The state of healthcare for Minnesota’s Latinos: year two. Where do we go from here?

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How many of us “shop” for clinics, doctors and other health care providers, getting references from patients and researching quality of care issues that have the potential to affect ourselves and our families? How many of us seek second opinions about health care options and treatments? The fact is that health care quality can—and does—vary widely. Many of us, as health care consumers, are not as aware of those variations or of our right to make informed decisions about our medical care as we should be. More important, most of us wouldn’t know where to find this information if we were to go looking for it.

Point: MN Community Measurement Evaluates Health Care Quality Annually…

MN Community Measurement, a nonprofit dedicated to improving the quality of healthcare in Minnesota, makes it easier than ever for the average healthcare consumer to learn about the performance of our healthcare providers. The group, whose founding members include the Minnesota Medical Association and seven nonprofit Minnesota health plans, recently released its latest findings in its annual 2006 Health Care Quality Report. The purpose of the report is twofold:

First, healthcare providers who agree to participate in this type of public reporting make themselves accountable to their patients and demonstrate a commitment to providing a high level of care. The Health Care Quality Report keeps healthcare providers informed of how their performance measures up against that of their peers, giving them a benchmark by which to set their goals for improvement.

Second, the Health Care Quality Report provides a tool for healthcare consumers that enables them to be more active in making healthcare decisions that are in their best interests an empowers them to talk with their care providers to ensure that they are receiving the best possible care for their needs.

Given Minnesota’s drive to offer the highest quality medical care in the United States, the overall results of the 2006 Health Care Quality Report—that the quality of care in Minnesota has changed very little in the past year and that clinics are maintaining the status quo—are mediocre at best.

The report provides data on 12 clinical measures. They include the treatment of the illnesses of asthma, diabetes and high blood pressure; the appropriate treatment for children with colds and appropriate testing of children with sore throats; screening for breast, cervical and colorectal cancer and for all three cancer screenings combined; screening for Chlamydia infections; and childhood immunizations and well child visits.

On a positive note, total clinic participation increased to 73 primary care groups—a substantial increase over the 54 groups included in the 2005 report. These 73 provider groups include more than 700 clinics in Minnesota and counties that border Minnesota. And MN Community Measure added new types of providers—endocrinology, nephrology, obstetrics/gynecology and urgent/convenience care—to its reporting mix. Finally, to address the criticism leveled against the results of previous years’ reports as inaccurate because they were based on a small sampling of patient records, MN Community Measure has started to link to clinics’ electronic medical records systems to evaluate the progress of patients. Less impressive are these results:

• Slight improvements: Results have improved for most measures statewide, but only small gains have been made and there is much room for improvement. For example, clinics increased their number of diabetic patients at optimal care by only one point, from 10 to 11 Percent. (Optimal diabetes care means that patients have tolerable blood sugar, blood pressure and cholesterol levels, don’t smoke and take daily aspirin when appropriate.)

• No change: Proper asthma treatment by clinics remained unchanged at 92 percent of patients.

• All over the map: The percentage of children who were seen at clinics for sore throats who received a strep test and given antibiotics ranged from 99 percent at the highest-performing medical group to 26 percent at the worst-performing group.

Of the 73 primary care groups that participated in the report, the St. Louis Park-based Park Nicollet Health Services was above the statewide average in 11 of the 12 categories of treatment assessed, giving it the most high-quality ratings of any primary care group. Bloomington’s HealthPartners, ranked a close second with above average marks in 10 of the 12 categories.

Diabetes is one of the fastest-growing diseases in the nation. According to the American Diabetes Association, there are 20.8 million children and adults—or 7 percent of the population—living with diabetes in the United States today. Of those, 6.2 million, or nearly one-third, are unaware that they even have the disease. Given the health risks faced by those with diabetes, from increased risk of heart disease and stroke to complications such as high blood pressure, blindness, kidney disease and more, the report places a primary emphasis on the effectiveness of diabetes care. The Minneapolis-based Fairview Health System topped the list in 2006, with 20 percent of its diabetes patients at optimal care, while 10 clinic groups had three percent or fewer of their patients at this level.

However, in the face of concerns that urban clinics are not able to make rapid diabetes care improvements—in part because they often serve low-income patient who cannot afford the medication and healthy food necessary to best treat their disease—the most impressive turnaround on the diabetes measure was made by the Neighborhood Health Care Network, which increased its diabetes score from one percent in 2004 to 19 percent in 2006. To achieve this gain, measures implemented by the St. Paul-based network include the use of a computer system to chart the progress of diabetic patients and the employment of bilingual support staff from within the community to help patients understand the challenges and issues they face.

MN Community Measure is already preparing for its 2007 Health Care Quality Report. Along with increasing the number of measures and provider groups, the nonprofit will explore new data collection methods. And, as a pilot site for the Better Quality Information initiative, co-funded by the Centers for Medicaid and Medicare Services and the Agency for Healthcare Research and Quality, MN Quality Measure’s 2007 Health Care Quality Report will include Medicare fee-for-service data for selected measures.

To download a full copy of the 2006 Health Care Quality Report and find out how your healthcare providers measure up, or to learn more about MN Community Measure, visit their Web site at www.mnhealthcare.org.

…And Counterpoint: Minnesota Medical Association Ranks the Insurers

Financial compensation for healthcare providers has certainly come a long way from the days when health insurance was non-existent and doctors accepted goods in exchange for medical services.

But where are we right now? And how did we get here?

In 2001, the Institute of Medicine (IOM), released a landmark study, “Crossing the Quality Chasm: A New Health System for the 21st Century.” Of the many flaws in the United States healthcare system cited by the report, emphasis was placed on the failure to align doctors’ payments with incentives for improvements. This study, as well as persistent deficiencies in the quality of the United States healthcare system and a growing frustration with rapid rises in healthcare costs provided the incentive for more than 100 “pay-for-performance” (P4P) programs to begin operating nationwide by September 2005.

The results is that many doctors and other healthcare providers throughout the nation are rated and paid bonuses based on their performance against an established set of measurements. For example, if you are a diabetic and your doctor’s rating for maintaining his or her diabetic patients’ optimal health is above average—nationally, the optimal health of diabetics is one of several primary measures of quality care—your doctor receives bonuses from private health insurance companies and the Medicare system to which he or she submits claims.

The theory behind P4P is that holding care providers accountable to national and regional benchmarks and providing financial incentives for performance creates a transparent system of care that leads to better treatment for all patients while establishing a pay system that rewards better performance.

Minnesota was ahead of the P4P curve, with HealthPartners establishing a pay-for-performance program in 1997. Today, all major Minnesota health plans utilize a P4P program, which each has devise using a combination of medical claims data and the annual ratings released by Minnesota Community Measurement (see previous section for its 2006 findings). It is estimated that nationwide between three and 20 percent of physician reimbursements come from bonuses. In fact HealthPartners expects to pay $21 million in bonuses this year, while Blue Cross and Blue Shield of Minnesota will pay out $10 million.

P4P caught the interest of the Bush administration and Congress when it achieved some initial successes in the private sector. As part of the Medicare Modernization Act of 2003 (MMA), Congress included provisions to encourage hospitals to report annually on a set of 10 quality measures. Hospitals that report are given a full increase in their payment rates, while those that do not report receive the increase in payment rate less 0.4 percent. With this financial incentive, more than 98 percent of participating Medicare hospitals now report on all 10 measures—and the Centers for Medicare and Medicaid Services (CMS) released a report on the early results of the reporting system in May 2005 that demonstrated that quality of care “improved significantly” at participating hospitals.

However, critics question why Medicare or any other payer needs to pay more for a level of care that should be a standard, while skeptics suggest that payment incentives may simply reward already high-performing providers. And doctors are frustrated by being forced to comply with a non-standardized system of reward.

Earlier this month, the Minnesota Medical Association (MMA), an organization of 11,000 members or approximately 60 percent of practicing physicians in the state, gave voice to those frustrations by doing some assessing and ranking of its own. It released its first report rating nine of Minnesota’s P4P plans, naming CMS as the best; Bridges to Excellence, a program used by large, self-insured employers as the worst; and the programs used by Blue Cross and Blue Shield of Minnesota, UCare, PreferredOne, HealthPartners and Medica as somewhere in the middle.

Among its issues with P4P, the MMA cited the following as its chief concerns:

• Different programs employ different bonus criteria, creating an unreasonable administrative burden.

• Programs don’t reward doctors for their investment in the information technology that tracks patient care and results.

• Programs don’t reward doctors for the time-consuming and complex coordination of the care of patients with chronic disease.

• Programs penalize doctors who treat sicker, poorer patients by failing to take into account different patient populations.

• Programs can potentially pit doctors’ self-interests against those of his or her patients, creating an ethical dilemma about when to follow the care guidelines dictated by an insurance company’s P4P and earn a bonus and when to make exceptions that will ultimately be in a patient’s best interests and forfeit that bonus.

The MMA rankings were shared at a meeting between the MMA and health insurers on Friday, November 16, 2007. Not all insurers agreed with the findings and their respective rankings, but all acknowledge that there is room for improvement in their bonus payment systems. Some insurance plans have already been working on such MMA hot-button issues as standardizing bonus criteria and paying for the care coordination of patients with chronic diseases.

(For more information about P4P, see the February 2006 report, “Pay-for Performance: A Promising Start” published by the Alliance for Health Reform and found at www.allhealth.org/Publications/pub_4.pdf.)

Are Ratings Necessary?

For us as health insurance and healthcare consumers, the ratings that evaluate health care providers and health insurance plans can help us make more informed choices. And as imperfect as these rating systems might be, anything that gets health care providers and health insurance companies talking about weaknesses in the system has the potential to improve patient care and drive down healthcare costs.

Where do we go from here?

One of the most rewarding aspects of creating these forums with leaders in our community is when we can look back at where we were from year to year and see real progress.

Today, we can look back and see that Frank Fernandez has been elevated to an executive role at Blue Cross and Blue Shield of Minnesota. We can look back and see that Luz Maria Frias is now a Director for Blue Cross and Blue Shield’s Foundation board. And we can look back and see that Jesse Bethke Gomez has been appointed to the Board of Directors for Portico Healthnet.

As we go forward, it will come as no surprise to anyone who knows Fernandez, Frias and Bethke Gomez that they are planning to create a Latino healthcare organization. With these three individuals taking the lead, we can expect that this will be an organization that does more than merely talk about the issues we have detailed in this three-part healthcare series. It will, instead, take action and create solutions to improve the quality of healthcare throughout Minnesota’s Latino community.

2008 will be the third year in this healthcare series. Realistically, we know that a year from now we will be continuing to uncover setbacks. But optimistically, we look forward also to celebrating many accomplishments. As a community, we ask that you support the healthcare organizations that support our community and this initiative.

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