We are at an inflection point in our efforts to measure the quality of U.S. health care. Most medical professionals accept that rigorous quality measurement is essential to improving care and fundamental to transitioning the way we pay for health care. The question we face now is this: How should we measure quality in meaningful and efficient ways?
The answer could either smooth the transformation to a value-based delivery and payment system or continue to allow performance measurement to impose a significant roadblock to this transition to value.
I say “we” because physicians and other health care providers share ownership of this issue with patients, payers, and purchasers. In a recent speech to representatives of all four groups, Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, called out the growing tension between patient-centered care and the administrative burdens that measurement imposes on physicians, hospitals, and health systems. Her diagnosis was spot on.
“We need to move from fee-for-service to a system that pays for value and quality ― but how we define value and quality today is a problem,” she said. “We all know it: Clinicians and hospitals have to report an array of measures to different payers. There are many steps involved in submitting them, taking time away from patients. Moreover, it’s not clear whether all of these measures are actually improving patient care.”
As president and chief executive officer of AMGA, I work with more than 450 multispecialty organizations representing 175,000 physicians. For three years in a row, we’ve asked them to tell us the major barriers they face in moving from fee-for-service to value-based payment for care. This year’s newly released survey results reconfirm the emerging paradox: measuring and reporting quality has become a barrier to actually improving it, diverting resources from the provision of care itself.
The 74 respondents, most representing multispecialty medical groups and integrated delivery systems with 50 to 1,000 physicians, cited several data-related obstacles to the transition to value-based care, including: the lack of access to administrative claims data from payers; data that are not actionable even if they are available; and complying with requirements to submit and receive data in different formats from different payers.
Sharon R. Gabrielson, chair of Mayo Clinic Global Business Solutions, has noted that Mayo is required routinely to report hundreds of different quality metrics in multiple formats to various public and private payers. A report in Health Affairs found that physicians in four common specialties spent $15.4 billion in 2015 reporting quality measures. A related survey of 23 health insurers found that they used 546 provider quality measures, few of which matched across insurers or with the 1,700 measures used by federal agencies.
To understand the problem with quality measurement today, consider a patient thinking about knee replacement surgery. By looking hard enough, he or she could probably find out how often a facility’s patients get antibiotics before surgery, contract infections from surgery, or return to the hospital due to complications after surgery. But he or she is highly unlikely to discover whether those patients walk better a year later.
This example also illustrates both the utility and difficulty of gathering data. Data about antibiotics administration, infection rates, or hospital readmissions are readily available in administrative data — captured in Medicare claims — about services delivered. This is useful for measuring quality or adjusting payments to facilities based on performances. But where it is relatively easy to track claims data, gathering information about a patient’s mobility is not. It requires asking patients questions about their health care experiences.
In the short run, the demand for quality reporting is outrunning our capability to produce it. Despite current complaints about electronic health records detracting from the physician-patient relationship, over time they will make it easier to track and improve patient care and produce population metrics. Indeed, I’m confident the health care sector eventually will harness information technology as effectively as other sectors. But right now we need to focus on the possible.
As we work toward producing more meaningful measures for patients, we should ease the reporting burden on providers and make better use of the measures we continue to require. Verma can lead the way. CMS collects hundreds of quality metrics from providers — 273 alone for its Merit-Based Incentive Payment System. Many of those track processes of care, such as antibiotics administration. To better assess clinical quality and ease the reporting burden, CMS should focus on measures that are readily available in claims data that reflect outcomes, such as readmissions or infections. CMS should also ask Congress to require federal and commercial payers and providers to work together to standardize the data submission and reporting processes and share all claims data with each other.
This is not a call for a retreat, but for a better way forward. The fits and starts that have marked the progress we’ve made in quality measurement and improvement are not unusual for such a relatively young field. The principles that guide our thinking about quality today didn’t exist until the mid-1960s. Joint Commission hospital accreditation, as we know it, has been around only since the late 1980s. I was just 10 years into practice as a family physician when the Institute of Medicine released its landmark 2001 report that defined quality health care as “safe, effective, patient-centered, timely, efficient, and equitable.” Quality of care hasn’t figured prominently in payment until the last five years.
If we want to go farther faster, the signpost on the road ahead should read: Less is more. For example, the 150 medical groups that participate in AMGA’s Diabetes Together 2 Goal campaign focus on just four metrics — blood sugar control, blood pressure control, lipid management, and medical attention for liver disease — for the 1.8 million patients in the program. The groups improved care for 1 in 3 patients in the first year of the campaign.
I’m optimistic we can achieve this type of improved patient care on a large scale if we redirect resources from unwarranted measurement to improving patient care.
Jerry Penso, M.D., is the president and chief executive officer of AMGA, which has 175,000 physicians practicing in its member organizations, delivering care to one in three Americans.
Quality metrics should aspire to measure the outcome specific to the intervention activity or prevention application even if the outcome is downstream in time. The best measure of value always must include and in the final analysis be the patient assessment of success not some arbitrary benchmark on function or complication or even death.
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Our medical group always negotiates with payers to develop a list of measures. We found claims measures are typically not valuable for improved patient care as they are missing critical components – like lab results, vitals and surgical or medication history. Our payers typically request HEDIS measures and we always move ways from these measures to the CMS provided specifications. This really is the key, reduce the number of measures and concentrate on truly valuable measures – not solely claims based measures.
I’ve been dealing with quality measures for just over a decade and what I don’t understand is why providers have allowed payors/CMS/NCQA dictate the measures. Why should a payor have a different diabetes measure than CMS? Why, when negotiating a contract with a payor, doesn’t the provider say, hey we already collect these 10 measures and these are what we will send you. Instead they are forced to collect a cadre of measures with slightly varying definitions depending on the contract. Its a total mess and all are to blame – CMS, hospital administrators, NCQA, AHRQ, payors… all need to get together and have ONE set of measures. Once you boil all these measures down, they aren’t that time consuming and could improve care.
As a long-time data expert who has had the privilege of experiencing an unusual amount of medical care, I have a few observations:
– When the subject of your action is dynamic, non-quantitative measures may well be more appropriate (cf the “Complex” quadrant of the Cynefin framework.)
– Many truly important measures are best known and understood via a long term relationship of trust. Our costly substitute methods, of endlessly asking every provider to record answers to banal questions, are hardly effective. (Why are all of my providers required to ask and record, for every visit, whether or not I smoke? And they’re dinged if they fail to ask?!!)
– I see many specialists; some are tops in their field. That they must fill out sometimes a few hundred observations that have NO relationship to my care, is more than a waste. It is unconscionable. It affects their attitude and mine.
– I tell you honestly, it’s this bad: during a recent hospital stay, it was clear that I the patient was in the way of my nurse’s primary job, which was to stare at her e-records system and fill out all the necessary fields. Her job performance, and that of her hospital, depends on those answers. Patient care comes a distant second.
No, it is not that bad everywhere. But providers must work hard to avoid going down that path.
My suggestion is the same as the advice I gave to a client many years ago in Silicon Valley: instead of mandating these new systems, let the users decide when a tracking system is worth purchasing. Until the new is obviously better, throw the bums out. That includes both vendors, and regulators who have become convinced that the Next New Thing will “obviously” help.
As a computer expert, I trust people’s insight far more than I trust computer-based analysis.
The notion of “quality” in healthcare has always been somewhat nebulous. It is a high level indicator and allows strategic pronouncement without any well descibed tactical or operational content. We need to agree the dimensions of healthcare which matter to the individual,patient and work from there. Thus: Healthcare must be as accessible, affordable, effective, safe, efficient, comfortable, comforting, confidential, convenient and economical as possible. Here we have 10 axes or dimensions each one of which could be weighted and could have specific measurable dimensions of its own. High score wins!
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