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Reform group takes pulse of La. health care quality

Section: Health

Kate Moran

Health-care researcher David Wennberg delivered a report last week that revealed a stealthy fact about medical care in Louisiana: It appears to be often driven by institutional factors, such as the number of hospital beds in a given area, that have little to do with the best interests of the patient.

Wennberg found that doctors often prescribe unnecessary treatments for patients with chronic disease, and their care decisions seem to be dictated as much by the economics of the health-care market where they work, including the supply -- or oversupply -- of equipment, hospital beds and specialists, as by the desires of the patient.

Wennberg pulled together an enormous trove of data for his study, and he donated it last week to a new group called the Louisiana Health Care Quality Forum, which aims to lift the state from the bottom of national health rankings by setting standards for the type of care delivered for chronic disease.

Just last week the United Health Foundation ranked Louisiana the second- worst state for the overall health of its population because of its low rate of immunization and its high number of uninsured patients. The state heralded the ranking as good news because Louisiana managed to move up from the No. 50 slot it occupied last year.

The quality forum plans to collect data from Medicare, Medicaid and private insurance companies, just as Wennberg did, to determine whether doctors in different parts of the state are following a consistent set of practices to manage chronic conditions such as diabetes and high blood pressure, which tend to account for a large proportion of insurance claims.

The forum also would use the data to measure the overall health of the population, including the percentage of residents who are obese, the number who have access to a primary care doctor and the number of premature deaths recorded every year. State lawmakers could then use this census as a foundation for setting health policy.

"If we have a high number of people who smoke and we know that's a health risk, we might impose a cigarette tax, for example," said Gery Barry, the chief executive of Blue Cross Blue Shield of Louisiana and a member of the quality forum.

Gauging quality statewide

The quality forum grew out of intensive discussions last year about how the state might use the destruction of Charity Hospital in New Orleans as an opportunity to reform how it cares for uninsured patients. Many of the proposals floated by the Health Care Redesign Collaborative stalled for lack of financing, but the quality forum took wing with the help of a $1.07 million startup grant from the state.

"One of the very positive things that came out of the collaborative was the commitment to a statewide effort to measure quality, measure cost and try to profile what type of health care is going on throughout the state," Barry said. From there, the forum would try to identify opportunities for improvement.

Although the state provided the initial round of financing, the quality forum is a nonprofit rather than a government agency. Its board of directors consists of doctors, insurance providers and patient advocates, and they plan to seek money from charitable foundations or health-care companies once the forum is better established.

Board members said the quality forum is not a regulatory agency that can discipline doctors or hospitals that do not meet quality standards. Instead, the board aims to establish a set of best practices that doctors should follow -- such as providing mammograms to women or foot exams to diabetics -- to maintain the health of their patients and reduce expensive and unnecessary procedures.

No 'pointing fingers'

"This is not about pointing fingers or saying someone is worse than someone else, but about how to focus the efforts of purchasers, payers and providers in a very concerted way to improve the quality of health care in Louisiana," said board member Karen DeSalvo, chief of internal medicine and geriatrics at Tulane University.

DeSalvo said the data Wennberg donated to the health quality forum will be available on the Web to researchers and policymakers in three to six months. Although members of the quality forum hope doctors can eventually use the data warehouse to assess their own performance, it does not provide information about individual practices in its current form.

Michael Fleming, a retired family doctor from Shreveport and the president of the quality forum, said the group's next step is to hire an executive director and a public relations firm. The board of directors is sifting through 26 resumes and hopes to have the director installed by early next year. The forum's offices will be in Baton Rouge.

The quality forum held its first public event last week at Tulane, where Wennberg, an internist with specialty training in health services and outcomes research, presented his report. Tulane commissioned the study by Wennberg and his firm, Health Dialog Analystic Solutions of Boston, with a grant from Blue Cross Blue Shield.

Variability issue

Wennberg found that doctors in different parts of the state prescribe many different courses of treatment for patients with chronic disease. He also found that the variations could not be fully explained by the health of the patients, by their race or by the type of insurance they carry.

"What is causing that variability?" Barry asked. "There is something going on that can't be explained by their health status or their insurance status or by anything other than the fact that doctors seem to be doing different things in different geographic locations. If there are more inpatient stays in a given area, it is presumably because there are more hospital beds there, but we have not tried yet to diagnose whether that is true."

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