Sec Q Key Outcome Measure, Triple Aim, Reporting

Question 1

Key measurement principles that apply to the triple aim

Answer 1

1. The need for a defined population - most triple aim measures, such as per capita cost, require a population denominator
2. The need for data over time - tracking data over time helps to gain insight into the relationship between interventions and effects and to better understand time lags between cause and effect
3. The need to distinguish between outcome and process measures, and between population and project measures. Measurement should include top-level population outcome measures, and related outcome and process measures for projects
4. The value of benchmark or comparison data - this data enables comparisons with other systems
   * The principles used by the National Quality Forum for evaluating quality measures also can apply to triple aim measurement: importance, scientific acceptability, usability, and feasibility*

Question 2

Menu of triple aim outcome measures from the IHI Triple Aim prototyping initiative

Answer 2

• IHI is the Institute for Healthcare Improvement*
  1. Population health measures
  a) Health outcomes:
  i) Mortality - years of potential life lost, life expectancy, and standardized mortality ratio
  ii) Health and functional status - single-question assessment (a person rating his/her own health) and multi-domain assessment
  iii) Healthy life expectancy - combines life expectancy and health status into a single measure, reflecting remaining years of life in good health
  b) Disease burden, such as incidence and prevalence of major chronic conditions
  c) Behavioral factors (such as smoking, alcohol consumption, physical activity, and diet) and physiological factors (such as blood pressure, body mass index, cholesterol, and blood glucose)
  2. Experience of care measures
  a) Standard questions from patient surveys - for e.g.:
  i) Rating all health care received in the last 12 months
  ii) Likelihood to recommend the provider of care to someone else
  b) Set of measures based on key dimensions, such as the Institue of Medicine’s six aims for improvement: safe, effective, timely, efficient, equitable, and patient-centered
  3. Per capita cost measures
  a) Total cost of the population PMPM, including costs by type of service
  b) Hospital and emergency department utilization rate and cost

Question 3

Domains of quality from the Agency for Healthcare Research and Quality

Answer 3

1. Access to care - whether a patient can readily obtain needed services. Performance measures include the number and geographic distribution of providers
2. Structure of care - whether care is provided by approprite providers who use up-to-date technology. Measures include assessment of referral policies and use of electronic health records
3. Process of care - whether services have been provided to appropriate member subpopulations. One measure is hospital readmission rates
4. Outcome of care - whether treatment has been effective. Measures include what percentage of patient with diabetes meet blood sugar targets
5. Experience of care - whether patients are satisfied with the care they have received. Is generally measured by surveys

Question 4

Role of the integrator in achieving the triple aim

Answer 4

• To achieve its purpose, the triple aim needs the cooperation of various entities (such as health care organization, public health departments, and employers). An integrator is needed to do the following:*
  1. Accept responsibility and pull together various resources to support the pursuit of the triple aim
  2. Create an appropriate governance structure
  3. Lead the establishment of a clear purpose for the pursuit of the triple aim
  4. Identify projects and investments to support that pursuit
  5. Create a set of high-leve measures to monitor progress

Question 5

Institute of Medicine definition of quality care

Answer 5

• Defn - the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge*
• Aims for or properties of high-quality care:*
  1. Safe - avoiding injuries to patients
  2. Effective - providing services based on scientific knowledge to all who could benfit, and refraining from providing services to those not likely to benefit
  3. Patient-centered - providing care that is respectful of and responive to individual patient preferences, needs and values
  4. Timely - reducing waits and somtimes harmful delays
  5. Efficient - reducing waste, including waste of equipment, supplies, ideas, and energy
  6. Equitable - providing care that does not vary in quality because of personal characteristics

Question 6

Dimensions of the triple aim of health care

Answer 6

• The triple aim is to simulatenously achieve all three dimensions*
  1. Improve population health
  2. Improve the patient experience of care
  3. Reduce per capita cost

Question 7

Reserve standards for the different types of financial statements

Answer 7

1. Statutory statement - the focus is on ensuring solvency, so reserves tend to be conservative
2. GAAP statement - the focus is on matching profit streams with revenue streams, with a lesser degree of conservatism (through provisions for adverse deviation)
3. Tax statement - IRS standards make sure profits beyond a set level are recongized, and therefore taxed, immediately
4. Embedded value based statement - may be needed for international companies. Standard are set by the International Accounting Standards Board

Question 8

Types of reserve reporting

Answer 8

1. Regulatory reporting - concerned with solvency and policyholder protection, so conservative
2. GAAP reporting - emphasis on realistic earnings. Assumptions include provision for adverse deviation
3. Experience reporting for remployers and providers - typically less sophisticated except for financial settlement and pricing review. For settlements, allow a 3 month run-out period to minimize the size of the estimated reserve
4. Valuations for acquisitions - reserves are material to profitability, so they are often a focal point of negotiations. There is often a final settlement after several months to revisit the purchase price and assess the impact of claim reserves

Question 9

Models for continuous quality improvement in health care

Answer 9

1) A universal model:
a) Plan - identify opportunities for improvement
b) Do - imprement interventions
c) Check - measure effect of interventions
d) Act - adjust or change interventions
2) Another standard model, taken from Lean Six Sigma:
a) Define the scope of the problem and benefits of the solution
b) Measure the variation of the performance data
c) Analyze the potential sources of variation of the performance data
d) Improve - optimize the sources of variation of the performance data
e) Control - establish a system to maintain the improvements

Question 10

Government documents for setting of reserves

Answer 10

• Referred to as “guidelines and standards of practice for calculating long-term claim reserves”*
  1) US Statutory governing documents
  a) NAIC Accounting Practices and Procedures Manual
  b) NAIC model laws: Standard Valuation Law, Actuarial Opinion and Memorandum Regulation, and Health Insurance Reserves Model Regulation
  c) NAIC Health Reserves Guidance Manual
  2) Canadian governing documents
  a) International Financial Reporting Standards for annual statements
  b) Publications and papers from the Canadian Office of the Superintendent of Financial Insurance and the Canadian Institute of Actuaries
  3) US GAAP governing documents
  a) Financial Accounting Standards Board: Statements and Interpretations, and Technical Bulletins
  b) Accounting Principles Board opinions, statements, and interpretations
  c) American Institute of Certified Publish Accountants: Statements of Opinion, and Industry Audit and Accounting Guides
  4) Tax governing documents
  a) In the US: IRS code
  b) In Canada: the Canadian Income Tax Act, which requires some adjustments be made to statutory numbers
  5) Actuarial governing documents
  a) Various ASOPs, includes 5, 7, 10, 11, 12, 18, 21, 22, 23, 28, 41, 42
  b) The American Academy of Actuaries’ series of Practice Notes
  c) The Guides of Professional Conduct of the American Academy of Actuaries
  d) Literature published in textbooks and by the actuarial profession