We can’t lose fo­cus on qual­ity in the pur­suit of value in health­care

Modern Healthcare - - COMMENT - By Dr. Cather­ine H. Ma­cLean

It’s widely rec­og­nized that the U.S. pays more for health­care than other de­vel­oped na­tions, yet achieves com­par­a­tively worse health out­comes, lead­ing for calls to lower costs to im­prove value.

But what if we in­creased qual­ity at the same cost? Wouldn’t value in­crease? “Value-based care” means we con­sider health­care cost di­rectly in the con­text of the qual­ity (or health out­comes) the care pro­duces.

With­out ques­tion, op­por­tu­ni­ties ex­ist to re­duce U.S. health­care costs by elim­i­nat­ing un­safe, un­nec­es­sary or du­plica­tive care, and we must work ag­gres­sively to elim­i­nate such care. This im­proves value by re­duc­ing cost and im­prov­ing qual­ity. At the same time, op­por­tu­ni­ties ex­ist to im­prove qual­ity that may not pro­duce cost sav­ings. Be­yond pre­ven­tive care, avoid­ance of com­pli­ca­tions and read­mis­sions, lit­tle ev­i­dence sug­gests higher qual­ity al­ways leads to lower costs.

A com­pre­hen­sive re­port com­mis­sioned by The Health Foun­da­tion asked, “Does im­prov­ing qual­ity save money?” It con­cluded, af­ter re­view­ing 264 stud­ies, that we mostly don’t know be­cause re­search is limited. A more re­cent sys­tem­atic re­view of 61 stud­ies found in­con­sis­tent as­so­ci­a­tions be­tween qual­ity and cost.

To re­al­ize high-value care, we must un­der­stand both the qual­ity and the cost of the care we pro­duce. Only then can we dis­cern value and make in­formed de­ci­sions about how we want to spend our health­care dol­lars. In hos­pi­tals, which ac­count for most health­care spend­ing, value can be elu­sive. This is be­cause we don’t mea­sure the qual­ity of many hospi­tal-based ser­vices. How can we know if care costs too much if we don’t un­der­stand its qual­ity?

When think­ing about qual­ity, there are three im­per­a­tives: avoid­ing com­pli­ca­tions, im­prov­ing health and achiev­ing pa­tient goals. We also need to con­sider pa­tient sat­is­fac­tion, a con­struct that, while im­por­tant, is dis­tinct from, and not well-cor­re­lated with tech­ni­cal qual­ity. Pa­tients can be sat­is­fied or dis­sat­is­fied with a hospi­tal stay for rea­sons wholly un­re­lated to the care they re­ceive. To date, the “qual­ity” com­po­nent of hospi­tal qual­ity and value pro­grams has fo­cused largely on com­pli­ca­tions and pa­tient sat­is­fac­tion, mainly be­cause th­ese data are avail­able, and the fewer com­pli­ca­tions, the lower the cost of care.

We must also know whether the care we de­liver is im­prov­ing health out­comes and achiev­ing pa­tients’ goals. Af­ter all, pa­tients don’t go to a hospi­tal to avoid com­pli­ca­tions—they go to get bet­ter or to con­trol chronic con­di­tions. When that’s not pos­si­ble, they go to al­le­vi­ate pain and seek com­fort. We need to en­sure that we mea­sure whether health­care achieves th­ese out­comes when con­sid­er­ing its value.

Value-based pay­ment mod­els that fo­cus pri­mar­ily on cost—im­ple­ment­ing in­suf­fi­cient or in­ad­e­quate qual­ity mea­sures—may have un­in­tended con­se­quences, such as in­creased com­pli­ca­tions and at­ten­u­ated health im­prove­ments. With­out mean­ing­ful safe­guards against short­cuts, health out­comes will suf­fer, be­cause such mod­els be­come cost-cut­ting schemes pro­mot­ing a “race to the bot­tom” for cost sav­ings, at the ex­pense of pos­i­tive health out­comes.

To achieve the trans­parency on out­comes needed to as­sess value, we must de­fine the out­come mea­sures that our de­liv­ery sys­tem needs and then rou­tinely mea­sure and re­port them. This re­quires a con­certed and co­or­di­nated ef­fort by clin­i­cians, in­formed by pa­tients, to de­fine im­por­tant health out­comes; pol­i­cy­mak­ers to fash­ion those con­cepts into mea­sures; and de­liv­ery sys­tems to de­vise ways to ef­fi­ciently and re­li­ably col­lect data. Such work is in its in­fancy, with un­even progress across health con­di­tions and re­gions.

For 20 years, Hospi­tal for Spe­cial Surgery has main­tained over 40 mus­cu­loskele­tal re­search reg­istries across more than 100,000 pa­tients, and found that rou­tinely col­lect­ing pa­tient-re­ported out­come mea­sures across large num­bers of pa­tients is fea­si­ble, but la­bor-in­ten­sive. To im­prove ef­fi­ciency, our re­searchers de­vel­oped two short­ened pa­tient-re­ported out­come tools for hip and knee re­place­ments, which Medi­care adopted for its Com­pre­hen­sive Joint Re­place­ment pro­gram.

I am op­ti­mistic that with in­creased mea­sure­ment of mean­ing­ful health­care qual­ity in­di­ca­tors, pro­moted by value-based pur­chas­ing pro­grams, and fa­cil­i­tated by in­for­ma­tion tech­nol­ogy, we will im­prove the health of our pop­u­la­tion and re­al­ize high value for the money spent. With that said, I think the jury is still out on whether this means we will spend less money.

Dr. Cather­ine H. Ma­cLean is chief value med­i­cal of­fi­cer at Hospi­tal for Spe­cial Surgery in New York City.

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