Transparency in health care

Narrator: The ABIM Foundation paired frontline physicians and leading experts to discuss building trust in healthcare. Chris Queram, a healthcare policy leader, and Beth McGlynn healthcare researcher, focused on efforts to build trust through transparency.

Chris Queram: I’m Chris Queram, the president and CEO of the Wisconsin Collaborative for Healthcare Quality.

Beth McGlynn: And I’m Beth McGlynn. I’m the vice president for Kaiser Permanente Research and also the immediate past chair of the board of the American Board of Internal Medicine Foundation.

Chris Queram: It’s a pleasure to be with you.

Beth McGlynn: It’s great to be with you, Chris. I’ve wondered if you could just tell a little bit about how the collaborative, that Wisconsin Collaborative for Healthcare Quality got started, what the motivation was, what brought you together?

Chris Queram: It the story goes back about 20, 20 or maybe even a little bit more than that years. The late 1990s, the early 2000s, there was a lot of restlessness among the business community and many of the stakeholders aligned with the employers’ labor unions, consumer groups, individual employers, business coalitions, who had been pushing for more information for quite some time. And the primary strategy was to go the legislative route and persuade the then governor to sign a bill that mandated physician groups to submit claims data to a state data agency. And about that same time, public file of hospital discharge data was used to develop a hospital report that was catalytic in the sense that I think it really changed the conversation with some of the health systems. And many of those health systems owned a health plan. So they were familiar with performance measurement through HEDIS, the clinical relevance, the pertinent of the specifications. But we’re frustrated with the fact that the HEDIS results were tied to an individual health plan.

And so there was this bringing together of these diverse groups to see if there could be some sort of a balance struck between the urgency that the demand side of the market wanted to bring to this issue and the desire of the provider organizations to measure in a way that would support their efforts to improve. And after a long series of discussions about how to balance those interests, the idea was to form a collaborative in a multi-stakeholder fashion and work together to make measurement meaningful and sustainable.

Beth McGlynn: That’s great. So one of the things I take from what you’re talking about was not a lot of trust going into the development of the collaborative. Can you talk a little bit about how you were able to build trust amongst those multiple stakeholders?

Chris Queram: I give a lot of the credit. The time I was running one of the business coalitions in the state and I give tremendous credit to the physician leaders who had the idea to bring everybody together and see if there was some way to work together. I have to confess, I was skeptical initially given the resistance that we had encountered and the obstacles that had been erected. But at each critical moment when there was a decision to be made, the clinical leaders would stop and ask those of us from the employer and labor union and consumer communities if what we were talking about made sense. Was it relevant to us? Would we use it? And really, took extra effort to reflect our perspectives in the design of the model. And gradually, trust was established through that process. And we’ve thought it was a better way and we gave the benefit of the doubt to the provider organizations and within a year of the sort of the penultimate decision to do this, the first performance measurement was released, and we’ve gone on from there.

Beth McGlynn: That’s pretty fast. So as a result of this transparency and reporting initiative, do you feel like you’ve seen real improvements in quality in Wisconsin?

Chris Queram: We have. Wisconsin consistently ranks very high among the 50 states on meta measures of clinical quality. We know anecdotally, talking with the leaders, both lay leadership, but also clinical leaders from our member organizations, that the measures are valid, they’re reliable, they’re actionable, they are making a difference in how quality is improved within the organizations. Observationally, we’ve begun to track our measures over time and the steady trend is upward, improving almost all of the measures. A good example is three years ago, we debuted a clinical depression screening measure and the initial results were very low. In aggregate, after one year, there was a 6% improvement and in the three years that we’ve been reporting in that measure now, there’s a 20% improvement. And then last but not least, as esteemed health services researcher, you may appreciate we wanted to contribute to the evidence base. And so we, with funding from the Commonwealth Fund, undertook to empirical evaluations of our work. One qualitative, one quantitative. And as a result of that, we’ve sort of taken the old aphorism that what gets measured gets improved, what gets measured and reported publicly improves faster.

Beth McGlynn: So you’ve talked a little bit about the business community and the provider community in this. What’s the level of engagement with the public or do you have a sense of how the public in Wisconsin has responded to the transparency in reporting?

Chris Queram: It’s been a struggle, to be perfectly candid about that. We’ve experimented with different approaches to try to make our measures and the results more accessible to the public. But the best we can tell through Google Analytics and some of the other tools that we have available, the primary users of our website are the provider organizations and the payers who use it for benchmarking and for different payment incentives. We’ve had some success partnering with consumer reports a few years ago. We repurposed some of our data, and as an insert into an issue of consumer reports, we saw a dramatic spike up in visits to our website after that. But that was unfortunately an experiment that was not repeated by consumer reports and we thought, you know, this is great. We’ll just, those organizations that have dedicated readers and dedicated followers who are really into data and into a numbers, that’s exactly the audience we want to reach. But they’ve moved in a different direction since then. And so that’s been our experience.

Beth McGlynn: That’s great.

Chris Queram: I would love to hear from your vantage point at Kaiser Permanente how transparency drives improvement within such a large complex organization?

Beth McGlynn: Well, it’s an interesting question. I think, in many ways, the transparency particularly in terms of public reporting is almost more important for our organization because we sit in a model that’s a largely prepaid model. And I think that there is, there are concerns, perhaps a lack of trust about whether the organization is withholding care. And so I think that the transparency provides a balancing perspective in terms of really looking at are you doing the best for us that you could possibly do. It has definitely driven pretty significant interventions or pretty significant campaigns, particularly, it’s in the area of management of chronic disease. And I was just talking to someone the other day about our journey with hypertension control, you know, heart disease is major reason for premature loss of life, and we have really seen dramatic improvements in our control of blood pressure.

And I think that started by getting these public reports and saying, wow, we really aren’t doing as well as we thought we could, as we think we should. And so really doubling down on what is at stake. And I think it’s important in our organization to note that, you know, it hasn’t been, it’s not easy. I mean, even with a big organization that has resources to bring to bear to help everybody achieve the kind of performance that we would hope to achieve. It took us a good ten years to get to the levels we’re at, which are some of the best in the country.

Chris Queram: That’s right. That’s wonderful. And is there a link with financial incentives or as is the primary use of the information more intrinsically motivated as opposed to the extrinsic motivators?

Beth McGlynn: I would say it’s primarily intrinsic motivation, although interestingly, for a number of quality measures, the executives in our organization have in their variable comp plans performance on quality measures. I’m not out there getting people’s flu shots or making sure their blood pressure is controlled and yet a part of my compensation is tied to how well we do in those areas. So I think it makes it clear that this is a top priority for the organization. The physicians similarly get a relatively small part of their compensation that’s attached to their quality performance. So I think, but I think when I talk to our docs, they are really clear on what they think is important. And I think this, what this has helped with, is to organize the kind of support systems around them that make it easier for them to do the right thing. And that’s kind of one of our mottoes. You talk about some of yours, which is make the right thing easy to do. And that’s really been many of the changes that we’ve been, that we’ve implemented have been kind of with that in that spirit.

Chris Queram: The other question I have is a lot of the focus that we’ve had over the first 15 or 16 years of our work has been clinical quality. We want to broaden beyond that to begin looking at cost, per capita cost and appropriateness of care. Do you have much experience and lessons that we can learn from how your organization has taken on the cost and the appropriateness of care issue?

Beth McGlynn: Well, appropriateness and costs are drivers for us. It’s interesting. The vision of our organization has had the term affordability in it since for… 75 years. We’ve almost been—yeah. So, you know, our mission is to provide high quality, affordable healthcare and that’s been there long before it was as popular as it is today. And actually, our current CEO has affordability as one of his absolute top drivers. And we’ve made commitments as an organization to not only look at the trajectory in the cost of care, to try to keep it at the level of inflation, but over time, to actually try to start making it lower than inflation. And I think the sense with what he says is, you know, if we’re a terrific health plan and nobody can afford us, what does it matter?

Chris Queram: Exactly.

Beth McGlynn: And so this is a huge part of our journey and really taking a look at where are the opportunities are. The nice thing in our system is because of the prepayment and the nature of our integrated system, the incentives between the health plan and the providers are very aligned. When we all do well, you know, we all do well. And so I think that that helps with the conversation. Tell people when I first got to Kaiser Permanente had this very interesting conversation with some of our vascular surgeons who said, you know, we’re seeing patients that we shouldn’t be seeing because they have preventable conditions and we really think we should be investing in some work earlier on. So that these patients never get to us. And I thought, are you really vascular surgeons? I mean, I’ve never had this conversation with a surgeon and. you know, and indeed we have been on the journey that they identified as being important.

And so that kind of is an example of what we’re able to do. And I think there are a lot of lessons to learn. It’s not easy. I mean, I wouldn’t at all pretend that this is easy, but I think it’s… and so we’re looking at a lot of how technology for instance, can be improved the patient experience, making it easier for them to get the care they need and in ways that may be less expensive to deliver. So it’s kind of an everybody wins type situation. So I think it’s opening people to think about a lot of different innovative approaches to healthcare delivery.

Chris Queram: Very nice.

Beth McGlynn: So as you think about the journey ahead for the collaborative, what do you think are the most critical issues you’re taking on? And talk a little bit about the role of trust in continuing to be able to execute on your vision and mission.

Chris Queram: Well, one other element of trust that I didn’t mention is when we were back in those conversations about doing something together to balance that urgency with a desire to be sustainable in this work. There was another commitment made by the health systems to not use the measures that would be developed and reported publicly for competitive advantage instead to use them to support the development of learning collaboratives with the goal of improving care across the state. And I think that sometimes gets referred to as sort of upper Midwest nice. Everybody likes to be nice to one another, say good morning and say goodbye when you’re leaving and work together. But one of our physician leaders put it this way. He said when he was in medical school, it was always his understanding, the way he was taught is that if he found a better way or an effective way to manage a particular condition or procedure, he had a professional obligation to share that with his colleagues.

And there is, I think this belief that best practices are should be shared. It’s the execution and the implementation of them that’s going to be a differentiator as opposed to hoarding that and keeping that. And one of the things that I’ve observed over the last 15 or more years is the environment has changed fairly significantly. And I think a lot of those values still hold. But I think sometimes the tendency is for leadership to focus internally as opposed to what they can do as part of a larger ecosystem. And so I think that’s one of our both challenges and opportunities going forward.

Beth McGlynn: It strikes me in this situation that maybe it doesn’t matter so much if patients are going to the website if they can trust that all of the rest of the system is working on delivering the best possible care to them. So to me, it could be a sign of faith, not just a centrist.

Chris Queram: Absolutely. Well, thank you for the opportunity to visit.

Beth McGlynn: Thanks.

Narrator: Visit buildingtrust.org to learn more.