George Isham was visiting last year at one of the ophthalmology practices that contracts with HealthPartners, the Minnesota integrated health system where he is the chief health officer and plan medical director. Isham was gratified, though perhaps not astonished, to hear that the ophthalmologists could tell which of their diabetic patients were covered by HealthPartners just by examining their retinas, because so few of them suffered from the retinopathy that afflicts so many with diabetes.
Healthier eyes in its diabetic patients is one result of an effort to measure and manage diabetes care that started at HealthPartners in 1994. "Our goal back then was to decrease complications by 30%," says Isham, a physician whose specialty is internal medicine. "People said we were crazy."
HealthPartners, based in Bloomington, first set up data collection systems to find out how diabetics were being treated throughout its network, which included both physicians employed in its own clinics and independent practices that contracted with HealthPartners’ HMO and other insurance plans. It established a standard examination and treatment protocol based on nationally accepted practice guidelines that included measurements and observations to be made at each office visit: an eye exam, a test to measure blood glucose over the previous several weeks, a screening for low-density lipoproteins and monitoring of kidney function. Equally important, the protocol called for immediate action on any abnormal results. In 1997, HealthPartners put in place a series of financial incentives to encourage physicians to adhere to the protocol.
It all worked better than anticipated. HealthPartners has cut its incidence of diabetes complications—heart attacks, amputations, blindness—by more than 30% since 1994.
And yet, there's still plenty of room for improvement. Rather than looking at quality indicators one at a time and congratulating itself for success rates of 70% or 80% on each one, HealthPartners prefers to go further, by clustering half a dozen indicators and seeing how well it does on all of them simultaneously—an innovative "all or none" technique that Isham thinks is the logical next step in quality measurement. Like juggling six balls at a time instead of one, such an approach is a lot harder.
As a result, the proportion of diabetic patients receiving what HealthPartners considers optimal care was around 13% last year, instead of the 75% that it’s aiming to attain by 2010.
HealthPartners has ambitious programs in place for cardiovascular disease and depression, and for improving the underlying health status of its patients in areas such as tobacco use and obesity. "Our 2010 goals are pretty aspirational, and I don't think I could in honesty say we'll hit all of them, but we’ll see quarter-over-quarter improvement that we didn’t see two or three years ago," says HealthPartners President and Chief Executive Officer Mary Brainerd. "We have an engine for improved performance that's beginning to hit on all cylinders."
For its achievements in improving quality of care, HealthPartners is the 14th winner of the National Quality Healthcare Award, presented by the National Quality Forum. The award is conducted in partnership with Modern Healthcare
and underwritten by the Cardinal Health Foundation. Prior awards were presented by the National Committee for Quality Health Care, which merged with the NQF last year. The criteria were revamped, and this year's award puts more emphasis on use of standardized quality measures and public reporting of performance data.
"HealthPartners demonstrated a systemwide commitment to implementation of safety and quality efforts through data collection, analysis, strategic planning, feedback and participation by staff at all levels," says Gary Gottlieb, chairman of the award jury and president of Brigham and Women's Hospital, Boston, which won the award last year. "These activities have resulted in significant improvements in key measures, and in their meeting or exceeding national benchmarks in performance."
HealthPartners celebrates its 50th birthday this year, having grown out of the credit union movement in the 1950s. When Minnesota credit union leaders looked at their members' debt problems, they discovered that healthcare costs topped the list. Their strategy was to create a not-for-profit, consumer-governed prepaid health plan with its own delivery system. Today HealthPartners insures one out of four people in the Twin Cities, and is a major insurer in the upper Midwest. It’s also a major provider, with a teaching hospital in St. Paul and thousands of physicians on its payroll.
As an integrated delivery system, HealthPartners escapes some of the conflicts of interest that can plague quality-improvement programs in more fragmented environments.
"We have challenges when things that benefit the hospital might not benefit the medical group and vice versa," Brainerd says. "But we have the advantage that every opportunity and challenge in healthcare, we have under our own roof. We have all the moving parts, and there's nowhere to hide, no external enemy to blame. There's no solution that depends on whether 'they' pay us more, because 'they' is us."
Brainerd says a turning point in HealthPartners' quality effort came in 2001 with its participation as one of 13 healthcare providers in the Pursuing Perfection program of the Institute for Healthcare Improvement, Cambridge, Mass., which allows the organization to focus on treating chronic illnesses such as diabetes, congestive heart failure and depression. "We began to work with a different definition and understanding of quality, and to understand the potential for using our medical group, hospital and health plan in an aligned way," she says. "That project also showed we shouldn't do disease-by-disease projects, but redesign the whole engine."
Isham's eventual goal is to create personalized quality indicators and standards of care for each patient, based not only on the diseases and conditions they have but also on their underlying characteristics, such as age, sex and heredity. "All these things drive what preventive care we ought to be getting or the behaviors we should follow, and healthcare should facilitate that on our behalf," he says.
Following are some of HealthPartners' achievements in the five areas examined by the award jury:
Effective prioritization of performance-improvement goals. HealthPartners has a three- to five-year strategic plan, a one-year operational plan and Health Goals 2010—a set of "stretch goals" focused on transforming the continuum of care. The organization participates in many quality-improvement groups, including the National Committee for Quality Assurance, the Agency for Healthcare Research and Quality, the Group Practice Improvement Network and the Leapfrog Group. It's also a founding member of the Institute for Clinical Systems Improvement, a consortium of providers in Minnesota and the Dakotas that work together to produce evidence-based best-practice guidelines.
Well-designed and deployed "scorecard" to measure and manage whole system performance. HealthPartners uses a "balanced scorecard" to measure progress on its goals. The scorecard is divided into four sections: people (effective use of employees), health (achievement of clinical quality-improvement goals), experience (delivering the service that consumers want at an affordable cost) and stewardship (ensuring good financial results). Progress on each goal is measured in all four sections. "The thing that has been most helpful to us is to quit thinking about quality as separate from our business plan," Brainerd says. "Our definition of quality includes safety, timeliness, effectiveness and efficiency. It's not an appendage to the business unit—it's built in."
A clinical indicators report supplements the score card, comparing providers' performance on 36 measures. They're measured against group averages, past performance and HealthPartners' goals, as well as external data available from the state of Minnesota and various national quality-improvement initiatives.
Data-driven improvement of patient care. HealthPartners started moving to an electronic medical record in the mid-'90s, recognizing that it was indispensable to any clinical quality-improvement effort. Installation began in clinics in 1997, and was finally completed at 399-bed Regions Hospital in St. Paul last summer. "Having the EMR in place has been a huge asset for us," Brainerd says. "It's the platform from which we do all our improvement work. It allows us to measure much more effectively and do a better job of coordinating care."
A significant portion of provider reimbursement is based on performance. HealthPartners pays annual bonuses for achieving quality targets. In 2006, the areas included optimal care for coronary artery disease, depression, diabetes and preventive care, as well as use of information technology.
Commitment to transparency. In addition to its participation in the Institute for Clinical Systems Improvement, HealthPartners is also a founding member of MN Community Measurement, a not-for-profit organization that communicates provider quality information to the public.
HealthPartners supplies patients with abundant quality-of-care data on its Web site. Report cards show how clinics score on treating asthma, depression, diabetes, heart disease, and other conditions, as well as on elements of patient satisfaction, such as the average length of time spent in the waiting room or the ease of getting advice over the phone, both before and after hours. HealthPartners also ensures quality data and measurement information are available to its providers, including how quality is measured, how much money is in the incentive pool and how each provider compares with others in the network.
Demonstrated results of high-quality care. Improved cardiovascular care has reduced by about 4,000 the number of deaths from heart disease. HealthPartners members with diabetes suffer 100 fewer heart attacks, 140 fewer amputations and 740 fewer eye complications each year compared with 1995. Since 2002, generic drug use has increased from 45% to 58%, reducing drug costs by $62 million. And almost 80% of adult members had all recommended preventive services in 2006, up from 67% in 2004.
Elizabeth Gardner is a former Modern Healthcare reporter and now a freelance healthcare writer based in Riverside, Ill. Contact Gardner at firstname.lastname@example.org.
This story initially appeared in the March 5 edition of Modern Healthcare magazine.
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