Interpreting the Volume-Outcome Relationship in the Context of Health Care Quality Workshop Summary (2000) / Chapter Skim
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Appendix D: When and How Should Purchasers Seek to Selectively Refer Patients to High-Quality Hospitals?
Appendix D: When and How Should Purchasers Seek to Selectively Refer Patients to High-Quality Hospitals?
Pages 103-119
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From page 103... ...
M.P.H. - 7 There has been evidence for years suggesting important variations in quality among doctors,~-3 hospitals,4-7 and health plans,8 9 and significant effort such as the development of the Health Plan Employer Data and Information Set (HEDTS)
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From page 104... ...
found a volumeoutcome relationship for coronary artery bypass grafting (CABG) in New York, but some low volume hospitals had risk adjusted mortality rates below the mean for high volume hospitals.7 For reasons such as these, purchasers should consider carefully the circumstances under which they would be willing to embark on a selective referral initiative.
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From page 105... ...
Even for common, frequently studied conditions like myocardial infarction, there are many clinical process decisions that probably affect outcome but that cannot be made on this basis of evidence from large randomized trials.28 Requirements that providers be certified or licensed are even more tenuously linked to outcomes than process measures. Thus, focusing quality measurement exclusively on process or structural variables that correlate with outcome would limit the breadth of quality assessment and penalize providers who have identified methods for improving quality that just happen not to have been studied yet.
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From page 106... ...
1 1 1 ~ 1On the other hand, patients who were at high volume hospitals before selective referral may benefit from the increased volume (if practice makes perfect) or may find that additional services perhaps a cardiac rehabilitation program are available given the revenues and economies of scale associated with higher volume.
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From page 107... ...
This necessitates some reporting mechanism so that health plans and medical groups bound by selective referral policies are not penalized by patient decisions. Clinical issues that must be addressed prior to initiation of selective referral include the determination that patients can be transferred safely and that preferred hospitals actually have the capacity to accept the new patients.
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From page 108... ...
if applied too stringently. In the only study examining the effects of CON laws on hospital mortality rates, states that had more stringent laws had higher risk adjusted mortality rates among Medicare inpatients.40 However, the risk adjustment methodology used was limited to age, sex, and a small number of comorbid conditions obtained from administrative files, so this finding may not be robust.
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From page 109... ...
Finally, there are other methods in addition to selective referral that focus primarily on purchaser-health plan relationships. For example, purchasers could offer quality withholds or bonuses for health plans that can document excellent risk adjusted outcomes, without requiring the use of preferred hospitals.48 49 This option allows health plans more contracting and implementation flexibility.
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From page 110... ...
For example, if a proposal to selectively refer patients with a particular condition only to major teaching hospitals would create markets in which plans could only contract with a single hospital (or in which the nearest preferred hospital was very distant) , it might be preferable to develop risk adjusted mortality reporting instead even at substantial administrative cost.
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From page 111... ...
The Department reports to hospitals both risk adjusted mortality rates and lists of preoperative risk factors that are significantly related to mortality. In addition, risk adjusted mortality rates for each hospital and surgeon that perform CABG are released in public reports.
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From page 113... ...
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Measures collected included risk adjusted hospital mortality for certain conditions, cesarean section rates, and patient satisfaction. As reports came out in the early 1990s, hospital mortality rates declined,43 but again only historical controls were available.
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From page 115... ...
For the other conditions, HealthGrades.com classified the hospitals within the lowest quartile with respect to volume as "lower volume hospitals." HealthGrades then uses HCFA discharge data to calculate condition-specific risk adjusted mortality rates. The data are available to consumers for free, and the site is supported by advertising, only some of which is for health-related products.
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From page 116... ...
In theory, referral based on actual outcomes and processes or public reporting of quality data are preferable to referral based on indirect indicators of quality like hospital volume. However, selective referral based on volume is currently much easier to achieve.
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From page 117... ...
T6entifying poor-quality hospitals. Can hospital mortality rates detect quality problems for medical diagnoses?
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From page 118... ...
The effects of regulation, competition, and ownership on mortality rates among hospital inpatients.
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From page 119... ...
From the Health Care Financing Administration.
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