Start us­ing qual­ity mea­sures that mat­ter and not process mea­sures

Modern Healthcare - - COMMENT - By Dr. John Cud­de­back

To move from vol­ume-based to value-based pay­ment, it’s es­sen­tial to mea­sure the qual­ity and cost of care. For all but health­care’s rear guard, this is now a given.

Un­for­tu­nately, as Mer­rill Goozner rightly pointed out in “How to keep pay­ment re­form mov­ing ahead” (Mod­ern Health­care, July 10), the ex­plo­sion of qual­ity in­di­ca­tors and the bur­den of com­pli­ance has en­gen­dered a re­volt among providers that threat­ens po­lit­i­cal sup­port for the tran­si­tion.

The ed­i­to­rial con­cluded that HHS should “stream­line qual­ity re­port­ing.” I’d go a step fur­ther: Blow it up.

The sys­tem we have is cum­ber­some and is im­pos­ing sub­stan­tial costs on providers.

• A study re­ported in Health Af­fairs found that physi­cians in four com­mon spe­cial­ties spend, on av­er­age, 785 hours per physi­cian and $15.4 bil­lion an­nu­ally on re­port­ing qual­ity mea­sures.

• A re­cent sur­vey by AMGA found that mem­ber med­i­cal groups and in­te­grated sys­tems em­ploy an av­er­age of 17 in­for­ma­tion tech­nol­ogy peo­ple per 100 physi­cians. Much of their work re­volves around data sub­mis­sion and re­port­ing.

• Of the 271 mea­sures used for the Merit-based In­cen­tive Pay­ment Sys­tem, the CMS iden­ti­fies only 27% as out­come or in­ter­me­di­ate out­come mea­sures. It iden­ti­fies 67% as process mea­sures.

In start­ing over, we need to dif­fer­en­ti­ate be­tween mea­sures for mea­sures’ sake, mea­sures for im­prov­ing in­ter­nal pro­cesses, and mean­ing­ful mea­sures re­ported for ex­ter­nal ac­count­abil­ity about how pa­tients fare.

In the first cat­e­gory are mea­sures spawned by var­i­ous med­i­cal spe­cial­ties cre­at­ing mea­sures to get their share of a few per­cent­age points of re­wards through pay-for-per­for­mance pro­grams.

In the sec­ond are proven in­ter­nal process mea­sures that dis­ci­plined sys­tems can use to achieve bet­ter out­comes at lower over­all cost. Sys­tems in­cented to en­hance value have ev­ery rea­son to con­tinue to use th­ese on their own.

The third cat­e­gory, ex­ter­nally re­ported mea­sures, is where we need to take a big leap. We need more clin­i­cally rel­e­vant, pa­tient-cen­tered mea­sures that cap­ture how pa­tients feel their care was de­liv­ered, whether their new knees work, whether they got an in­fec­tion in the hos­pi­tal, and so on. Th­ese mea­sures are es­sen­tial to take us beyond pay-for-per­for­mance to a true value-based pay­ment sys­tem. Lack­ing th­ese, we’re flood­ing the mar­ket­place with “noise,” process mea­sures that are re­lated to good out­comes but fall short of mean­ing­fully re­flect­ing qual­ity, as per­ceived by the pa­tient.

Con­sider the ex­am­ple of di­a­betes. To­day we place un­due fo­cus on ex­ter­nally re­port­ing whether pa­tients get their an­nual eye and foot exam or re­ceive in­struc­tion to stop smok­ing and take as­pirin. It’s vi­tal for a sys­tem to know whether it is do­ing th­ese things, but it’s more mean­ing­ful to know whether pa­tients are achiev­ing good glycemic and blood pres­sure con­trol, whether they avoided loss of limbs or car­dio­vas­cu­lar events.

Th­ese data are cap­tured, but they’re of­ten lost in the noise.

In ad­di­tion, mea­sures should re­flect so­cial de­ter­mi­nants of health and ac­knowl­edge pa­tients’ ac­count­abil­ity for their own choices, fol­low­ing through on shared de­ci­sion-mak­ing with their care team.

HHS Sec­re­tary Dr. Tom Price wants to re­duce the re­port­ing bur­den. He might start by us­ing his au­thor­ity to al­low providers who are tak­ing risk via value-based con­tracts to meet mea­sures that re­flect clin­i­cally rel­e­vant out­comes. Th­ese groups in­her­ently use process mea­sures in­ter­nally to drive improvement and re­duce costs.

You can’t im­prove what you don’t mea­sure, and you can’t im­ple­ment a value-based pay­ment sys­tem with­out an un­der­ly­ing sys­tem of mea­sure­ment. But the sys­tem we have is not the sys­tem we need. It wastes pre­cious re­sources on un­war­ranted mea­sure­ment, re­sources that would be bet­ter spent on im­prov­ing pa­tient care.

In­ter­ested in submitting a Guest Ex­pert op-ed? View guide­lines at mod­ern­health­ Send drafts to As­sis­tant Man­ag­ing Ed­i­tor David May at dmay@mod­ern­health­

Dr. John Cud­de­back is chief med­i­cal in­for­mat­ics of­fi­cer for AMGA, an Alexan­dria, Va.based as­so­ci­a­tion rep­re­sent­ing mul­ti­spe­cialty med­i­cal groups and in­te­grated sys­tems of care.

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