Preventing Chronic Disease: July 2010: 09_0243 / Measuring Health Care Access and Quality to Improve Health in Populations

Volume 7: No. 4, July 2010

SPECIAL TOPIC
Measuring Health Care Access and Quality to Improve Health in Populations

Thomas E. Kottke, MD, MSPH; George J. Isham, MD, MS
Suggested citation for this article: Kottke TE, Isham GJ. Measuring health care access and quality to improve health in populations. Prev Chronic Dis 2010;7(4). http://www.cdc.gov/pcd/issues/2010/jul/09_0243.htm. Accessed [date].

PEER REVIEWED

Abstract
Poor health status, rapidly escalating health care costs, and seemingly little association between investments in health care and health outcomes have prompted a call for a “pay-for-performance” system to improve population health. We suggest that both health plans and clinical service providers measure and report the rates of 5 behaviors: 1) smoking, 2) physical activity, 3) excessive drinking, 4) nutrition, and 5) condom use by sexually active youth. Because preventive services can improve population health, we suggest that health plans and clinical service providers report delivery rates of preventive services. We also suggest that an independent organization report 8 county-level indicators of health care performance: 1) health care expenditures, 2) insurance coverage, 3) rates of unmet medical, dental, and prescription drug needs, 4) preventive services delivery rates, 5) childhood vaccination rates, 6) rates of preventable hospitalizations, 7) an index of affordability, and 8) disparities in access to health care associated with race and income. To support healthy behaviors, access to work site wellness and health promotion programs should be measured. To promote coordinated care, an indicator should be developed for whether a clinical service provider is a member of an accountable care organization. To encourage clinical service providers and health plans to address the social determinants of health, organizational participation in community-benefit initiatives that address the leading social determinants of health should be assessed.



Background
Poor health status, rapidly escalating health care costs, and seemingly little association between investments in health care and health outcomes have prompted a call for a “pay-for-performance” system to improve population health (1). The goal is to link structure and process to outcomes in the health system, which is the set of institutions and actors that affect people’s health, such as organizations that deliver care, health plans, educational systems, and city and county governments. Linking these organizations will contribute to the control of health care costs, improve the health of the US population relative to the health of other developed nations (2), and reduce disparities by region, race, ethnicity, and educational attainment (3).

The lack of tools to measure the effect of clinical services on US population health is rooted in the historical development of the American clinical health care system, which evolved to respond to the acute care needs of the individual: relief of pain and suffering through diagnosis, therapeutic intervention, and reassurance (4). Responsibility for population health needs was with the public health sector alone, and the effect on health of social policies related to education, work, transportation, and other factors was neglected. The Centers for Disease Control and Prevention might be considered the national population health agency, and many state health agencies monitor population health, but these agencies do not have regulatory authority over the health care delivery system. Many local public health agencies are mostly safety net providers. Notions of accountability for population health are underdeveloped at all levels.

Although clinical care accounts for only a small portion of the population health determinants (5), clinical service providers and health plans can contribute to population health initiatives by promoting healthy behaviors and providing clinical preventive services. At a population level, the behaviors that most powerfully affect health are physical inactivity, unhealthy diets, tobacco use, and excessive alcohol consumption (6,7). These behaviors can shorten life expectancy by 10 or more years (8,9). Behavioral support, when delivered with sufficient intensity in settings such as work sites, increases people’s odds of adopting and maintaining a healthy lifestyle (10,11). Behavioral and social support is necessary to increase the prevalence of healthy lifestyles because, even when presented with the opportunity to adopt a healthy lifestyle, people still must choose a healthy lifestyle. They are unlikely to do so in a physical and social environment that encourages poor health habits.

Properly selected clinical preventive services also improve population health (12). People are more likely to receive appropriate preventive services when quality assessment systems ensure that they are informed about the benefits of the services and invited to accept the services.

Clinical indicators can identify gaps in access to care — an indicator of quality — and guide the application of incentives to close the gaps. Reporting clinical indicators of population health may also increase the salience of health incentive programs to stakeholders such as clinicians or purchasers of health services, who might be more focused on clinical performance than on long-term mortality trends. The level of clinical indicators can change more rapidly than death rates and longevity, and thus, may give more immediate feedback about the effectiveness of intervention programs. For example, feedback can be provided about positive changes in smoking rates and physical activity rates long before the effect on mortality can be observed.

open here to see the full-text:
Preventing Chronic Disease: July 2010: 09_0243