Start using quality measures that matter and not process measures
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.
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Dr. John Cuddeback is chief medical informatics officer for AMGA, an Alexandria, Va.based association representing multispecialty medical groups and integrated systems of care.