Reforming Health Care by Focusing on Quality

by Senator Hillary Clinton

A reformed high-quality healthcare system must include a strong evidence base so we know what treatments work best, a quality measurement infrastructure based on this evidence to assess the quality of care patients receive from their health care providers, the integration of those quality measures into the delivery of care through health information technology, reimbursement incentives and accountability, and a commitment to placing patients at the center of the system, through increased transparency and greater access to information. To achieve this, Hillary will:

Empowering Providers:

1. Empower Physicians to Improve Quality Through Physician-Driven Certification Programs: In our health care system today, there is tremendous variation in the cost and quality of care from state to state, and even from hospital to hospital in the same town. For example, in Wilkes-Barre, Pennsylvania spine surgery rates are 1.99 per 1,000 Medicare patients, while in Lancaster, they are 5.44 per 1,000. Physician specialty boards, such as the American Board of Internal Medicine, have established Maintenance of Certificate (MOC) programs to promote lifelong learning and help doctors stay up to date on the latest scientific advances and procedures. Doctors who scored higher on MOC examinations had better outcomes in treating patients with diabetes, and were more likely to ensure that their patients received mammograms. Heart attack patients treated by board certified doctors were 15% less likely to die than those treated by non-certified doctors. MOC programs help ensure that the right care is given to patients at the right time, improving quality, while reducing costs. Hillary’s proposal would federally recognize these initiatives and create financial incentives for participating in them.

2. Recognize Independent Private-Public Quality Trust and Improve Quality Measures: As President, Hillary would direct the Secretary of HHS to invest $125 million in federal funding to recognize a private-public consensus-based organization, such as the National Quality Forum, to (a) certify for enhanced reimbursement physician, hospital, and nursing home MOC programs, (b) identify gaps in existing national quality measures, (c) set national priorities for the development and testing of new quality measures, (d) fund organizations with expertise to develop additional measures that advance national priorities, and (e) endorse quality measures for use in MOC programs and more broadly by physicians, hospitals, nursing homes, and other healthcare providers. And through the Best Practices Institute announced by Hillary earlier this year, disseminate the highest quality, most effective protocols and treatments to ensure they are used everywhere. This proposal will help hold healthcare providers to the highest standards and ensure they have the best information to inform their work with patients.

3 . Emphasize Quality in Health Care Workforce, with Focus on Nurses: Provide federal funding to address nursing and nurse faculty shortages and nurse retention issues by establishing innovative training and mentoring programs. A severe nursing and nurse faculty shortage has led to understaffing and nurse-to-patient ratios that jeopardize patient safety in hospitals and limit the availability of care outside of hospitals. America is not training enough nurses to meet our needs yet nursing schools turned away more than 32,000 qualified applicants in 2005. And we are not retaining those who do join the profession; currently 50 percent of new nurses leave their jobs within the first year. To address this problem, Senator Clinton will invest $300 million to:

· Address Nurse and Nurse Faculty Shortages: Provide short-term funding to schools of nursing to expand their capacity to train nursing students, as well as to recruit and retain faculty to teach the next generation of nurse professionals. Provide priority in funding to schools that collaborate with innovative worker training programs that recruit, train, and place nurses, and that provide career pathways across the spectrum of care settings.

· Prioritize the Retention of New Nurses: Provide funding for innovative nurse mentoring and nurse residency programs that have been shown to improve retention of new nurses.

· Increase Number of Direct Support Professionals: Make federal funding available to states, in partnership with local organizations, to develop credentialing programs for professionals like nursing assistants and personal care attendants, who are critical to ensuring that patient needs are met and that nurses are available to do the core functions of their jobs. As a condition of receipt of grants states must collaborate with state universities and community colleges to allow credentialing programs to count as college credit.

· Address Diversity and Cultural Competency in the Healthcare Workforce: Provide opportunities and incentives to encourage greater diversity in our health care workforce through recruitment initiatives, scholarships and loan-forgiveness programs.

· Link Nursing Education and Quality: Provide federal funding for the implementation of initiatives in nursing education programs to enhance and integrate quality measurement and patient safety efforts.

Empowering Patients:

4. Empower Patients with Information on Provider Performance: Informed consumers make decisions that promote the right kind of competition and higher quality and reflect their underlying values and preferences. However, very limited information is available to help patients understand how to choose the best providers, what treatment options are available, what works, and how to stay healthy. Hillary would expand and improve information available to patients by making data and decision-making tools that give consumers information about their local providers readily available and understandable. Patient-centered care should be designed to improve patient decision making as well as the quality of their health care; it should not shift health care costs onto patients. At the Dartmouth Hitchcock Medical Center, the Center for Shared Decision Making helps breast cancer patients understand their options and make informed decisions about their treatment. The program gets high marks from patients - 98 percent reporting that they understood their treatment choices and 96 percent reporting they understood which treatment risks and benefits mattered most to them as they made their decision. Senator Clinton will:

· Develop a Patient-Friendly Quality Database: Patients want to know more about their providers and should know what their track record is. Hillary would invest $50 million in federal funding to improve and expand a web-based tool, such as Medicare Compare, to make provider and other information more usable, accurate, and consumer-friendly. This will assist patients in choosing physicians, hospitals, and permit meaningful comparisons across various health care delivery systems for patients, providers and purchasers.

· Develop Patient-Friendly Decision Aids to Promote Informed Patient Choice: Provide $25 million in federal funding to encourage the development of new programs like the successful model at the Dartmouth Center for Shared Decision Making to ensure that patients have access to up-to-date information and tools to help them understand their treatment options and make decisions that reflect their values.

5. Reduce Health Care Disparities: Racial and ethnic disparities are pervasive throughout our entire health care system. In 2003, the Agency for Healthcare Research and Quality (AHRQ) found “that racial, ethnic and socioeconomic disparities are national problems that affect health care at all points in the process, at all sites of care, and for all medical conditions – in fact, disparities are pervasive in our health care system.” Minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer compared to whites, and Hispanics hospitalized for acute myocardial infarction are less likely to receive optimal care. Infant mortality rates among African American populations are more than twice as high as those for whites. According to the annual National Healthcare Disparities Report, released by the AHRQ, blacks and Hispanics received poorer quality care than whites on more than 70 percent of the measures. To address these problems, Senator Clinton will:

· Reduce Racial and Ethnic Disparities as Part of the National Quality Agenda: Require the development and testing of quality measures for use by doctors, hospitals, nursing homes and other providers targeted at racial and ethnic disparities in health care.

· Require More Accurate Data Collection: Direct the Department of Health and Human Services (HHS) to develop a uniform reporting format for the collection of quality information on race and ethnicity, so that we can know the full extent of the problem and measure our progress in addressing it.

· Improve Cultural Competency in Clinical Care: Provide $50 million in federal funding for the development of culturally and linguistically competent clinical care programs, to ensure that our healthcare providers can communicate with their patients and have training and skills to fully understand and respect cultural differences in the patients they serve.

· Prioritize the Development of Medical Homes Designed to Improve Quality for Racial and Ethnic Minorities: Provide enhanced payments to healthcare providers who use coordinated care or medical home models and the practice of evidence-based medicine, designed to ensure that race and ethnicity are not a factor in the quality of care received.

Empowering Purchasers and Payers:

6. Incentivize Quality Through Increased Federal Payments: Hillary proposes providing higher payments to healthcare providers that use coordinated care delivered by teams of health professionals to treat the whole patient instead of the patients’ individual illnesses. Most federal payments to health care providers do not differentially reward high quality providers. Our current system of reimbursement creates barriers to collaboration among organizations and among health care professionals, leading to fragmentation in the health care system. Doing what’s best for patients shouldn’t be bad for business. To overcome these barriers, Senator Clinton will:

· Financially Reward Excellence in Care: Physicians demonstrating their commitment to quality care through participation in certified Maintenance of Certification programs, and over time through improved patient outcomes, will be recognized as providers of high quality care and will receive higher reimbursement in federal programs, such as Medicare and the Federal Employee Health Benefit Program. Hillary proposes that our federal reimbursement system rewards care based on how effective it is. For example, the Marshfield Clinic, in Wisconsin, where doctors were paid based on the quality of care they provided for common diseases like diabetes and heart disease. They could earn up to 80% of the Medicare savings that resulted from their good treatment. Preliminary results revealed a 50% increase in electronically documented foot exams for diabetics, a 29% decrease in hospitalizations, and a savings of over $270,000 per 100 patient years.

· Develop New Reimbursement Models to Encourage Innovative Care Delivery
Systems that Reward Quality -- Not Assembly-Line Care.

To address system-wide fragmentation, increased reimbursement will be provided to models of care that treat patients as whole individuals instead of treating each of their illnesses separately. Such approaches will eliminate piecemeal medicine, where multiple doctors and nurses treat conditions like diabetes or cancer without communicating
and undermining care as a consequence. Care models that use teams of providers - physicians, nurses, pharmacists, nutritionists, social workers, and other allied health professionals -- that meet consensus-based quality measures will be
recognized. They deliver health care that is better coordinated to ensure that every patient gets the appropriate care in the way they need it and at the time they need it, instead of being left to navigate the complex health care system alone.

7. Prohibit Payment of “Never Events” in FEHBP and all Federal Programs: The Bush Administration’s recent decision to refuse Medicare payments for preventable infections, injuries and errors--so-called “never events”--sustained during hospital stays is a positive step. Hillary will insist that any insurance company wishing to provide coverage through the Federal Employee Healthcare Benefits Program also refuses to cover these costs. This proposal will incentivize good care with smart reimbursement policies

These proposals to improve quality build on Hillary’s existing health care agenda:

Institute a New “Paperless” Health Information Technology System: Modernizing our health care system through the use of information technology will empower doctors and other healthcare providers to communicate electronically and will reduce waste and redundancy while improving safety and quality by reducing medical errors. Overall, the RAND Corporation estimates net savings to be $77 billion per year. An up-front and phased-out $3 billion a year investment fund would be provided to help hospitals and doctor’s offices adopt and implement HIT. The proposal will give doctors financial incentives to adopt health IT and facilitate adoption of a system where high quality care and better patient outcomes can be rewarded.

Transform Care of Today’s Chronically Ill Population to Improve Outcomes: The largest driver of health care costs in the nation is related to the small numbers of Americans who have multiple chronic diseases. These diseases, such as cardiovascular disease and diabetes, account for 75 percent of our total national health expenditures and are the leading causes of death in the U.S. A recent RAND study projected nearly $30 billion in national health expenditure savings per year after implementing disease and lifestyle management programs. Combined with prevention and health information technology, with full participation, the U.S. health system could save $147 billion alone for better care of this vulnerable population. Senator Clinton will ensure higher quality and better coordination of care by using state-of-the-art chronic care coordination models within federally-funded programs to provide care for Americans afflicted with these costly, multi-faceted illnesses. She’ll provide incentives to participate in these chronic care management programs.

Create an Independent “Best PracticesInstitute and Invest in Research for New Treatments: Patients, providers, and payers would benefit from getting better information on what works in health care and how treatments compare to one another. Researchers at Dartmouth have found that more care is not better care, and that inefficient care may do more harm than good. Therefore she will create a new Best Practices Institute, which would be funded by both the private and public sectors, since its results will benefit all payers. Research will compare the effectiveness of alternative treatments such as pharmaceuticals, devices, and surgeries. For example, information supplied by organizations such as the Drug Effectiveness Review Project (DERP) has been used in North Carolina to educate providers and improve quality of care, saving the state an estimated $80 million in 2003. This research will facilitate the development of quality and outcomes measures for use by hospitals, physicians, nursing homes, and other healthcare providers.