Craig Brammer
Director,
Cincinnati AF4Q

As discussions of reform accelerate in Washington, what is the local market to do to ensure a high-performance health sector for its citizens and employers? Health care reform requires attention at different levels and in multiple areas. Put simply, the health care conundrum is about access, quality and cost, and everyone recognizes the need to address all three for comprehensive, sustained change.

Despite the discussions in DC about cost – and quality to a lesser extent – the national reform agenda is largely about access. The uninsured and underinsured are the public’s greatest concern, and its assessment of any reform bill hinges on the bill’s ability to improve access for those who don’t have it. The economic crisis is beginning to raise the issue of cost in the public’s eye, although consumers continue to assert that health care quality is nearly uniformly good.

This is not to suggest that national reform discussions are completely devoid of strategies to reduce cost and improve quality. Significant investments in technology, comparative effectiveness and other key areas are expected to bring long-term cost savings and improve performance. But many argue that responsibility for addressing these two legs of the three-legged health care stool – cost and quality – falls in large part to the local community.

Cost and Quality:
Responsibility of the Local Community?

In addition to the political realities supporting this view, there’s good science demonstrating significant variation in the quality and cost of health care in communities across the United States. For more than a decade, researchers at Dartmouth have used Medicare data to document variation within and among markets on numerous indicators, controlling for differences in severity of illness. This body of research is expertly described in a recent New Yorker article by Atul Gawande.

Gawande – a surgeon, staff member at Brigham and Women’s Hospital and assistant professor at Harvard – is one of the best at describing complex health care issues in a digestible style. He was raised here in Ohio, and both parents are practicing physicians in Yellow Springs.

In the article Gawande explores McAllen, Texas, one of the most expensive health care markets in the country where per capita Medicare spending is almost twice the national average. He differentiates McAllen from more efficient, high-performing systems like the Mayo Clinic and communities such as Grand Junction, CO. He also contrasts McAllen with nearby El Paso where Medicare spends half as much per enrollee, though there is no discernable distinction in the profile or health status of patient populations. Despite enormous differences in health care spending compared to other parts of the country, people in McAllen do not receive higher quality care or have better health outcomes as measured by standard methods.

Gawande’s article – which I highly recommend – concludes, “As America struggles to extend health care coverage while curbing health care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.”

Is Greater Cincinnati Different?

Here in Greater Cincinnati we conducted a similar analysis using the Dartmouth Medicare data, like Gawande did for McAllen. The total Medicare reimbursements per enrollee (Parts A and B) in 2006 for our region were $8,105, nearly identical to the national average of $8,303 and significantly less than the $15,000 per enrollee in McAllen.

We’ve also used these data to investigate more clinically relevant topics such as “ambulatory care-sensitive hospital discharge rates.” Many hospital admissions are for medical conditions – such as poorly controlled diabetes or worsening heart failure – which can be treated in either the inpatient or outpatient setting, and for which hospitalization can often be prevented by better outpatient management. Our rate is 83.3 discharges per 1,000 Medicare beneficiaries compared to the average of 78.3. Again, not too dissimilar from the nation.

What to conclude? We in Greater Cincinnati are average?

Over the past few years leaders from our community have stepped forward and said, “We’re not satisfied with average.” Because of this leadership we now have one of the nation’s leading Health Information Exchanges – HealthBridge – which securely moves clinical data across the region so clinicians have the information they need, when they need it. And we have world-class institutions like Cincinnati Children’s.

More recently, a growing body of leaders – including employers, insurers, hospitals, physicians and others – has come together at the Health Improvement Collaborative of Greater Cincinnati’s Aligning Forces for Quality (AF4Q) neutral table. Together they’ve agreed on a set of strategies for making Greater Cincinnati better than average. These strategies are based on careful analysis of what’s working in other markets and refined with the technical assistance of national experts supported by the Robert Wood Johnson Foundation.

For example, we’re now working closely with AF4Q leaders in Minnesota and their coalition, Minnesota Community Measurement (MNCM). Researchers at Dartmouth cite Minnesota as one of the most efficient, high-quality markets in the country. Minnesotans point to consistent, market-wide performance measurement, public reporting and pay-for-performance as critical success factors. (Read Economist article about MNCM.)

Our community is the first outside of Minnesota to contract with them to assist with our own local measurement strategy. Physician groups across Greater Cincinnati are currently working to organize their data for analysis by MNCM, the nation’s leader in performance measurement using clinical data.

Last month I wrote about Cincinnati’s measurement strategy in a report on the handful of U.S. markets using clinical data for measurement. The report’s lead author wrote, “Cincinnati, Cleveland and New York are not just miles apart, but worlds apart. And yet the efforts they have embarked on have similar objectives: the improvement of quality care for their residents… Cincinnati has the broadest vision for reporting medical record data of the three communities and offers a glide path for how that goal can be practically implemented.”

This is not a quick fix. Gawande suggests, “Dramatic improvements and savings will take at least a decade.” Regardless of what transpires in Washington, work is underway by a broad coalition of stakeholders to improve health and health care across Greater Cincinnati. AF4Q is a start-up whose only competition is the status quo – a truly formidable competitor. It is a journey, not a destination. And a distinct privilege for those of us on the AF4Q team.

Sincerely, Craig Brammer Director, Cincinnati AF4Q