In American health care, we continue to see aggressive adoption of new technologies that don’t fulfil their promise. We continue to wonder who’s minding the store – who is evaluating these technologies, assessing their “value” and their risks, and designing coverage and benefit programs to encourage the use of effective treatments and discourage the use of questionable ones. Today’s news is about failed hip implants:
http://www.nytimes.com/2011/12/28/business/the-high-cost-of-failing-artificial-hips.html?_r=1&ref=health;
last summer it was angioplasty: http://online.wsj.com/article/SB10001424052702304760604576428323005864648.html?mod=googlenews_wsj
and spine surgery: http://www.npr.org/blogs/health/2011/08/24/139923555/hospitals-have-got-your-back-maybe-a-little-too-quickly.
Fortunately, a number of professional societies are working with purchasers and payers to reduce the frequency of this kind of unaccountable overuse of expensive services. Registries are large data bases that capture detailed clinical information and patient reports of the benefits of treatment, and create real-time feedback loop to clinicians and patients about what works – and what doesn’t.
Registries to the Rescue
Registries, which are databases that collect information about a patient’s care for a condition or procedure, are a key tool towards measuring “value” in health care. Value is defined by Michael Porter as being the full set of a patient’s health outcomes for a condition/total cost of care (not charges). These outcomes shouldn’t be measured just by checking off a list of processes (i.e., did the patient have a diagnostic test), but should be measured by asking the patient about their function before, during and after the episode they had (e.g., arthritis, and then a hip replacement) or for as long as they have a certain condition (e.g., diabetes). If registries can collect clinical information and couple it with patients’ information, that information can be used to support and accelerate change in the delivery system, and can be used to support incenting and paying providers for true value.
Who has registries now?
Many countries in Europe have used registries to measure and improve care for years, with great results. Patients get better care for their condition, have fewer infections and less need for repeated procedures, and the whole system saves money. In the U.S., there are several registries for specific diseases or procedures that have been operational, and have comparable results. Perhaps the best known are the cardiac registries, run by the American College of Cardiologists. Reporting to these registries is required for procedures like having an implantable defibrillator put in. Similarly, the Society of Thoracic Surgeons has a longstanding registry. These registries collect information about the devices and clinical procedures performed.
PBGH is one of three sponsors of the California Joint Replacement Registry http://www.caljrr.org/, which was formed last year and recently received another grant to expand to include more sites. PBGH serves as the manager for the registry, which is the first of its kind in the country. This registry collects information on hip and knee replacements – from hospitals, physicians and patients. It includes clinical information, device information and, most importantly patients reports on their functional status before and after their procedure.
We’re also partnering with CHCF and the California Maternal Quality Care Collaborative (CMQCC) to build a statewide data repository that can drive quality improvement in maternity care. Almost 30% of the births in CA each year are c-sections, and we know that the outcomes for both babies and moms in c-sections that aren’t medically necessary are inferior. With this data, we will design quality improvement projects, patient information campaigns and reimbursement systems that encourage the right care.
This is a great start. To really drive change, though, we should be measuring the patient’s care across the delivery system. For this to happen, registries would need to connect with each other and exchange information. As more and more hospitals and medical groups move to electronic health records, and as reimbursement changes to reward them for using them, we think we will see more and more registry participation.
A role for purchasers
Purchasers should take an active role to support and promote registries. Purchaser actions will directly affect whether and how quickly providers move to create, use and share this important information. Purchasers should:
Tell your health plan that you want their networks to include only providers who participate in and use registry information
• Plans should be designing their networks to include high value providers, and ones who are participating in this type of quality effort.
• ACOs should certainly contribute to and access information about the patients’ total experience.
Design benefits that drive patients to high value providers.
• Offer benefit designs that encourage patients to choose high quality, cost effective care and participate in their care planning (e.g., lower or no copays for engaging in shared decision making).
• Tie reference pricing preferred "list" to registry participation.
Pay providers for value
• Develop episode payments that are linked to registry participation and reporting.
Invest in registry startup.
Fund activities related to the development of registry infrastructure.
Publicly recognize providers who participate
List hospitals and physicians in “excellent” category on health plan provider directories and preferred provider lists. Require participation for inclusion in preferred programs.
Insist on the development of professional standards and guidelines that encourage appropriateness and identification.
Tie payment to guideline adherence and reporting of appropriateness indications.
If purchasers continue to beat the drum, urging health plans and providers to step up, and encouraging consumers to use information when making decisions, they can play an invaluable role shaping the health care system we want for tomorrow. PBGH looks forward to continuing this work in 2012.
Kate Chenok is a Director at PBGH, who focuses on PBGH's Redesigning Care strategy. She can be reached at
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