data to start with. WHIO is dedicated to doing this right,” said Bartels. (For detailed information on the WHIO Cost Efficiency Measurement Methodology, click here to view the Quality Forum presentation by Tom Knaebel, MD: Vice President of Medical Informatics Consulting for Ingenix.)
WHIO Physician Cabinet member Timothy Bartholow, MD, has taken an active role in advancing the WHIO initiative on behalf of the physician community. Doctor Bartholow said WHIO has the potential to, among many things, reduce redundant medical investigations, advance the practice of preventative health care and provide feedback on physicians’ practices.
“I’m glad to be evaluated, but only if the data can accurately reflect my practice,” said Dr. Bartholow. “We’re trying to attain accurate data to communicate to the outside world and physicians.”
WHIO Clinical Advisory Group member John Hartman, MD, also is directly involved in WHIO’s data mart development. “It’s about delivering value to citizens, coupling affordability with quality,” said Hartman. “We have to address both cost and quality.”
Following presentations by Kirshenbaum, Dr. Bartholow and Dr. Hartman, Forum attendees engaged in an active discussion regarding potential strengths and weaknesses of WHIO’s forthcoming data mart. Planning for the next symposium on physician measurement is currently underway and tentatively scheduled for September 16, 2008. This will be an important physician event considering the WHIO data mart is planned for release by year-end.
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The eight-member group includes five Society members: John Hartman, MD, Eric Christianson, MD, Bud Chumbley, MD, Sally Kraft, MD and Gordon Wong, MD.
While CAG’s sister committee—the Physicians Cabinet (see last week’s article in Medigram)—focuses on the practical application of data, CAG examines the scientific aspect of provider performance measurement.
The complexity of human health, medical practices and the health care system presents many challenges in attaining complete, accurate, timely data and assigning valid performance measurements based on that data.
“The real question is: Given the limited amount of clinical information available in claims data, what activities, which are billed for and therefore available in claims data, are strongly linked to desired or undesired outcomes?” said Dr. Hartman. “We in Wisconsin are trying to improve the value of the dollar spent on health care by exploring this linkage.”
Doctor Hartman also emphasized the importance of aligning with national standards for medical practice guidelines and taking Wisconsin quality measures, such as those by the Wisconsin Collaborative for Health Care Quality, into account. These standards represent what various experts believe are the “best practices” for physicians.
“The real difficulty is that we have many health plans and specialty societies with their own recommendations for medical practices,” said Dr. Hartman. “We need to all read the same set of recommendations to avoid patient and provider confusion and reduce administrative costs.”
The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs, which was recently released by the Consumer-Purchaser Disclosure Project, represents a tremendous step forward for CAG. (For more information on the Charter, click here.)
“The Charter explains how data marts and data reporting are to be used in relation to transparency, accuracy and some key concepts regarding underlying methodology,” said Dr. Hartman. “This allows CAG yet another opportunity to align some of its recommendations regarding these methodological issues with national standards.”
CAG’s focus, and that of WHIO, is to increase health care quality while simultaneously decreasing cost. CAG, the Physician Cabinet and WHIO as a whole bring together payers, purchasers and physicians in this shared goal.
“We know the health care system needs to change,” said Dr. Hartman. “Who is better than physicians, the ones who implement care, to be directly involved in improving how health care is delivered and incentivized?”
CAG members work toward applying evidence-based guidelines and sound, reproducible methodology for the creation of reports. From these, physicians will understand how they are performing in comparison to national standards and their peers. Additionally, WHIO will provide public reporting of this information for patients to factor into their health care decisions.
“As a physician, I welcome the opportunity for peer comparison, to have a quality and cost analysis and identify where I might best focus quality improvement efforts,” said Dr. Hartman.
Doctor Hartman stresses that though the initial data mart may not be perfect, the tool has the potential to be quite useful.
“The key is to be measured by a standard tool and to ensure its validity before jumping to conclusions and expanded uses,” he said. “We all became physicians for a reason—we care about patients. This is an important, additional step forward in our journey to improve the quality of care delivered to patients in Wisconsin.”
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“We want to identify some of the best practices and translate those into broad, increased value for patients and physicians,” said Dr. Bartholow.
As WHIO aggregates administrative claims data from 1.9 million of Wisconsin’s 5.5 million citizens, Dr. Bartholow and many of his colleagues believe WHIO’s “data mart” will help physicians identify where quality and cost variation exists and answer the question, “Which care provides the most value to patients?”
The WHIO data mart, which is targeted for initial completion in December 2008, will be comprised of health care claims information submitted by the participating insurance companies. It will be populated continuously with up-to-date administrative claims data from several data submitting organizations, mostly health insurers. The data will be used for tracking, analyzing and measuring episodes of care and their costs over time.
To assure that Wisconsin physicians are fairly measured by a robust, credible data set, the PC works with the WHIO Clinical Advisory Group—which provides the scientific focus and use of evidence-based principles to evaluate WHIO’s data measurements and methodologies.
“Hastily measuring doctors with data that does not accurately reflect the complexity of practices may ultimately damage the patients’ trust in their doctors and unfairly measure physicians,” said Dr. Bartholow. Fortunately, purchasers (employers) and payers (insurers) increasingly appear to acknowledge the delicate relationship between patients and their doctors.
“In over 20 states, similar efforts are underway and mandated by those states. In Wisconsin, we hope to achieve this without legislative force,” said Dr. Bartholow.
This desire has led to a forthrightness and candidness among WHIO stakeholders that have not always come to a consensus.
“We need everybody at the table in order to make the greatest possible difference for physicians and patients,” added Dr. Bartholow. “Yet, if we’re unsuccessful, the potential benefit to Wisconsin citizens will not be achieved.”
To Dr. Bartholow, this effort is about the quality and affordability of Wisconsin health care and protecting the trust of the patient-physician relationship.
“I am grateful for patients allowing me into their lives, for trusting me and communicating their medical needs openly,” said Dr. Bartholow. “Initiatives such as WHIO need to respect and honor that important relationship as they do their good work.”
Members of the Society’s Quality Forum were recruited to serve as representatives on WHIO’s Physician Cabinet and include the following physicians: Dr. Bartholow, Gregory Blommel, MD, Jay Gold, MD, JD, MPH, Rita Hanson, MD, Mark Kehrberg, MD, Lowell Keppel, MD, and David Smith, MD.
Please e-mail any questions or concerns to QandE@wismed.org. We will address them directly or through future Medigram updates. And stay tuned for future updates in Medigram and more information on the Society’s Web site.
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WHIO is a not-for-profit organization comprised of key health care stakeholders in Wisconsin. Its goal is to use health care data to improve the equality, affordability, safety and efficiency of Wisconsin health care.
Who are WHIO’s members?
The organizations currently participating in WHIO include the Society, Anthem Blue Cross Blue Shield of Wisconsin, Employers Health Care Alliance Cooperative, Greater Milwaukee Business Foundation on Health, Humana, the Wisconsin Departments of Health and Family Services and Employee Trust Funds, United Healthcare of Wisconsin, WEA Trust, Wisconsin Collaborative for Healthcare Quality, Wisconsin Hospital Association and WPS Health Insurance.
What is WHIO’s primary mission?
WHIO is working to develop a statewide data mart by the end of 2008 that will be comprised of health care claims information submitted by the participating insurance companies. The data will be used for tracking, analyzing and measuring episodes of care and their costs over time.
How does this relate to the Society’s mission?
The Society’s mission is to “improve the health of the people of Wisconsin by supporting and strengthening physicians’ ability to practice high-quality patient care in a changing environment.” To help achieve that goal, we have made a commitment to transparency—or the use of credible, robust data to improve the quality and efficiency of health care. Our efforts in performance measurement, quality improvement and patient-centered care can be enhanced if WHIO is able to maintain a balanced approach between the objectives of its stakeholders and the important relationship between a physician and their patient.
The Society is a WHIO member because it is critical for the physician voice to be represented. Complex and challenging decisions must be made that will determine how the WHIO data will be aggregated, validated and used by health care payers, purchasers, providers and the public. The Society has a responsibility to ensure that physicians are aware, engaged and influencing key state and national initiatives that focus on improving the quality and efficiency of our health care system.
What is the Society’s role in WHIO?
In addition to being a founding member of WHIO, the Society has a designated seat on its Board of Directors. Several Society physicians serve on two important WHIO working committees, the Clinical Advisory Group (CAG) and the Physicians Cabinet (PC). The Physicians Cabinet also has a designated seat on the WHIO Board. Regular updates on the status of WHIO, including the work of CAG and PC, are provided at the Society’s quarterly Quality Forums.
In fact, Society members are invited to attend the June 24 Quality Forum to learn more about the issues of physician attribution, severity adjustment, sample size, outliers, missing data and measure validity.
What is the biggest obstacle to achieving WHIO’s goals?
The greatest challenge to WHIO’s success will be balancing the varying goals and objectives of its diverse stakeholder group. While payers and purchasers have a sense of urgency to impact rising health care premiums, health care providers—physicians and hospitals—want to ensure that the WHIO data has integrity when used for quality and efficiency efforts. This dialogue requires discipline, pace, trust and compromise. We won’t get a second chance to do this right.
Can Society members get involved in these efforts?
Absolutely. If you are interested in participating in an advisory role for the Society in the areas of performance measurement, quality improvement or patient-centered care, please send your contact information to QandE@wismed.org.
Additionally, we encourage you to e-mail any questions or concerns to QandE@wismed.org. We will address them directly or through future Medigram updates, and we will also provide this information anonymously back to WHIO. And stay tuned for future updates in Medigram and more information on the Society’s Web site.
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- January 15, 2008—WHIO requests information from Ingenix regarding settlements
- December 18, 2008—Early Society findings from the WHIO Data Mart
- December 4, 2008—WHIO Data Mart ready for participating organization access
- November 13, 2008—A Perspective: Why physician satisfaction must matter to WHIO
- November 6, 2008—Society milestones in transparency
- October 30, 2008—Are we up for the tipping point?
- October 23, 2008—What physicians should know about the WHIO Data Mart
- October 16, 2008—Society Board approves transparency principles
- October 9, 2008—WHIO Physician Cabinet meets October 15
- October 2, 2008—WHIO Pilot Program Scheduled For First Quarter 2009
- September 25, 2008—McGlynn focuses on cost and performance measures at Efficiency Symposium
- September 18, 2008—Rattray, McGlynn featured at Efficiency Symposium
- August 28, 2008—The differences between UnitedHealthcare's assessments and WHIO's Data Mart
- August 14, 2008—WHIO's Top 10 Q&A
- August 7, 2008—Interview with John Foley: the payer perspective
- July 31, 2008—Q&A with Julie Bartels, executive director of WHIO: Key issues
- July 24, 2008—Society keeps pulse on key physician issues in WHIO
- July 17, 2008—Society and WCHQ partnering on efficiency symposium in anticipation of WHIO Data Mart
- July 10, 2008—WHIO: A public-private collaboration in health care transparency
- July 3, 2008—Massachusetts Medical Association addresses Society’s Quality Forum
- June 26, 2008—Clinical Advisory Group maintains scientific focus in WHIO’s data mart initiative
- June 19, 2008—Advancing the patient-physician relationship together: An interview with Tim Bartholow, MD
- June 12, 2008—WHIO Q&A: Who, what and why?
From Medigram January 15, 2008
WHIO requests information from Ingenix regarding settlements
On behalf of its participating organizations, WHIO CEO Julie Bartels, requested that Ingenix respond immediately to settlements announced this week. Ingenix, a wholly-owned subsidiary of UnitedHealth Group Inc. (UHG), is the Wisconsin Health Information Organization’s (WHIO) technology partner.In a written response, Ingenix Consulting CEO Theodore Chien said, “The Prevailing Health Charges System (PHCS) and Medical Data Research (MDR) database products are not in the scope of the current or planned services provided to WHIO by Ingenix.”
New York Attorney General Andrew Cuomo’s investigation concerned allegations that the Ingenix database intentionally skewed “usual and customary” rates downward through faulty data collection, poor pooling procedures and lack of audits.
The intent of WHIO’s first quarter study period is to identify limitations, gaps and credibility of the data. In light of these recent actions, the Wisconsin Medical Society will continue to monitor and evaluate the WHIO database for any impact related to this situation.
Questions or concerns can be directed to QandE.
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From Medigram December 18, 2008
Early Society findings from the WHIO Data Mart
Two Society staff members joined other WHIO organizations the week of December 8 for an in-depth training on the WHIO Data Mart and its tools and applications. During WHIO’s first quarter study period, the Society’s efforts will be centered on, first and foremost, evaluating the reliability and validity of the WHIO data and then in identifying the potential uses and value of the Data Mart for physician practices in Wisconsin. General and early findings from working with the Data Mart are presented below.Possible Advantage: USABILITY
The biggest asset of the Data Mart and its tools may be that it takes into consideration a multitude of metrics to ascertain standardized costs, utilization of services and quality of care. These metrics then can be used to assess the comprehensive performance of physician practices. In a positive way, the Data Mart can be likened to a labyrinth—they key is in learning how to navigate the data with the designated tools, thus determining the credibility of the reported findings.
The information appears to be useful in monitoring costs by condition, gauging compliance with the evidence based guidelines and tracking differences in health risks within the member and patient populations. Not only does the tool allow the user to get the numbers for all these different categories, it also provides the aptitude of mixing and matching these metrics for comparative study. The application can break this detail down to the level of encounters, episodes of disease, number of scripts, generic vs. brand name drugs prescribed, inpatient admits, outpatient services, specialties, lab and imaging services provided.
The application appears to be fairly facile and can be mastered in little time to generate these figures and comparisons by a trained user.
Possible Disadvantage: RELIABILITY AND VALIDITY
The biggest drawbacks relate to ascertaining the reliability and validity of the information obtained from the WHIO Data Mart. During the first quarter of 2009 WHIO stakeholders will be evaluating if the data accurately represent practice patterns and cost of care. The information offered, especially the performance measures, ratios and indices, is disconcerting and even confusing to the uninitiated viewer of the data. There is no way to ascertain the 'accuracy of representation' of the criteria mentioned, unless we fully understand the algorithms and formulae that constitute them.
Also, the comparisons in data may vary depending upon a plethora of factors like case mix, episode, size of facility, etc, and it is difficult to determine if all physicians/practices are being compared by the same touchstones. These intrinsic technicalities of the application may generate increased hesitancy by the physician community. The purpose of the study is to build an understanding of the breadth and depth of data and evaluate the limitations that may exist.
The Society will continue to work with WHIO and Ingenix to enhance the transparency of the application, as well as the flexibility of the reporting tools so physicians identify some perceptive and actionable value from the information. Currently, the reported data demands some amount of translation to make the final product more lucid and evident.
During the first quarter study period, the Society will continue to provide updates on both the potential uses and limitations of the WHIO Data Mart through Medigram. If you have any questions or concerns, please contact the Society's Quality & Efficiency department.
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From Medigram December 4, 2008
WHIO Data Mart ready for participating organization access
Over the last several months, the Wisconsin Medical Society (Society) has worked to keep members and the physician community aware of the activities of the Wisconsin Health Information Organization (WHIO). As a founding member of WHIO, the Society is proud to announce that the first version of the WHIO Data Mart was delivered to the WHIO Executive Director on Tuesday, December 2—one day ahead of schedule. This first version of the Data Mart included the following inputs:- 1.6 million unique members (or patient lives)
- 25,000 providers (physicians and other medical professionals)
- 56 million individual claims
- 6 million treatment episodes
So what happens next?
- All participating organizations will sign the Board-approved Data Use Agreement. This is required for any organization to have access to the WHIO Data Mart.
- All participating organizations will attend a two-day training session the week of December 8 to understand the Data Mart structure and its analytical tools.
- All participating organizations will have access to the Data Mart during the first quarter 2009 study period. The Society will be evaluating the reliability and validity of the data during this time frame.
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From Medigram November 13, 2008
A Perspective: Why physician satisfaction must matter to WHIO
The just-released report, “Who Will Care for Our Patients?” indicates that Wisconsin is short nearly 374 primary care physicians across 31 counties. The research conducted by the Wisconsin Council for Medical Education and Workforce (WCMEW), of which the Society is a member, also indicated the demand for physicians will grow by nearly 30 percent in the next 10 years alone, and that the supply will fall far short of demand.So why do efforts like WHIO matter to the growing and real concerns regarding physician shortages in Wisconsin?
The Society provided additional data for the WCMEW report, which was gathered through a robust survey of Wisconsin physicians. The survey indicated over 40 percent of respondents are either “dissatisfied” or “very dissatisfied” with their quality of life in relation to the demands of the profession. Anecdotal responses from these physicians make a compelling case that non-clinical activities like excessive documentation, redundant and unnecessary administrative duties, pressure to implement costly electronic medical records software and required reporting to multiple entities with little to no standardization—which are mandated by various government and private constituencies—are key factors contributing to the declining supply of physicians and the rising cost of medical services.
The Wisconsin Medical Society’s mission is to improve the health of the people of Wisconsin by supporting and strengthening physicians' ability to practice high-quality patient care in a changing environment. Efforts like WHIO are important to the collaborative process of improving the current health care delivery system for all stakeholders. Yet thoughtful deliberation must be given to the impact—and possible unintended consequences—these efforts may have on patients and the physicians who provide their care. The Society is working to ensure that, at a minimum, initiatives like WHIO safeguard against adding pressure to the already known shortage of physicians in Wisconsin.
To learn more about WHIO, click here. If you have questions, e-mail QandE@wismed.org.
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From Medigram November 6, 2008
Society milestones in transparency
For the past four months, Medigram has featured weekly updates on the work of the Wisconsin Health Information Organization and the Wisconsin Medical Society’s role in these initiatives. But the Society’s work toward increased health care transparency is not limited to its involvement at the WHIO table. The following provides a brief overview of Society milestones over the past 12 months.- October 2007
The Wisconsin Medical Society (Society) was formally designated by the U.S. Department of Health and Human Services (HHS) as a Community Leader—or an organization that works to achieve the four cornerstones of value-driven health care. The Executive Order, Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs, was intended to ensure that health care programs administered or sponsored by the federal government build on collaborative efforts to promote:- Interoperable Health Information Technology (Health IT Standards)
- Measure and Publish Quality Information (Quality Standards)
- Measure and Publish Price Information (Price Standards)
- Promote Quality and Efficiency of Care (Provider Incentives)
- February 2008
HHS Secretary Mike Leavitt named 14 community collaborations as Chartered Value Exchanges (CVEs), including the Wisconsin Healthcare Value Exchange. The Society, and its fellow members of the Wisconsin CVE, has access to information from Medicare that gauges the quality of care that physicians provide to patients. These performance measurement results may be combined with similar private-sector data to produce a more comprehensive guide to the quality of care in the CVE communities. - April 2008
The Society endorsed a resolution on Adverse Events and Patient Safety in partnership with the Wisconsin Hospital Association. The resolutions states that no patient should be billed for hospital care that results in one of the following serious adverse events:- Surgery on wrong body part
- Surgery on wrong patient
- Wrong surgical procedure
- Unintended retention of a foreign object
- Patient death or serious disability associated with air embolism that occurs while being treated in a health care facility
- Patient death or serious disability associated with a hemolytic reaction due to administration of ABO/HLA incompatible blood or blood products
- Artificial insemination with the wrong donor sperm or wrong egg
- Infant discharged to the wrong person
- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances
- June 2008
The Society, along with Metastar and the Wisconsin Collaborative for Healthcare Quality, were selected by HHS to participate in a national Medicare demonstration project that provides incentive payments to physicians for using certified electronic health records (EHR) to improve the quality of patient care. This is a five-year, first-of-its-kind project that will commence with physician practice recruitment in 2009. - October 2008
The Society passed a set of Transparency Principles for use by Society staff and its physician members in external forums. These principles are intended to provide a general, yet succinct description of the Society’s position on Transparency. The recommended principles include the following:- The Society believes the relationship between the Patient and Physician is critical to positive health outcomes. Transparency efforts should not supersede or unnecessarily impact the patient-physician trust.
- The Society believes there is benefit to using a common database of health care information that is aggregated across key stakeholder groups for multiple uses, including quality improvement, population health research, public reporting, financial risk-sharing models and product development.
- The Society believes the value associated with the database is based on the credibility of the data, which results from the collaborative process and methodological rigor applied to these data products. The credibility must be preserved and enhanced as the scope, sources and uses of the data expand.
- The Society believes it is critical to deploy a collaborative system to measure error rates and gaps in the data, as well as performance variations. Stakeholders must commit to correct/improve these conditions over time and thus make fair and reasonable decision on public reporting of information.
- The Society believes that the use of nationally vetted and endorsed measures will serve to decrease variation and allow for improvements in health care delivery.
- The Society believes that Quality and Cost Measurement should be evidence-based and reported together whenever possible for stakeholder decision-making.
- The Society believes that it is essential, for the public good, that the measures derived from the database are reliable, valid and can favorably influence the outcome of patient care.
- The Society believes that a disciplined, neutrally operated appeals/dispute resolution policy, that audits data results and processes used to reach results, must accommodate the database. Further, if an appeal is significant and pervasive in the data, a moratorium on access to and use of the data must be activated until the data is remedied.
- The Society expects that users of the data would commit to the following:
- Users will use data in a way that is accurate, meaningful and statistically valid.
- Users will openly disclose to the physician community the objectives, measures and methods related to any use of performance data.
- Users will work to include the most effective risk adjustment as possible, and any adjustment methods included in the users analysis will be fully described including the limitations of such adjustments.
- Users will reference the source of the data and display its imprimatur.
- Users will develop and implement strategies for monitoring the impact of the implied uses of performance data that are not unduly burdensome.
- Throughout 2009
The Society will continue to foster collaboration across multiple stakeholders, promote the effective application of national provider performance measures, support use of inter-operable health information technologies and enhance knowledge transfer on improvement efforts.
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From Medigram October 30, 2008
Are we up for the tipping point?
Tim Bartholow, MD
I recently attended a conference on quality and safety, along with several hundred other smart, motivated and practical people affiliated in various ways to our health care delivery system. During the course of the presentations, one of the speakers posed the question, “Surely all of our physicians will quickly and willingly engage in opportunities to improve quality. Right?” To which the majority of the audience responded with knowing laughter. Although I was a bit stunned—and maybe embarrassed—by the response, I couldn’t help but ask myself, “Am I, and my physician colleagues, ready to proactively lead efforts that will improve the cost-efficiency and quality of health care we provide to our patients?”
Malcom Gladwell, author of the acclaimed best seller The Tipping Point, claims that the theory of the tipping point requires that we reframe the way we think about the world in which we operate. The stakeholders participating in the Wisconsin Health Information Organization (WHIO) have faced the difficult challenge of working together when individual goals and interests are not always aligned. Purchasers may use the WHIO data to identify better health care value; insurance companies may use the WHIO data to determine “high performing” provider networks. Hospitals and physicians may use the WHIO data to drive quality improvement initiatives, study geographic practice variation or reduce health care disparity in patient populations.
The WHIO Data Mart will be operational by the end of this year. During the first quarter of 2009, the credibility and value of the WHIO data will be tested by the participating organizations, including the Wisconsin Medical Society. The availability of WHIO data will create a “tipping point moment” for many physicians. Some of us may to decide to ignore the data and continue to practice status quo. Others of us will engage the information to improve our practice and the care we provide our patients.
As physicians, we have the choice to lead transparency initiatives in Wisconsin and nationally—or to follow. This may require us to look differently at how we respond to and use information from organizations like WHIO. Through a physician-led tipping point, we may find unexpected partners who share a mutually beneficial vision for improving our health care delivery system. Who could refuse a health care system that better aligns access, quality and cost? I, for one, am ready to lead this charge.
Note: Doctor Bartholow is a family practice physician from Sauk City, Wisconsin. Over the past year, he has served a Chair of the WHIO Physician Cabinet and as its representative on the WHIO Board of Directors. He recently joined the Wisconsin Medical Society staff as Senior Vice President of Member Services, Policy Planning and Physician Professional Development.
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From Medigram October 23, 2008
What physicians should know about the WHIO Data Mart
Development of the Wisconsin Health Information Organization’s (WHIO) Data Mart is on target for its initial launch in early December 2008. WHIO participating organizations will be trained on how to access the data mart and its data in December. Meanwhile, the following bullet points highlight core information about the Data Mart that every physician in Wisconsin should know.- The initial data mart is comprised of administrative claims information representing 1.9 million fully insured and self-funded lives who received health care services in Wisconsin.
- The administrative claims data was submitted by five insurance companies including Anthem BCBS, UnitedHealthcare, Humana, WEA Trust and Wisconsin Physicians Service. Three additional data sources, including Medicaid are committed to feeding data into the data mart in 2009.
- The data mart will hold 27 months of member eligibility information and claims data, ranging from January 2006 through March 2008. The data mart will be refreshed twice/year always maintaining a rolling 27 months of data.
- The data fields pertaining to payer source, purchase/employer name and patient/member information have been de-identified.
- Physician information will be reported by practice affiliation, site location and area of specialty, but not at the individual physician level. WHIO will not report performance results of a practice site that would have the effect of disclosing the performance results of a physician in solo practice at that site. Such performance results will be reported with a proxy group designation or other acceptable method to avoid individual physician disclosure.
- WHIO participating organizations, including the Wisconsin Medical Society, will have access to aggregate comparison reports, the Ingenix analytical tools and reporting functions and the raw data for internal business purposes.
- In the designated first quarter 2009 study period, participating organizations will work to identify defects, gaps and uses of the data. A pilot project will also be conducted with four physician practices to evaluate the data mart’s reporting capacity, including the credibility and usefulness of the data for practice improvement efforts. The Society will assist WHIO during this study to assess the resource physicians will need to address their issues with the data mart outputs.
- The Society will be conducting a series of independent studies of the data contained in the data mart during the first quarter of 2009. These studies will evaluate data reliability for use in cost-efficiency measurement and data validity for improving patient outcomes.
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From Medigram October 16, 2008
Society Board approves transparency principles
“Transparency” is a concept frequently referenced in health care reform discussions. Policymakers from all points of the political spectrum believe that transparency, in various forms, may serve to positively impact health care quality, cost and access issues. The Society has recognized that issues leading to transparency are deeper and more complex than campaign bullet points and if not well considered can actually have a negative impact on patient care. This past weekend, the Society’s Board of Directors took action to inject more clarity and depth to discussions about transparency by approving a set of transparency principles.This is not the first time the Society has addressed this issue. In 2004, the Society House of Delegates passed a policy regarding the use of data as it relates to performance measurement. The policy, (DHC-004: Characteristics of Ideal Performance Measures), established a set of criteria to guide a disciplined approach to transparency.
Over the last several years, initiatives by insurers, employers and the federal government have incorporated the use of data and performance measurement into their Pay for Performance strategies. The Society (as well as other provider stakeholders) has diligently represented the interests of the physician community regarding transparency—the ability to compare cost and quality information for improved health care decision-making—in national and state debates, including those occurring at the Wisconsin Health Information Organization (WHIO).
Over the past several months, WHIO’s Board of Directors has been deliberating over the terms and conditions in the organization’s Data Use Agreement. The Society has been actively involved in these challenging discussions and in efforts to reach compromising language to serve physicians’ best interests. The finalized Data Use Agreement will become a formal legal document and all WHIO participating organizations, who sign this portion of their WHIO contract, will be required to comply with its terms. WHIO anticipates Board approval of this document at its November meeting.
Society members are encouraged to review and reference the Board-approved transparency principles in discussions on transparency and use of data. These principles do not replace DHC-004; rather, they are intended to provide a more general, yet succinct description of the Society’s position on transparency.
It is likely the November elections will only enhance calls for reforming the health care system, including bipartisan calls for more transparency. The Board’s action allows the Society to continue its commitment to ensuring physicians have a say in how these issues evolve.
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From Medigram October 9, 2008
WHIO Physician Cabinet meets October 15
With the WHIO data mart targeted for initial release in early December 2008, the seven-member physician advisory group will be meeting October 15 to determine details of the first quarter study period, including finalizing the expectations of Physician Reporting Pilot Program.The Study Period Process, approved by the WHIO Board, is composed of two large scale acceptance test functions that will run concurrently throughout the first quarter of 2009. The Pilot Program will exercise and evaluate the processes and outputs of the performance measurement program at a micro or provider group level. The Data Study will focus on analysis and evaluation of the accuracy and completeness of the data in the data mart at a macro or market level. Information from the Pilot Program and the Data Study will be collected and shared with WHIO participating organizations throughout the quarter. A final report of findings and recommendations will be issued to the WHIO Board of Directors at its April Board meeting.
“Hastily measuring doctors with data that does not accurately reflect the complexity of practices may ultimately damage the patients’ trust in their doctors and unfairly measure physicians,” said Tim Bartholow, MD, Chair of the Physician Cabinet. The Physician Cabinet, created by WHIO to provide real world focus on what data will be useful to both physicians and patients, advises the WHIO Board on practical physician measurement and reporting applications.
The Cabinet will also be reviewing a slate of physician practices identified to particiapte in the Pilot Program at its upcoming meeting. Practices were considered eligible for the pilot based on the volume of claims they have in the initial data mart and on several other criteria relating to their current use of data for quality improvement.
If you or your practice is interested in learning more about the WHIO Study Period Process, please send an e-mail or your questions to qande@wismed.org.
Also, the Physician Cabinet is interested in recruiting additional physicians to serve in an advisory capacity to WHIO. Members of WHIO’s Physician Cabinet currently include these physicians: Tim Bartholow, MD, Gregory Blommel, MD, Jay Gold, MD, JD, MPH, Rita Hanson, MD, Mark Kehrberg, MD, Lowell Keppel, MD, and David Smith, MD. Please e-mail qande@wismed.org if you are interested.
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From Medigram October 2, 2008
WHIO Pilot Program Scheduled For First Quarter 2009
WHIO will begin the process of selecting its first group of physician practices to test the processes and outputs of the WHIO reporting program. This pilot will be conducted during the first quarter of 2009 and will use “live” WHIO data.By working with physicians in a pilot setting, WHIO expects to identify defects in the initial data mart, gain an understanding of the impact of data gaps and determine reasonable and viable methods for improving the data. WHIO CEO Julie Bartels commented, “It is important that we understand this is a 'test' and that the process will involve finding out what works and what doesn't work.”
Phyician practices (large, small, rural, urban, speciality, etc) will be considered for the pilot based on ranking a set of criteria that includes the following:
- The practice presently receives performance reports
- The practice uses information from these reports in its Quality Improvement initiatives
- The practice considers itself to be an ‘early adopter’ of new treatments/processes
- The physicians in the practcie actively seek to involve patients in decisions regarding their care
- The practice routinely sets aside time to discuss clinical and business issues and it has a mechanism for follow up to evaluate its actions
The initial pilot will include no more than six physician practices. WHIO will work very closely with these groups, delivering the first reports in person and providing a walk-through of the results. If your practice is interested in being considered for this, or any WHIO pilot activity, please provide your name, clinic location and contact information to qande@wismed.org.
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From Medigram September 25, 2008
McGlynn focuses on cost and performance measures at Efficiency Symposium
Note: This article is the second brief summary of presentations from the “Efficiency Symposium: Methods, Measures and Policy Impact” which was held September 16 and sponsored jointly by the Wisconsin Medical Society and the Wisconsin Collaborate for Healthcare Quality. (Click here to read a summary of the presentation by speaker Mark Rattray, MD, which was in last week’s Medigram.)Elizabeth McGlynn, PhD, spoke about key considerations involving health care cost and performance measurement to nearly 100 attendees of last week’s “Efficiency Symposium: Methods, Measures and Policy Impact,” which was jointly sponsored by the Wisconsin Medical Society and the Wisconsin Collaborate for Healthcare Quality. Dr McGlynn is an associate director for RAND Health and holds its Distinguished Chair in Health Care Quality. She is currently leading the COMPARE initiative, which is developing a comprehensive method for evaluating options to improve the performance of the U.S. health care system.
Noting that the latest trend is consumer-directed health care, McGlynn emphasized patients will be the “engine of change.” It is critical that adequate information exist for patients to choose the right health care professional based upon quality and cost metrics. “Employers providing insurance coverage might be willing to give (patients) a Hyundai but they’re not going to pay for a Mercedes,” she said, but added that “just putting information out there does not appear to drive patients to do anything differently.”
From 2003 until 2005, a study was conducted using data from four Massachusetts health plans. The study focused on adults, 18-65. “Grouping” methodology bundled care into episodes (types of treatment). Then costs were assembled for each episode of care. “These actual costs are then compared to the average of that type of care,” McGlynn said. Ranking of physicians then was applied with the following considerations: aggregation, attribution, reliability, classification, metrics, level of analysis and standardized costs; McGlynn elaborated on the first four.
Aggregation is determining “if we are able to compile data across health plans, does it increase our opportunity to profile physicians through increased sample sizes?” The conclusion was that combining data did not provide as much of a “lift” as was hoped. “However, it was still a worthwhile consideration,” McGlynn added.
Attribution is determining how episodes of care are attached to particular doctors. McGlynn noted that more than half of all patients saw five or more physicians over the period of the study. Admitting that this was not an exact science, she pointed out that vital considerations are how the information is aligned with patient choices and that the information is adequate to making decisions combining quality and value.
Reliability measures how much variation in observed scores is explained by real differences in physician performance. The metrics must differentiate the performance of one physician from the other, however, “We may have to measure reliability beyond the individual physician level,” said McGlynn. She proposed that lower levels of reliability (70-80%) are acceptable for drawing conclusions at the group level. Psychometricians use a rule of thumb of 90% reliability for determining individual physician conclusions. Reliability can be increased by a larger number of observations and greater clarity in the measurement. Using low reliability information to drive physician change could have undesirable consequences. McGlynn also cautioned that reliability does not address validity.
Classification of physicians breaks down into two methods. First, the “bright line” test essentially categorizes doctors into quartiles with an emphasis on the comparison of performance above or below the halfway point. Second, the statistical classification is a measurement of performance that is statistically different from peers. The breakdown effectively mirrors a bell curve. McGlynn concluded that the most rigorous tests (statistical classification) must be used.
McGlynn concluded her comments by encouraging stakeholder involvement in efforts in cost-efficiency. She reminded the attendees that “getting something for nothing probably isn’t one of the options.”
A DVD of this presentation is available on a limited basis, please call the Society at 608.442.3800. For a copy of the slides from her presentation, click here.
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From Medigram September 18, 2008
Rattray, McGlynn featured at Efficiency Symposium
Mark Rattray, MD, and Elizabeth McGlynn, PhD, addressed nearly 100 attendees during Tuesday’s “Efficiency Symposium: Methods, Measures and Policy Impact,” which was jointly sponsored by the Wisconsin Medical Society and the Wisconsin Collaborate for Healthcare Quality.Doctor Rattray, president and executive consultant of CareVariance LLC, offered insights into physician practice measurement and examined the following key considerations for effective measurement:
- Measurement and improvement drivers
- Current measurement and improvement environment
- Improving measurement
- Improving ‘improvement”
“There must be critical stakeholder commitment to the process,” he said. Increasingly, physicians better understand the connection between measurement and positive patient outcomes, he noted and it is now widely accepted that “until you measure your performance, you can’t accurately assess the impact you are having on treating patients.” However, Dr. Rattray went on to explain that it is tough to realize that “the bell-shaped curve is alive and well in medicine and that there will be physicians at the lower end of the curve and the upper end regardless of the measurement device you use.”
In a 2004 study of 40 million claims, it became evident that the medical profession couldn’t use quality measurement to predict efficiency, and efficiency and cost of care measurements weren’t accurate predictors of quality. “Employers were disappointed because in their world quality and efficiency go hand in hand,” said Dr. Rattray. Consequently, it has been accepted that the involvement of clinicians as a “critical mass” is a primary driver in the accurate measurement process.
The measurement and improvement environment is evolving rapidly as national, state and regional groups enter the fray with more sophisticated approaches. “Accurately developed claims data that includes physician input and review can be quite reliable for assessing process quality,” Dr. Rattray offered. However, specialty practices have a unique challenge in that the number of measurements is more limited than primary practice physicians. “With narrow measurement parameters, are you really measuring the quality of that practice,” he added. This process of evaluation has led to three categories of care for measurement purposes:
- Effective Care which is care all patients should get if they qualify.
- Preference Sensitive Care where different choices carry different benefits and risks
- Supply Sensitive Care where the “right mount of care is provided at the right time for the right reasons.”
Doctor Rattray went on to assess factors in improving measurement. “Measures should be meaningful to consumers and address a broad array of physician activities.” In addition, targets for measurement must be actively engaged in the process. Measures and methodology must be “transparent and valid” and measures must be based upon national standards whenever possible.
Finally, “improving improvement’ will be a dynamic process where accountability, payment reform and “more actionable” reporting are critical.
To access slides from Dr. Rattray’s presentation, click here.
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From Medigram August 28, 2008
The differences between UnitedHealthcare's Premium Designation Program and WHIO's Data Mart
In an article in today’s Medigram, UnitedHealthcare notified Society members about changes to its Premium Designation Program (UHPD) and that its 2008 review cycle is underway. For the past several weeks, Medigram has published a series of articles about the Wisconsin Health Information Organization (WHIO). The timing of UnitedHealthcare’s announcements affords us the opportunity this week to examine some of the differences and similarities that exist between a health plan program like that of UnitedHealthcare’s and the work underway with WHIO.UHPD: In October 2008, Wisconsin physicians will receive their annual assessment report from UnitedHealthcare’s Premium Designation program. This is not a new program, nor does it currently use data provided by WHIO. Other insurers have similar programs or Pay for Performance initiatives either in development or operation.
WHIO: The WHIO Data Mart remains on schedule for a December 2008 production date. A proposed “study period” during the first quarter of 2009 is being proposed to the WHIO Board of Directors. The study period will allow participating WHIO organizations, including UnitedHealthcare, to test the data for defects and uses.
UHPD: In a letter to the Society, UnitedHealthcare commented, “The enhancements to the Premium program for 2008 incorporated recommendations from the physician community, medical specialty societies and physician advisory boards. “
WHIO: The endorsed provisions of the Patient Charter and NCQA Quality Reporting Guidelines will assist in the more credible and accountable use of physician measurement and reporting by insurers. Many national insurers have endorsed the Charter. The WHIO Board is prepared to approve a set of Data Use Guidelines that adopt these criteria at their September meeting.
UHPD: UnitedHealthcare’s annual assessment reports are based on refreshed paid claims data. The upcoming report will include claims paid through Feb. 19, 2008 with dates of service from Dec. 1, 2005 through Nov. 30, 2007.
WHIO: WHIO’s Data Mart will be comprised of historical administrative claims data currently submitted by five insurers doing business in Wisconsin. The Clinical Advisory Group of WHIO has also selected a starter set of measures that will be reported using the WHIO data. The Society is positioning itself to conduct a “validity study” to assess the variation between administrative claims data and clinical information when using it for quality improvement and/or measurement and reporting purposes.
UHPD: UnitedHealthcare will notify physicians of their individual designation status at least 45 days prior to any public disclosure of the results to give physicians the opportunity to seek clarification and, if necessary, to request reconsideration. New designations will be available on their consumer Web sites by the end of the year.
WHIO: The transparency requirement in the Patient Charter states that “reporting organizations must be prepared to identify and share patient data that was used to generate the provider performance measure.” At this time, WHIO data on patients will be de-identified, thus the WHIO data cannot be used by insurers like UnitedHealth in the development of their Premium Designation Program. WHIO does anticipate that when conflicting measures are produced from other sources, using different data or other measurement methods, physicians will be able to challenge the results by comparing it to WHIO data and methods. This has the potential to drive more open conversation about real practice patterns and real costs and lead to consistency in measurement methods across sources.
UHPD: Comprehensive information about the program is available on UnitedHealthcare’s physician Web site.
WHIO: The Wisconsin Medical Society has been publishing a series of articles about WHIO in Medigram. This series of articles can be found here.
“Programs like UnitedHealthcare’s are evidence that insurers are being pushed hard by their customers to give them information about their choice of physicians and to get costs under control,” said Julie Bartels, WHIO CEO. “Directionally it is good, but specifically (especially at the practicing physician level) we have a lot to learn.”
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From Medigram August 14, 2008
WHIO's Top 10 Q&A
For the past nine weeks, Medigram has published a series of articles about WHIO, the Wisconsin Health Information Organization. To recap, we’ve put together this “Top 10 Q&A” to provide Society members and other readers with a summary of key need-to-know WHIO info.- What is WHIO?
The Wisconsin Health Information Organization is a not-for-profit organization comprised of key health care stakeholders in Wisconsin. Its goal is to use health care data to improve the equality, affordability, safety and efficiency of Wisconsin health care. - Who are WHIO’s members?
Organizations currently participating in WHIO include the Society, Anthem Blue Cross Blue Shield of Wisconsin, Employers Health Care Alliance Cooperative, Greater Milwaukee Business Foundation on Health, Humana, the Wisconsin Departments of Health and Family Services and Employee Trust Funds, United Healthcare of Wisconsin, WEA Trust, Wisconsin Collaborative for Healthcare Quality, Wisconsin Hospital Association and WPS Health Insurance. - Besides being a WHIO member, how is the Wisconsin Medical Society involved?
The Society is a founding member of WHIO and holds a seat on its Board of Directors. Society members are also involved WHIO’s Physician Cabinet and Clinical Advisory Group. - What is WHIO’s Physician Cabinet (PC)?
The PC is a seven-physician advisory group that provides real world focus on what data will be useful to both physicians and patients and advises on practical physician measurement and reporting applications. - What is CAG?
WHIO’s Clinical Advisory Group (CAG) advises WHIO regarding methods and measurements for producing provider performance reports. - What is WHIO’s Data Mart?
Scheduled for initial completion in December 2008, the Data Mart will aggregate administrative claims data from 1.9 million of Wisconsin’s 5.5 million citizens. It will be populated continuously with up-to-date administrative claims data from several data-submitting organizations, mostly health insurers, and will be the data will be used for tracking, analyzing and measuring episodes of care and their costs over time. - Who will benefit from the impending WHIO Data Mart and the availability of health care information?
According to John Foley, vice president of Health Services for Anthem Blue, payer, purchasers and health care professionals will all benefit from this data. As health care cost and quality information becomes public, the WHIO data will create metrics and measurements the entire industry can use to find ways to improve how we do business, and contribute to the health of our communities. - What are the WHIO Board of Directors and committees focused on right now?
Finalizing the WHIO data use guidelines, outlining the expectations of a first quarter study period and preparing sample reports for physicians and other WHIO data users. - Why is finalizing data use guidelines right now so important?
According to WHIO’s Executive Director Julie Bartels, these guidelines are essential as WHIO moves forward in order to establish consistency in data reporting across health plans and to support innovation and quality improvement. - How can physicians learn more about efficiency of care issues?
The Society is partnering with the Wisconsin Collaborative for Healthcare Quality (WCHQ), to hold a symposium on efficiency and effectiveness of care: Methods, Measures and Policy Impact Tuesday, September 16, 2008, from 7:30 a.m.-noon. The symposium is being held in conjuction with the Society’s regularly scheduled Quality Forum on that day and will feature two industry experts Elizabeth McGlynn, PhD, and Mark Rattray, MD.
Medigram readers interested in attending the Symposium or in receiving further information about the Society’s Quality Forum may e-mail QandE@wismed.org or click here to read the original article.
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From Medigram August 7, 2008
Interview with John Foley: the payer perspective
The Wisconsin Health Information Organization (WHIO) involves the collaboration of health care payers, purchasers and providers in a landmark health care transparency endeavor. John Foley, vice president of Health Services for Anthem Blue Cross and Blue Shield in Wisconsin, answers questions regarding WHIO and payer involvement in the Data Mart effort.What, from a payer perspective, would make health care data credible enough to be reported?
As a payer, we want health care cost and quality data to be available, so consumers are empowered to have the information they need to make decisions about their care. This means working with providers to make sure data is standardized, statistically valid and appropriately reflects a provider’s practice pattern.
Anthem Blue Cross and Blue Shield (Anthem), through our parent company, WellPoint, has taken the first step in collaborating with providers on behalf of consumers by adopting the patient charter initiated by Attorney General Andrew M. Cuomo in New York State.
In previous interviews, you’ve addressed “variations in health care.” How does payer involvement and WHIO’s upcoming Data Mart address variations in health care?
Price variation is one factor in why Wisconsin has been seen as a state with higher health care costs. Anthem believes making cost and quality data available is important if that is going to change.
The full disclosure of the cost and quality of an episode of care (meaning all the costs involved in a given procedure—doctor, anesthesia, facility, etc.) is a first step in controlling rising health care costs. The public needs to understand there is variation in health care costs and quality, and they have a choice in their health care professionals. Tools and reports from initiatives like WHIO will assist in reducing the variation in health care and empower consumers to make informed decisions. As cost and quality data is more widely available, we anticipate variation in costs between providers will narrow, thereby helping to control overall health care costs.
Why do you believe the WHIO endeavor is taking longer than previously expected?
WHIO is a landmark endeavor. Never before have a hospital association, a medical society, five payers, purchasers of health care, and state government come together to improve the quality and efficiencies of health care.
WHIO is breaking new ground, and everyone involved wants to make sure we get it right before the data hits the marketplace. We are learning how to work together, recognizing each other’s concerns and expectations, and building a strong working relationship to get the data right for the consumers.
How do you see payers benefiting from this collaboration of payers, providers and purchasers?
Payers will always be looking to differentiate themselves from one another, but we all understand that everyone – payers, providers and consumers – stand to benefit from the availability of health care data.
As health care cost and quality information becomes public, the WHIO data will create metrics and measurements the entire industry can use to find ways to improve how we do business, and contribute to the health of our communities.
What are the sources and extent of pressure for the creation and maintenance of this Data Mart?
The drive to undertake this project and get it right is coming from everyone involved with WHIO.
Employers are feeling cost pressures. Providers are seeking quality scores in an industry that does not have well-established quality measures. Physicians are high achievers looking to improve the quality of the health care they provide to help their patients get better faster and stay healthy.
For health care in Wisconsin to retain its high quality and become more affordable, we have to create a market in health care; that’s what the WHIO data is going to do for consumers. In an open and accountable marketplace, competition among providers will then focus on providing consumers with the best value proposition available, based off of quality scores. This is a desirable outcome for all who use and participate in our health care system.
In short, everyone wants to improve the customer’s health care experience. To do that, we need the data to know how we’re doing and what we can do better.
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From Medigram July 31, 2008
Q&A with Julie Bartels, executive director of WHIO: Key issues
Over the next few months, the Wisconsin Health Information Organization (WHIO) will continue their diligent efforts in acquiring, testing and producing a statewide health care Data Mart. Julie Bartels, the executive director of WHIO, offered insight into WHIO’s progress toward advancing Wisconsin’s transparency agenda.What are the key issues slated for WHIO over the next 60 to 90 days?
Anthem BCBS, United Healthcare, WEA Trust, WPS and Humana are currently sending their Wisconsin-based administrative claims data to Ingenix, a health care information and research company, to import into the WHIO Data Mart. We are on schedule so far, and remaining on schedule is so critical to delivering a productive Data Mart at year’s end.
WHIO must finalize the Data Use Guidelines so that all current members and potential new members understand what data will be made available and how it can be used for member company business purposes. This is tricky, because we're looking to create consistency in reporting of the data across health plans, while supporting innovation and quality improvement at the same time.
WHIO is also preparing to test the data contained in the Data Mart. This will include establishing minimum parameters on sample size, assessing data credibility and determining effective data uses. The data must be accurate and actionable in order to support provider practice quality improvement activities.
How is WHIO navigating through these key decision-making areas?
WHIO is a multi-stakeholder organization that depends on the participation of its members and work groups established to consider these tough issues. Fortunately, our members have been willing to commit tremendous in kind staff resources to these efforts. At any point in time, there can be as many as 35 to 40 people working on WHIO projects from member health plans, employer purchasing groups or provider organizations.
Physician participation is especially critical in addressing issues of WHIO Data Use Guidelines and Reporting Parameters, as mentioned previously. Many physicians have dedicated a significant amount of time to this effort through the Physicians Cabinet and the Clinical Advisory Group—both are voluntary work groups. In addition, we have consulting expertise provided through our contract with Reden&Anders, the consulting arm of Ingenix.
Where do key stakeholder stand on these key issues?
All stakeholders agree on WHIO’s core objective—that is, aggregating administrative claims data for reporting purposes. It just makes sense that a more reliable result can be achieved by collecting data from multiple sources and producing reports on a more statistically significant base of data.
The difference among stakeholders occurs in how the data will be put to work. Some believe that the data should only be used be when there are valid and consistent outputs/measures. Others are concerned that too many restrictions on data use will stifle innovation that could lead to product or process breakthroughs and opportunities for quality improvement. These potential breakthroughs might have a significant, positive impact on future health care costs.
WHIO is breaking new ground, and, therefore, we have no specific model to follow. The best case scenario will be determined by bringing together the best minds with the best intentions and asking them to work collectively and collaboratively through the issues. Shared understanding of motivation and intention of the various stakeholders, and a willingness to compromise in order to make progress, will get us to where we need to go.
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From Medigram July 24, 2008
Society keeps pulse on key physician issues in WHIO
The Wisconsin Medical Society, along with the Wisconsin Hospital Association and the Wisconsin Collaborative for Healthcare Quality, continue to actively represent the interests of health care professionals on key WHIO issues related to transparency. Following are four key areas of critical decision-making currently being considered by WHIO committees and its Board of Directors.1) Data Use Guidelines
- WHIO has been diligently working with its stakeholder groups to establish a set of guidelines for use with the Data Mart. Although there are many areas of consensus in how the data will be used, there also are conflicting and competing approaches among payers, providers and purchasers. (Note: The launch of the Data Mart is anticipated in December 2008. See this article for more information.)
- The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs was designed to ensure transparency, fairness and an independent review of data use. This nationally supported document is being used as the template for discussion.
- The WHIO work group addressing data use will convene in early August for further discussion on the guidelines, with a WHIO Board decision scheduled for September 2008.
- With the Data Mart’s launch expected by year-end, physician representatives have strongly advocated for WHIO to designate a study period prior to the release of data.
- A physician/practice pilot will be conducted during the first quarter of 2009 to test training, communication, measure reporting and inquiry/resolution processes. During this proposed study period, WHIO participating organizations would also have access to the data to assess its defects and/or gaps. All work resulting during this period would be considered a test and not used for productive proposes.
- It is anticipated that the WHIO Board will vote on this important recommendation in August.
- While most WHIO stakeholders agree that a set of cost/resource measures for public reporting is vital, the methodology of reporting complex health care data has inspired much discussion among WHIO stakeholders. Those discussions, which include the critical role of data reliability and validity, continue among members of WHIO’s Clinical Advisory Group. These discussions are also serving to shape the Data Use Guidelines.
- Currently, plans are for data to be reported at the physician “group” level rather than the “individual” physician level.
- At this point, WHIO has five health plans contributing data to the Data Mart, which represent approximately 1.9 million Wisconsinites. Expanding the number of health plans participating in WHIO will generate a more complete and robust view of the state’s health care utilization.
- As WHIO recruits new members, it must also work to maintain balanced representation among its health care stakeholders (payers, providers and purchasers), especially on its Board of Directors.
- The WHIO Board will continue to discuss adding new members, particularly as it relates to Wisconsin’s provider-sponsored plans. One of several issues for discussion is whether provider-sponsored plans are providers or payers of health care.
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From Medigram July 17, 2008
Society and WCHQ partnering on efficiency symposium in anticipation of WHIO Data Mart
The Wisconsin Medical Society (Society) is partnering with the Wisconsin Collaborative for Healthcare Quality (WCHQ), to hold a symposium on efficiency and effectiveness of care: Methods, Measures and Policy Impact. This symposium is set for Tuesday, September 16, 2008, from 7:30 a.m.-noon and will be held in conjunction with the Society’s regularly scheduled Quality Forum on that day.WHIO’s impending health care Data Mart presents numerous challenges and questions for physicians and other health care professionals including the credibility, validity and actionability of the WHIO data in regard to efficiency and effectiveness measurement. The symposium will feature two industry experts, Elizabeth McGlynn, PhD, and Mark Rattray, MD, whose research and experiences in this area promises to offer symposium participants the opportunity to gain new understanding and have a dialogue on critical issues that may influence the direction of Wisconsin’s effort through WHIO.
Dr. McGlynn, an international expert on methods for assessing and reporting on quality of health care delivery, is an associate director with RAND Health and is the RAND Corporate Chair in Health Care Quality. She is currently leading a project to examine the methodological and policy issues of implementing health care efficiency measures at the individual physician level.
Society CEO Susan Turney, MD, and Cindy Helstad, PhD, RN, the Society’s Director of Research, recently attended a meeting hosted by the Massachusetts Medical Society and Physicians Advocacy Institute to review McGlynn’s key findings to date. Following the meeting, Dr. Turney said, “This work will be a landmark study that provides evidence on the state of the science for individual physician-level performance measurement.”
Doctor Rattray worked directly with episode-based physician profiling as a former executive at Regence Blue Shield in Washington. He is currently president of his own health care consulting company, CareVariance LLC and has served as a technical advisor on health care efficiency measurement initiatives for several national organizations.
Medigram readers interested in attending the Symposium or in receiving further information about the Society’s Quality Forum may e-mail QandE@wismed.org. A formal invitation to the Efficiency and Effectiveness of Care Symposium will be sent to interested Society members in mid-August.
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From Medigram July 10, 2008
WHIO: A public-private collaboration in health care transparency
The Wisconsin Health Information Organization (WHIO) and the State of Wisconsin finalized contract negotiations in May to formalize a public-private partnership that advances efforts in health care transparency. Ensuring access to high quality, affordable health care for Wisconsin citizens is a key element of Governor Jim Doyle’s Affordability Agenda, and the State of Wisconsin’s involvement in WHIO allows it—along with other key stakeholder groups—to influence the collection, analysis and public reporting of cost and quality information from WHIO’s administrative claims Data Mart.Legislation passed in 2006 amended Wisconsin law related to the Physician Office Visit Data (POVD) initiative conducted by the former Wisconsin Department of Health and Family Services. The amendment established a sunset of POVD data collection activities, while allowing the State to directly contract with a data aggregation entity such as WHIO. The annual physician assessment, which funded POVD, remained in place and will be redirected to WHIO activities, as well as to other State-sponsored initiatives that support improvement in health care quality and efficiency. The annual assessment is currently $70 per physician.
Department of Health Services (DHS) Secretary Karen Timberlake recognizes the importance of the partnership between the State and other health care stakeholders in WHIO’s endeavor. “This is an extremely important initiative for Wisconsin to achieve transparency in health care and promote better health care outcomes for the people of Wisconsin,” Timberlake has said. “We are fully committed to working in partnership with the other health care stakeholders across the state through WHIO.”
Two individuals represent the State on the WHIO Board of Directors: Karen Timberlake, Secretary of the Department of Health Services (DHS), and David Stella, Secretary of the Department of Employee Trust Funds (ETF). Among its various efforts, DHS administers Wisconsin’s Medicaid program and its related programs: BadgerCare, SeniorCare and Family Care. In 2009, plans include integrating Medicaid data into the WHIO Data Mart. ETF manages the benefit programs for more than 250,000 active and retired State of Wisconsin employees through contracts with nearly 20 different health plans doing business in Wisconsin. WHIO is actively recruiting these health plans to participate and submit their data to the Data Mart.
“This is an extremely important initiative for Wisconsin to achieve transparency in health care and promote better health care outcomes for the people of Wisconsin,” said Timberlake said in this press release. “We are fully committed to working in partnership with the other health care stakeholders across the state through WHIO.”
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From Medigram July 3, 2008
Massachusetts Medical Association addresses Society’s Quality Forum
More than 30 physicians and other health care executives and representatives came together last week to learn about Massachusetts’ experience with physician tiering and health care quality measurement from Elaine Kirshenbaum, vice president of policy, planning and member services of the Massachusetts Medical Society.With the Wisconsin Health Information Organization (WHIO) currently building a statewide data mart from administrative claims information, health care quality and cost efficiency measurement is in the foremost of industry discussion. The Wisconsin Medical Society’s June 24 Quality Forum provided a venue for exploring both the potential and concerns that surround the complex endeavor of gathering, analyzing and publicly reporting health care data.
“It was a challenging three years, having to squeeze quality and cost scores from claims data,” said Kirshenbaum. “The problem was that not all physicians were measured on the same things; methodologies used by the insurers varied.” In May, the Massachusetts Medical Association filed legal action seeking to “correct the wrongs” of the physician ranking program implemented by the Massachusetts Group Insurance Commission, the purchaser of health insurance for most Massachusetts state employees and retirees (www.massmed.org).
Kirshenbaum stressed the need for physicians to be “deeply engaged” in cost and quality dialogues, along with investing in external expertise and resources. She says this may have lessened data errors, physician grievances and related injustices to patients and physicians in Massachusetts.
Julie Bartels, WHIO’s executive director, and the WHIO Board of Directors have been tracking and learning from similar national initiatives to best avoid errors in developing data marts and tiering physicians.
“We must have great data to start with. WHIO is dedicated to doing this right,” said Bartels. (For detailed information on the WHIO Cost Efficiency Measurement Methodology, click here to view the Quality Forum presentation by Tom Knaebel, MD: Vice President of Medical Informatics Consulting for Ingenix.)
WHIO Physician Cabinet member Timothy Bartholow, MD, has taken an active role in advancing the WHIO initiative on behalf of the physician community. Doctor Bartholow said WHIO has the potential to, among many things, reduce redundant medical investigations, advance the practice of preventative health care and provide feedback on physicians’ practices.
“I’m glad to be evaluated, but only if the data can accurately reflect my practice,” said Dr. Bartholow. “We’re trying to attain accurate data to communicate to the outside world and physicians.”
WHIO Clinical Advisory Group member John Hartman, MD, also is directly involved in WHIO’s data mart development. “It’s about delivering value to citizens, coupling affordability with quality,” said Hartman. “We have to address both cost and quality.”
Following presentations by Kirshenbaum, Dr. Bartholow and Dr. Hartman, Forum attendees engaged in an active discussion regarding potential strengths and weaknesses of WHIO’s forthcoming data mart. Planning for the next symposium on physician measurement is currently underway and tentatively scheduled for September 16, 2008. This will be an important physician event considering the WHIO data mart is planned for release by year-end.
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From Medigram June 26, 2008
Clinical Advisory Group maintains scientific focus in WHIO’s data mart initiative
The Wisconsin Health Information Organization’s Clinical Advisory Group (CAG) advises WHIO regarding methods and measurements for producing provider performance reports.The eight-member group includes five Society members: John Hartman, MD, Eric Christianson, MD, Bud Chumbley, MD, Sally Kraft, MD and Gordon Wong, MD.
While CAG’s sister committee—the Physicians Cabinet (see last week’s article in Medigram)—focuses on the practical application of data, CAG examines the scientific aspect of provider performance measurement.
The complexity of human health, medical practices and the health care system presents many challenges in attaining complete, accurate, timely data and assigning valid performance measurements based on that data.
“The real question is: Given the limited amount of clinical information available in claims data, what activities, which are billed for and therefore available in claims data, are strongly linked to desired or undesired outcomes?” said Dr. Hartman. “We in Wisconsin are trying to improve the value of the dollar spent on health care by exploring this linkage.”
Doctor Hartman also emphasized the importance of aligning with national standards for medical practice guidelines and taking Wisconsin quality measures, such as those by the Wisconsin Collaborative for Health Care Quality, into account. These standards represent what various experts believe are the “best practices” for physicians.
“The real difficulty is that we have many health plans and specialty societies with their own recommendations for medical practices,” said Dr. Hartman. “We need to all read the same set of recommendations to avoid patient and provider confusion and reduce administrative costs.”
The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs, which was recently released by the Consumer-Purchaser Disclosure Project, represents a tremendous step forward for CAG. (For more information on the Charter, click here.)
“The Charter explains how data marts and data reporting are to be used in relation to transparency, accuracy and some key concepts regarding underlying methodology,” said Dr. Hartman. “This allows CAG yet another opportunity to align some of its recommendations regarding these methodological issues with national standards.”
CAG’s focus, and that of WHIO, is to increase health care quality while simultaneously decreasing cost. CAG, the Physician Cabinet and WHIO as a whole bring together payers, purchasers and physicians in this shared goal.
“We know the health care system needs to change,” said Dr. Hartman. “Who is better than physicians, the ones who implement care, to be directly involved in improving how health care is delivered and incentivized?”
CAG members work toward applying evidence-based guidelines and sound, reproducible methodology for the creation of reports. From these, physicians will understand how they are performing in comparison to national standards and their peers. Additionally, WHIO will provide public reporting of this information for patients to factor into their health care decisions.
“As a physician, I welcome the opportunity for peer comparison, to have a quality and cost analysis and identify where I might best focus quality improvement efforts,” said Dr. Hartman.
Doctor Hartman stresses that though the initial data mart may not be perfect, the tool has the potential to be quite useful.
“The key is to be measured by a standard tool and to ensure its validity before jumping to conclusions and expanded uses,” he said. “We all became physicians for a reason—we care about patients. This is an important, additional step forward in our journey to improve the quality of care delivered to patients in Wisconsin.”
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From Medigram June 19, 2008
Advancing the patient-physician relationship together: An interview with Tim Bartholow, MD
Society member Tim Bartholow, MD, plays many roles within the medical community. In addition to working as a family physician in Sauk City, Wis., he also serves as chair of the Wisconsin Health Information Organization’s Physicians Cabinet (PC). The PC is a seven-physician advisory group that provides real world focus on what data will be useful to both physicians and patients, and advises the WHIO Board on practical physician measurement and reporting applications. As chair of the PC, Dr Bartholow also serves as a WHIO board member, providing a direct communication channel for physician input in WHIO.“We want to identify some of the best practices and translate those into broad, increased value for patients and physicians,” said Dr. Bartholow.
As WHIO aggregates administrative claims data from 1.9 million of Wisconsin’s 5.5 million citizens, Dr. Bartholow and many of his colleagues believe WHIO’s “data mart” will help physicians identify where quality and cost variation exists and answer the question, “Which care provides the most value to patients?”
The WHIO data mart, which is targeted for initial completion in December 2008, will be comprised of health care claims information submitted by the participating insurance companies. It will be populated continuously with up-to-date administrative claims data from several data submitting organizations, mostly health insurers. The data will be used for tracking, analyzing and measuring episodes of care and their costs over time.
To assure that Wisconsin physicians are fairly measured by a robust, credible data set, the PC works with the WHIO Clinical Advisory Group—which provides the scientific focus and use of evidence-based principles to evaluate WHIO’s data measurements and methodologies.
“Hastily measuring doctors with data that does not accurately reflect the complexity of practices may ultimately damage the patients’ trust in their doctors and unfairly measure physicians,” said Dr. Bartholow. Fortunately, purchasers (employers) and payers (insurers) increasingly appear to acknowledge the delicate relationship between patients and their doctors.
“In over 20 states, similar efforts are underway and mandated by those states. In Wisconsin, we hope to achieve this without legislative force,” said Dr. Bartholow.
This desire has led to a forthrightness and candidness among WHIO stakeholders that have not always come to a consensus.
“We need everybody at the table in order to make the greatest possible difference for physicians and patients,” added Dr. Bartholow. “Yet, if we’re unsuccessful, the potential benefit to Wisconsin citizens will not be achieved.”
To Dr. Bartholow, this effort is about the quality and affordability of Wisconsin health care and protecting the trust of the patient-physician relationship.
“I am grateful for patients allowing me into their lives, for trusting me and communicating their medical needs openly,” said Dr. Bartholow. “Initiatives such as WHIO need to respect and honor that important relationship as they do their good work.”
Members of the Society’s Quality Forum were recruited to serve as representatives on WHIO’s Physician Cabinet and include the following physicians: Dr. Bartholow, Gregory Blommel, MD, Jay Gold, MD, JD, MPH, Rita Hanson, MD, Mark Kehrberg, MD, Lowell Keppel, MD, and David Smith, MD.
Please e-mail any questions or concerns to QandE@wismed.org. We will address them directly or through future Medigram updates. And stay tuned for future updates in Medigram and more information on the Society’s Web site.
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From Medigram June 12, 2008
In this interview, Society CEO Susan Turney, MD, addresses several key questions about WHIO.WHIO Q&A: Who, what and why?
What is the Wisconsin Health Information Organization (WHIO)?WHIO is a not-for-profit organization comprised of key health care stakeholders in Wisconsin. Its goal is to use health care data to improve the equality, affordability, safety and efficiency of Wisconsin health care.
Who are WHIO’s members?
The organizations currently participating in WHIO include the Society, Anthem Blue Cross Blue Shield of Wisconsin, Employers Health Care Alliance Cooperative, Greater Milwaukee Business Foundation on Health, Humana, the Wisconsin Departments of Health and Family Services and Employee Trust Funds, United Healthcare of Wisconsin, WEA Trust, Wisconsin Collaborative for Healthcare Quality, Wisconsin Hospital Association and WPS Health Insurance.
What is WHIO’s primary mission?
WHIO is working to develop a statewide data mart by the end of 2008 that will be comprised of health care claims information submitted by the participating insurance companies. The data will be used for tracking, analyzing and measuring episodes of care and their costs over time.
How does this relate to the Society’s mission?
The Society’s mission is to “improve the health of the people of Wisconsin by supporting and strengthening physicians’ ability to practice high-quality patient care in a changing environment.” To help achieve that goal, we have made a commitment to transparency—or the use of credible, robust data to improve the quality and efficiency of health care. Our efforts in performance measurement, quality improvement and patient-centered care can be enhanced if WHIO is able to maintain a balanced approach between the objectives of its stakeholders and the important relationship between a physician and their patient.
The Society is a WHIO member because it is critical for the physician voice to be represented. Complex and challenging decisions must be made that will determine how the WHIO data will be aggregated, validated and used by health care payers, purchasers, providers and the public. The Society has a responsibility to ensure that physicians are aware, engaged and influencing key state and national initiatives that focus on improving the quality and efficiency of our health care system.
What is the Society’s role in WHIO?
In addition to being a founding member of WHIO, the Society has a designated seat on its Board of Directors. Several Society physicians serve on two important WHIO working committees, the Clinical Advisory Group (CAG) and the Physicians Cabinet (PC). The Physicians Cabinet also has a designated seat on the WHIO Board. Regular updates on the status of WHIO, including the work of CAG and PC, are provided at the Society’s quarterly Quality Forums.
In fact, Society members are invited to attend the June 24 Quality Forum to learn more about the issues of physician attribution, severity adjustment, sample size, outliers, missing data and measure validity.
What is the biggest obstacle to achieving WHIO’s goals?
The greatest challenge to WHIO’s success will be balancing the varying goals and objectives of its diverse stakeholder group. While payers and purchasers have a sense of urgency to impact rising health care premiums, health care providers—physicians and hospitals—want to ensure that the WHIO data has integrity when used for quality and efficiency efforts. This dialogue requires discipline, pace, trust and compromise. We won’t get a second chance to do this right.
Can Society members get involved in these efforts?
Absolutely. If you are interested in participating in an advisory role for the Society in the areas of performance measurement, quality improvement or patient-centered care, please send your contact information to QandE@wismed.org.
Additionally, we encourage you to e-mail any questions or concerns to QandE@wismed.org. We will address them directly or through future Medigram updates, and we will also provide this information anonymously back to WHIO. And stay tuned for future updates in Medigram and more information on the Society’s Web site.
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