Clin­i­cians must push back against crit­ics chal­leng­ing the role of qual­ity mea­sures

Modern Healthcare - - COMMENT - By Leah Binder

The new­est move­ment in healthcare is the quest for “value,” pay­ing for the best out­comes at the best price. Nearly ev­ery­one agrees this is a good idea.

But our $3 tril­lion de­liv­ery sys­tem is not built on ideas, it’s built on dol­lars, most of which still come from fee-for-ser­vice. So “value” has its op­po­nents.

Nonethe­less, the value move­ment is pro­gress­ing rapidly, and will suc­ceed where prior re­forms stalled. Its mo­men­tum comes from three main trig­gers.

The first trig­ger is the force of law. “Value” is en­shrined in the Af­ford­able Care Act, with the CMS now ty­ing al­most 6% of hos­pi­tal Medi­care re­im­burse­ment to per­for­mance and Congress re­plac­ing the sus­tain­able growth-rate sys­tem with a val­ue­based for­mula.

The sec­ond trig­ger is the mar­ket. Al­ready 40% of com­mer­cial pay­ments may be linked to value—surg­ing from 9% a year ear­lier. Con­sumers are pay­ing more out of pocket, so they are sen­si­tive to value as well.

The third trig­ger is mea­sure­ment. Thanks to big data, good re­search and nim­ble lead­er­ship by the Na­tional Qual­ity Fo­rum and oth­ers, we can de­fen­si­bly mea­sure the qual­ity side of the value equa­tion.

Value op­po­nents can’t do much about the first two trig­gers: Try con­vinc­ing a politi­cian or a rest­less mar­ket to ex­empt healthcare from ac­count­abil­ity. But the third trig­ger, mea­sure­ment, does of­fer op­por­tu­ni­ties to de­lay the move to­ward value.

As a re­sult, never be­fore have we seen such emo­tional fer­vor, some­times out­right vit­riol, in ne­go­ti­a­tions about mea­sures. At the NQF, provider stake­hold­ers now seg­re­gate “higher stakes mea­sures”—those af­fect­ing provider pock­et­books—for es­pe­cially rau­cous de­bate. (For pa­tients, all mea­sures rep­re­sent the high­est stakes imag­in­able).

Ad­vice to clin­i­cians: Be­ware of ar­gu­ments made in your name to de­nounce mea­sures. Many of those ar­gu­ments might de­press you—a risky propo­si­tion in an era when nearly 50% of physi­cians re­port burnout and a third of nurses want to quit. Two re­cent publi­ca­tions that os­ten­si­bly dis­credit spe­cific mea­sures il­lus­trate this haz­ard.

The first, in the jour­nal BMJ, ques­tioned the “stan­dard­ized mor­tal­ity ra­tio.” Through chart re­view of in­pa­tient deaths in the United King­dom, the re­searchers ob­served that the vast ma­jor­ity of those deaths (85% to 95%) did not di­rectly re­sult from a “prob­lem” in care, clin­i­cian er­ror or omis­sion. So the re­searchers con­clude clin­i­cians have lit­tle im­pact on the stan­dard­ized mor­tal­ity ra­tio, and it’s un­fair to hold them ac­count­able for it.

Here’s the dam­ag­ing as­sump­tion in the study: The only way physi­cians or nurses im­prove pa­tient sur­vival is by avoid­ing killer mis­takes. Surely clin­i­cal skill im­pacts mor­tal­ity more than that.

Another re­cent study in JAMA sim­i­larly min­i­mized the im­pact of clin­i­cians. The re­searchers com­pared how U.S. hos­pi­tals did on a tested and val­i­dated com­pos­ite of safety mea­sures used by the CMS to de­ter­mine how they per­formed on two untested and un­val­i­dated composites the re­searchers in­vented.

One of the in­vented composites cred­its cer­tain hos­pi­tal char­ac­ter­is­tics to­ward its qual­ity score, such as Level 1 trauma or teach­ing sta­tus, while the other cred­its qual­ity pro­cesses.

The study finds that some hos­pi­tals ex­cel on the in­vented qual­ity composites but fail on the CMS safety com­pos­ite. Il­log­i­cally, the re­searchers con­clude that the CMS safety com­pos­ite is flawed. One might just as well con­clude that the re­searchers’ composites are flawed.

Ul­ti­mately, this paints a dis­mal por­trait of the po­ten­tial of in­di­vid­ual clin­i­cians. If you prac­tice in a hos­pi­tal that’s not a teach­ing hos­pi­tal with a Level 1 trauma cer­ti­fi­ca­tion, then— try as you might—you will not de­liver the high­est-qual­ity care. If you ex­cel on some but not all mea­sures, the mea­sures are wrong and you don’t ex­cel at any­thing.

While thought­ful cri­tiques of mea­sures are im­por­tant, po­lit­i­cally mo­ti­vated de­nial of mea­sures is de­struc­tive in un­in­tended ways. It of­ten fol­lows the un­for­tu­nate pat­tern of these stud­ies in as­sum­ing that providers per­form at es­sen­tially the same level of qual­ity and/or their ac­tions can’t be linked to pa­tient sur­vival or heal­ing. If all physi­cians and nurses be­lieved their work had such mod­est im­pact, the burnout prob­lem might be even worse. Peo­ple who choose a ca­reer in healthcare tend to be bright, com­pet­i­tive and car­ing, and they won’t last long if they be­lieve their tal­ents make vir­tu­ally no dif­fer­ence.

I salute the many physi­cians and nurses who coura­geously in­sist on trans­parency and ac­count­abil­ity for their pa­tients. For them, the pa­tients come first, not some in­sti­tu­tion’s fi­nances or pol­i­tics. Clin­i­cians have a choice: Seize the mo­men­tum of the value move­ment to fi­nally get re­warded for ex­cel­lence, or re­cite tired po­lit­i­cal talk­ing points that min­i­mize your life’s work. Value will suc­ceed ei­ther way, but it will be so much bet­ter in­fused with the knowl­edge and gifts of prac­tic­ing providers.

Leah Binder is CEO of the Leapfrog Group.

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