‘What are we re­quir­ing providers to do, and is there a good rea­son to re­quire it?’

Modern Healthcare - - Q & A -

At the be­gin­ning of this year, Dr. Shan­tanu Agrawal was se­lected to head the Na­tional Qual­ity Fo­rum, a not-for-profit, non­par­ti­san or­ga­ni­za­tion that aims to im­prove health­care through qual­ity mea­sure­ment. The NQF also works closely with the CMS and endorses mea­sures used in fed­eral pro­grams. Agrawal joined the NQF from the CMS, where he was most re­cently deputy ad­min­is­tra­tor and di­rec­tor of the agency’s Cen­ter for Pro­gram In­tegrity. Agrawal re­cently sat down with Mod­ern Health­care safety and qual­ity reporter Maria Castel­lucci to dis­cuss his plans for the NQF in­clud­ing ef­forts to ad­dress so­cial de­ter­mi­nants of health, the opi­oid cri­sis and physi­cian burnout. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: You’ve been in the role of CEO for a few months now. What are your pri­or­i­ties for the Na­tional Qual­ity Fo­rum?

Dr. Shan­tanu Agrawal: We re­ally want to play a role in cat­alyz­ing health re­form and pay­ment re­form. We’ve had an im­por­tant role in that through our qual­ity mea­sure­ment and qual­ity im­prove­ment work, and that needs to con­tinue un­abated even as we might be en­ter­ing an­other round of re­form.

Sec­ond—and I per­son­ally feel very con­nected to this— is to bet­ter con­nect our work and mis­sion to the front lines of medicine, whether that’s on the clin­i­cian side or the pa­tient side, to make sure that they are able to make more and bet­ter de­ci­sions around their own health­care.

We can some­times play a more aca­demic role, which tends to hap­pen in sci­en­tif­i­cally driven or­ga­ni­za­tions like ours. That is im­por­tant, but we can also do more to bring that ex­per­tise and the out­comes of our work, or the prod­ucts of our work, to the front lines.

Third, there con­tinue to be re­ally im­por­tant top­ics in the health­care qual­ity and qual­ity im­prove­ment space that we need to play a lead­er­ship role on. A cou­ple that come im­me­di­ately to mind are so­cial dis­par­i­ties or health in­equity is­sues and the opi­oid cri­sis.

Those are is­sues that I feel per­son­ally con­nected to. I did a lot of work on opi­oids while still at the CMS, and that con­tin­ues to be a crit­i­cal topic that NQF can im­pact.

MH: How can the NQF ad­dress those two ar­eas?

Agrawal: On so­cial dis­par­i­ties, it’s clear that there isn’t great data on char­ac­ter­iz­ing or that help to char­ac­ter­ize so­cial dis­par­i­ties or health in­equity is­sues, and at the same time there aren’t great mea­sures. So, that’s clearly in our wheel­house to con­vene ex­perts and help to elu­ci­date what good data sources might be or per­haps help to de­velop them from an ad­vo­cacy stand­point and a sci­en­tific stand­point so that as a so­ci­ety we can bet­ter un­der­stand this is­sue.

On the mea­sure­ment front, there’s an im­por­tant ques­tion around risk ad­just­ment and strat­i­fi­ca­tion that ob­vi­ously has been an im­por­tant pol­icy ques­tion on the Hill, im­por­tant in the govern­ment over­all, and im­por­tant to all our stake­hold­ers. We have played an im­por­tant role there and con­tinue to do so, those mea­sures re­flect the right ap­proach. Our work in­her­ently ties to re­im­burse­ment and pay­ment in­cen­tives, so where we can help to im­prove mea­sure design and bring the right risk ad­just­ment or strat­i­fi­ca­tion ap­proach, that will be a re­ally im­por­tant role.

Opi­oids are a lit­tle bit of a dif­fer­ent topic. There are na­tion­ally ac­cepted guide­lines that we have re­flected in our mea­sures, so it’s not so much a data and mea­sure­ment is­sue. The con­tri­bu­tion that we can make is on build­ing tools and re­sources to help providers and help pa­tients make bet­ter de­ci­sions around opi­oid use.

One thing we can do in this area and in a lot of oth­ers is launch what we call an ac­tion team to help de­vise so­lu­tions to ad­dress a par­tic­u­lar chal­lenge in health­care. We did that around is­sues like an­tibi­otic stew­ard­ship and shared

“Trans­parency to pa­tients and pa­tient choice is re­ally core to NQF.”

de­ci­sion­mak­ing. It helps to bring na­tional at­ten­tion to an is­sue and helps to cre­ate an ac­tual tool that providers can use to make im­prove­ments. That’s the kind of ac­tion we want to take on opi­oids as well.

MH: A few months ago, the NQF rec­om­mended that HHS re­move 51 of 240 qual­ity mea­sures that you didn’t think added value. Could you talk about the chal­lenges to en­sur­ing that qual­ity mea­sures are ac­tu­ally pro­vid­ing value?

Agrawal: This was a new ac­tiv­ity for us. It was the first time that we looked at the en­tire port­fo­lio of Medi­care and Med­i­caid mea­sures through the Mea­sure Applications Part­ner­ship process and tried to iden­tify those mea­sures that we thought could be re­moved. We made those rec­om­men­da­tions for two main rea­sons: ei­ther the mea­sure it­self wasn’t the best mea­sure any­more or the mea­sure topped out and there wasn’t enough vari­abil­ity in how providers per­formed on that mea­sure.

One of the chal­lenges in mea­sure­ment is to stay cur­rent, right? New ev­i­dence is be­ing gen­er­ated all the time; mea­sures have to be re­viewed pe­ri­od­i­cally to make sure that they are still based on the best sci­ence. We do that in our en­dorse­ment work, so ev­ery mea­sure gets re­viewed at least ev­ery three years, if not more quickly. If some fun­da­men­tally im­por­tant new sci­ence comes out, then we’ll bring that mea­sure back for re­view even more quickly. We’re try­ing to bring that think­ing to MAP as well.

Per­for­mance vari­abil­ity is also cen­tral to the process. We won’t endorse a mea­sure if providers are essen­tially do­ing equally well on that mea­sure; that’s a phi­los­o­phy we’re try­ing to bring to MAP.

As you noted, we rec­om­mended a 20% re­duc­tion in mea­sures as a re­sult of this kind of think­ing. Our plan, very much in agree­ment with the CMS, is to con­tinue per­form­ing that ac­tiv­ity year af­ter year so that MAP can be a place where it re­ally is con­sid­er­ing the most vi­tal mea­sures. There’s this con­stant cy­cle of im­prove­ment.

MH: What about qual­ity mea­sures and how they re­late to burnout?

Agrawal: That’s a very im­por­tant ques­tion, and I feel per­son­ally con­nected to it as an emer­gency room doc and hav­ing been on the re­ceiv­ing side of mea­sure­ment as well. First, we should think of this more broadly than just the ques­tion of bur­den. The real ques­tion is, what are we re­quir­ing providers to do, and is there a good rea­son to re­quire it?

The good rea­son should al­ways be ac­tu­ally im­prov­ing care at the bed­side, ac­tu­ally get­ting pa­tients the kind of care and the value of care that they need. Where a mea­sure isn’t im­prov­ing qual­ity or doesn’t have the po­ten­tial to do that, the ex­pec­ta­tion on providers cer­tainly starts to seem un­rea­son­able and bur­den­some.

There are a few things we can do. First, mak­ing sure that we are fo­cused on the right kind of mea­sures, that we’re en­dors­ing the right mea­sures, that they are out­comes-fo­cused, that they re­ally give in­cen­tives for care co­or­di­na­tion and in­te­gra­tion, that they are fo­cused on the is­sues that mat­ter most to pa­tients.

More broadly, and frankly big­ger than NQF, is help­ing to ad­dress the align­ment ques­tion. Part of the un­nec­es­sary bur­den of mea­sure­ment comes from small, or rel­a­tively small, dif­fer­ences in mea­sure design. Two mea­sures might look to as­sess the same thing, but they do it in slightly dif­fer­ent ways. That can look small at the mea­sure­ment level, but at the provider level, those kinds of dif­fer­ences can be re­ally sub­stan­tial.

NQF has an im­por­tant role to play in try­ing to bring more con­sen­sus and more align­ment, but clearly that’s a process that has to be driven by a num­ber of other or­ga­ni­za­tions as well, and, if done cor­rectly, could have a lot of im­pact on providers’ lives and, frankly, pa­tients’ lives, to make sure that there’s agree­ment on what good looks like.

MH: Re­gard­ing pa­tients and con­sumers, what sort of em­pha­sis have you been mak­ing to en­sure these qual­ity mea­sures ac­tu­ally are help­ful for them?

Agrawal: Trans­parency to pa­tients and pa­tient choice is re­ally core to NQF. We in­volve pa­tients, con­sumers, pur­chasers of health­care at ev­ery level of our or­ga­ni­za­tion. They ac­count for more than half of our board. They sit on ev­ery sin­gle com­mit­tee, on ev­ery en­dorse­ment body, to en­sure that the pa­tient voice is be­ing rep­re­sented. Re­mem­ber, all of this is be­ing done to im­prove the value of care they’re get­ting.

So, any­thing that expands trans­parency for pa­tients we con­sider a pos­i­tive.

One other big thing that we are work­ing on is bring­ing more pa­tient-recorded out­come mea­sures to health­care. There’s a lot of agree­ment in the qual­ity com­mu­nity that these kinds of out­come mea­sures are crit­i­cally im­por­tant, but not many of them ex­ist. Not a lot of them have been en­dorsed by us, and it’s be­cause ac­tual pa­tient-re­ported out­come mea­sure design has been lag­ging.

One of the things that we are try­ing to do through projects like the Mea­sure In­cu­ba­tor is re­ally cat­alyze the cre­ation of these mea­sures so that they can be used. I think that’s the next big it­er­a­tion of health­care qual­ity, so that the pa­tient voice is not just kind of an end prod­uct but it is built into the qual­ity mea­sure­ment ap­proach it­self.

MH: What other is­sues does your agency have its eye on?

Agrawal: NQF reau­tho­riza­tion. We have a crit­i­cal role to play. We’re one of the few or­ga­ni­za­tions where the pa­tient lit­er­ally sits at the table, ev­ery sin­gle table. We do a lot to drive the cre­ation of the right mea­sures, their im­ple­men­ta­tion and the re­sult­ing im­prove­ment in health­care.

Our mis­sion needs to con­tinue, and folks need to un­der­stand that we get au­tho­rized by Congress, our fund­ing comes from Congress and needs to be reau­tho­rized this year. It would be great to have stake­hold­ers get in­volved and en­sure that NQF con­tin­ues to drive qual­ity im­prove­ment.

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