measuring what matters for the triple aim - ihi

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Measuring What Matters forthe Triple Aim

Kevin Nolan, Mstat, MA

This presenter has nothing to disclose

April 29, 2014

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Learning Objective

Gain ideas and inspiration for measuring

the Triple Aim in your organization

A Guide to Measuring the Triple Aim

http://www.ihi.org/knowledge/Pages/IHIWhitePapers/AGuidetoMeasuringTripleAim.aspx

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Definition

System designs that simultaneously improve three

dimensions:

Improving the health of the populations;

Improving the patient experience of care (including quality and

satisfaction); and

Reducing the per capita cost of health care.

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5Stages of Measurement Development

1. Exploration

2. Selection of practical population measures across the three dimensions and the collection of data

3. Integration of measurement into a learning system to support work on the Triple Aim

Population Measures Projects Project Measures

Population Measures Worksheet

Dimension Proposed Measure Data Source Data plotted on

run chart (Y/N)

Population Health

Experience of Care

Per Capita Cost

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7Population Health

What would be a good measure of population health?

Mobilizing Action Toward Community Health, University of WI Population Health Institute8

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Disease Burden

Parrish RG. Measuring Population Health Outcomes.

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Disease Burden

1.

2.

3.

3.

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Potential Population Health Measures

1. Health Outcomes: • Mortality: Examples - Years of potential life lost; Life

expectancy; Standardized mortality rates

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Mortality: Years of Potential Life Lost (YPLL)

Queens Health Network - 2000-2007

(Jamaica and Northwest, Southeast, Southwest, and West Queens)

Year 2000 2001 2002 2003 2004 2005 2006 2007

YPLL 74,755 78,888 72,374 71,827 66,603 67,235 66,137 62,104

Population (in millions)

1.385M 1.387M 1.384M 1.385M 1.385M 1.385M 1.397M 1.403M

YPLL = Sum of (75 – age at death)

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Years of potential life lost from conditions considered amenable to healthcare. (Per 100,000 population)

Cornwall (pop = 540,000) – Orange

England - blue

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YPLL = Sum of (75 – age at death)

Population Health: Mortality Data

Public Sources

US Social Security Administration

US State and local vital statistics

US County Health Rankings - YPLL

Canada: CIHI, Stats Canada, CANSIM table 102-4307;

CANSIM table 102-0504 , Local Population Health Dep'ts

Hospitals and health plans within an integrated system or regional collaborative

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1. Health Outcomes: • Mortality: Examples - Years of potential life lost; Life

expectancy; Standardized mortality rates

• Health/Functional Status: Examples - single

question health status or multi-domain (e.g. SF-12)

Health Outcome:

Health Status Single Question

Would you say that in general your health is:Excellent, very good, good, fair, poor

CDC Health Related Quality of Life (HRQOL-4)

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Relationship Between Single Question and Mortality, Cost

“Predicting Mortality and Healthcare Utilization with a Single Question”, DeSalvo et. al. Health Services

Research 40:4 (August 2005)

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Single Question Self-Reported Health

National/International Use/Sources

US HRQOL-4 (several national instruments), US CAHPS,

Medicare Health Outcomes Survey, PROMIS, BRFSS

(community), European Health Interview Survey, Canadian

Health Measures Survey

Health System Potential Sources

Health Risk Assessments

Include in care experience survey

Post-visit questionnaires

Birthday greetings

Vital Signs (testing)

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Single Question Health Status

Genesys Health Plan

Gathered on all enrollees at time of enrollment and annual re-enrollment


1. Health Outcomes:

• Mortality: Years of potential life lost; Life expectancy;

Standardized mortality rates

• Health/Functional Status: single question (e.g. from CDC

HRQOL-4) or multi-domain (e.g. SF-12)

Note: Healthy Life Expectancy (HLE): combines life

expectancy and health status into a single measure,

reflecting remaining years (e.g. at birth, age 65) of life

in good health

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LE and DFLE for men at age 65 in Great Britain, 1981-2002

DFLE (Disability-free Life Expectancy) (UK - General Household Survey)Do you have any long-standing illness, disability or infirmity? By long-standing I mean anything that has troubled you over a period of time or that is likely to affect you over a period of time. Yes/No.

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1. Health Outcomes: • Mortality: Years of potential life lost; Life expectancy;

Standardized mortality rates• Health/Functional Status: single question (e.g. from CDC

HRQOL-4) or multi-domain (e.g. SF-12)

Note: Healthy Life Expectancy (HLE): combines life expectancy and health status into a single measure, reflecting remaining years (e.g. at birth, age 65) of life in good health

For calculation of Life Expectancy and Healthy Life Expectancy (HLE): Sullivan Method http://www.ehemu.eu/pdf/Sullivan_guide_final_jun2007.pdf

Statistics Canada (2013) CANSIM table 102-0122

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1. Health Outcomes:

• Mortality: Years of potential life lost; Life expectancy;

Standardized mortality rates

• Health/Functional Status: single question health status or multi-

domain (e.g. SF-12)Note: Healthy Life Expectancy (HLE): combines life expectancy and health

status into a single measure, reflecting remaining years of life in good

health

2. Disease Burden: Incidence and/or prevalence of chronic illness

Incidence versus Prevalence

Prevalence: widespread a disease is in a population (i.e.

ratio of total number of patients with disease to the total

population)

Incidence: new cases of the disease in the population in

a time period (i.e. ratio of total new cases in a population

to the total population)

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2

3

4

5

6

7

8

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10

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12

Jan-Mar

'10

Apr-Jun

'10

Jul-Sept

'10

Oct-Dec

'10

Jan-Mar

'11

Apr-Jun

'11

Jul-Sept

'11

Oct-Dec

'11

Jan-Mar

'12

Apr-Jun

'12

Jul-Sept

'12

Oct-Dec

'12

Jan-Mar

'13

Apr-Jun

'13

Jul-Sept

'13

Oct-Dec

'13

Inci

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/10

00

Use

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op

median

Incidence of Diabetes per 1000 User Population Chinle Service Unit, 1 QTR 2012-4th QTR 2013

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Population Health: Data on Chronic Conditions

Claims

Electronic medical records

Disease management registries

Community surveys: for example,

-In the US, Behavioral Risk Factor Surveillance Survey

(BRFSS)

-In Canada, Statistics Canada Community Health Survey

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1. Health Outcomes:

• Mortality: Years of potential life lost; Life expectancy; Standardized mortality rates

• Health/Functional Status: single question health status or multi-domain (e.g. SF-12)

Note: Healthy Life Expectancy (HLE): combines life expectancy and health status into a single measure, reflecting remaining years of life in good health

2. Disease Burden: Incidence and/or prevalence of chronic illness

3. Behavioral and Physiological factors: • Behavioral factors: e.g., smoking, alcohol, physical activity, and diet

• Physiological factors: e.g., blood pressure, BMI, cholesterol, and

blood glucose

Note: Health Risk Assessment (HRA) contains multiple factors.

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Bellin Health: Employed Population Health Measure

HRA - Physiological FactorsBellin Results

2011 = 78.7

2012 = 78.5

2013 = 79.3

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Potential Sources of Data for Behavioral and Physiological Factors

EMRs

Health Risk Assessments (HRA)

Claims

Community surveys – County Health Rankings/ BRFSS; Statistics Canada 2013

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run chart (Y/N)

Population Health

Experience of Care

Per Capita Cost

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33Experience of Care

What would be a good measure of Experience of Care?

US Institute of Medicine (IOM) Quality Chasm Aims

34Measuring Experience of Care

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Overall Experience of Care: from CAHPS

Health Plan Survey “Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months?”

https://www.cahps.ahrq.gov/content/products/PDF/CAHPS_AMB_PG_041310.pdf

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Overall Experience of Care:

from “HowsYourHealth”

When you think about your health care, how much do

you agree or disagree with this statement “I receive

exactly what I want and need exactly when and how I

want and need it”?

John Wasson, MD, Dartmouth College - http://www.howsyourhealth.org/

Martin’s Point Healthcare

HowsYourHealth

US Family Health Plan and MP Primary Care

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Study by Dr. John WassonThe key components to getting strong agreement to

“I receive exactly . . .”

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Adverse events

HSMR

HEDIS Composite

Joint Commission Comp.

Access

Patient engagement or

confidence

Measures stratified by race

and gender

ACSH Rates

Readmissions


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CareOregon: Stability of Diabetes and Hypertension (effectiveness)

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1,780 1,936 2,308

909

1,0281,156

Experience of Care: Key Dimensions - KP Example

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Experience of Care: Data Sources

US

CAHPS - Consumer Assessment of Healthcare Providers and

Systems from the Department of Health and Human Services

HEDIS - Healthcare Effectiveness Data and Information Set from

the National Committee for Quality Assurance (NCQA) is a tool for

health plans

TJC - The Joint Commission Quality Check includes rates for

hospitals on key quality indicators by condition

Canada - CIHI’s Hospital Results Report

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run chart (Y/N)

Population Health

Experience of Care

Per Capita Cost

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Potential Population Measures for

Per Capita Cost

1. Total cost per member of the population per month

2. Hospital and ED utilization rate and/or cost

HealthPartners Medical Trend – Health Plan Overall

* trend continues at lower rate

(HealthPartners Commercial Group Fully Insured & Self Insured Per Member Per Month)

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Cost: Chinle Service Unit

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Month

Emergency Department Utilization: Emergency Department

Visits per 100 User Population, CSU, Jan 2010-Dec 2013.

Potential Sources of Data on Cost

Claims data from health plans and Medicare (Dartmouth Atlas; QIOs)

For integrated systems without a health plan: -Data available within the system (hospital, ED and primary care) -Collaboration with affiliated health plans, Regional Health Information Organization (RHIOs) or Accountable Care Organizations (ACOs)

NCQA: Relative Resource Use Measures

HealthPartners: Total Cost of Care (NQF-endorsed)

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Definition

System designs that simultaneously improve three

dimensions:

Improving the health of the populations;

Improving the patient experience of care (including quality and

satisfaction); and

Reducing the per capita cost of health care.

Potential Triple Aim Population Outcome Measures

Dimension Measure

Population Health

1. Health Outcomes: � Mortality: Years of potential life lost; Life expectancy; Standardized mortality rates

� Health/Functional Status: single question (e.g. from CDC HRQOL-4) or multi-

domain (e.g. VR-12, PROMIS Global-10)

� Healthy Life Expectancy (HLE): combines life expectancy and health status into

a single measure, reflecting remaining years of life in good health

2. Disease Burden: Incidence (yearly rate of onset, average age of onset) and/or

prevalence of major chronic conditions

3. Behavioral and Physiological Factors: Behavioral factors include smoking,

alcohol, physical activity, and diet. Physiological factors include blood pressure, BMI,

cholesterol, and blood glucose.

(possible measure: a composite Health Risk Assessment (HRA) score)

Experience of Care

1. Standard questions from patient surveys, for example:

� Global questions from Consumer Assessment of Healthcare Providers and Systems (CAHPS) or ”How’s Your Health” surveys

� Likelihood to recommend

2. Set of measures based on key dimensions (e.g., US IOM Quality Chasm

Aims: Safe, Effective, Timely, Efficient, Equitable and Patient-centered)

Per Capita Cost 1. Total cost per member of the population per month

2. Hospital and ED utilization rate and/or cost

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Measurement Quiz51

A measure of the % of diabetics whose blood pressure is

under control is a good measure for:

A. Population Health

B. Experience of Care

C. Cost

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The best measure of cost for a Medicare (65 and older)

population is:

A. Inpatient admissions

B. ER utilization

C. Pharmacy costs

D. None of above

Measurement Quiz

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If my organization or community cannot measure a

population health outcome (that is, mortality or health

status), we should not have a measure of population

health at this time.

True

False

Measurement Quiz



run chart (Y/N)

Population Health

Experience of Care

Per Capita Cost

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Selected References

County Health Rankings: Mobilizing Action Toward Community Health:

http://www.countyhealthrankings.org/

Evans RG, Stoddart GL. Producing health, consuming health care. Soc SciMed.1990;31(12):1347–1363.Evans RG, Barer ML, Marmor TR, eds. Why are Some People Healthy and Others Not? The Determinants of Health of Populations. Hawthorne, NY: Aldine De Gruyter; 1994.Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-383.McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff. 2002;21(2):78-93.Parrish RG. Measuring Population Health Outcomes. Prev Chronic Dis 2010:7(4). http://www.cdc.gov/pcd/issues/2010/jul/10_0005.htm Stiefel MC, Perla RJ, Zell BL. A Healthy Bottom Line: Healthy Life Expectancy as an Outcome Measure for Health Improvement Efforts. The Milbank Quarterly. 2010;88(1):30-53. DeSalvo, K.B., N. Bloser, K. Reynolds, J. He, and P. Muntner. 2006. Mortality Prediction with a Single General Self-RatedHealth Question. A Meta-analysis. Journal of General Internal Medicine 21:267–75.Crossing the Quality Chasm: A New Health System for the 21st Century (2001) - Institute of Medicine (IOM)Health Partners: Total Cost of Care – www.healthpartners.com/tcoc

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