Why We Need to Shift Healthcare Quality Measures from Volume to Value

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healthcare quality measuresPhysicians are feeling a time crunch as never before. We hear many reasons for physicians’ increasingly hectic schedules: declining reimbursement that requires them to see more patients in a day, the added burden of documenting care in an electronic medical record.

Now, a new study published in Health Affairs highlights another significant contributor to the physician time crunch: quality measures. The study revealed that physicians and staff spend approximately 15 hours per week per physician reporting quality measures. What’s more, providers spend $15.4 billion annually on quality reporting—as much as the U.S. spends on healthcare for 1.6 million people in a year!

Why do providers spend so much time and money reporting quality measures? Because they are dealing with an unmanageable number of them.

Recently, the Centers for Medicare and Medicaid Services (CMS) and America’s Health Insurance Plans (AHIP) announced a major step toward rectifying this situation. That announcement marks an exciting turning point. But, when it comes to improving the quality of our quality measures, we still have a long way to go.

A Bajillion Quality Measures … and Some Progress toward Alignment

It might be an exaggeration to say that providers are required to deal with a bajillion quality measures, but they do have to deal with at least 1,958 of them. In truth, not everyone has a clear scope as to how many measures are really out there, but the following are the major ones:

  • HEDIS (Healthcare Effectiveness Data and Information Set): Developed by the National Committee for Quality Assurance (NCQA), these 81 clinically centric measures are familiar to most U.S. providers. Health plans generally require providers in their network to report these measures. They then use them, combined with cost data, to identify high- and low-performing providers.
  • CMS: CMS defines a whopping 1,514 different measures across 22 programs! To complicate matters further, within each of the 22 programs, not all measures apply to all providers equally.   Providers have to figure out which measures and which programs apply to them.
  • The Joint Commission (TJC): TJC previously aligned its measures for health failure and acute myocardial infarction with those of CMS—an important step forward—but TJC also has 12 other measure sets.

Providers also have to juggle variations on these standard measures. Sometimes health plans tweak standard measures and add exclusion criteria. And while most health plans use HEDIS, they often introduce additional measures based on the performance requirements for a specific accountable care contract.

In the past, the industry has seen limited success in broadly aligning quality measure definitions. Some industry collaboration and consensus has occurred, but not enough. That’s why the announcement by CMS and AHIP (as part of a broad collaborative of health care system participants) is such a big deal. These groups announced their intention to standardize quality measures across commercial and government payers and outlined an initial set of quality measures in seven categories:

  • Accountable Care Organizations (ACOs), Patient Centered Medical Homes (PCMHs), and Primary Care
  • Cardiology
  • Gastroenterology
  • HIV and Hepatitis C
  • Medical Oncology
  • Obstetrics and Gynecology
  • Orthopedics

Because AHIP and CMS are now leading the charge for aligning quality measures, we can expect all payers to jump on board with this effort. In the long run, this alignment should decrease the complexity and frustration physicians face as they attempt to demonstrate the quality of care they provide.

Turning Our Focus to the Best Quality Measures

Even as we celebrate this significant move toward standardization, we need to stop and acknowledge an extremely important issue. Yes, all providers will soon be measuring the same things, but are we really measuring the right things?

The truth is that as an industry, we are still putting most of our focus on process-based metrics—on whether a provider did what the evidence shows was the right thing to do. For example, did the physician prescribe the right antibiotic at the right time? Did the nurse follow the correct protocols when inserting a central line? In short, did they follow the processes that we believe lead to better outcomes?

While these measures are useful and appropriate, they don’t measure actual outcomes. We can better serve our patients by retiring some of our process metrics and focusing more of our limited resources on measuring real outcomes.

A recent article published in the New England Journal of Medicine describes the situation very clearly:

“[I]n health care we’ve allowed ‘quality’ to be defined as compliance with evidence-based practice guidelines rather than as improvement in outcomes. Of the 1958 quality indicators in the National Quality Measures Clearinghouse, for example, only 139 (7%) are actual outcomes and only 32 (<2%) are patient-reported outcomes. Defaulting to measurement of discrete processes is understandable, given the historical organization of health care delivery around specialty services and fee-for-service payments. Yet process measurement has had limited effect on value. Such measures receive little attention from patients, who are interested in results.”

One body that exemplifies the kinds of quality measures we should focus on is the International Consortium for Health Outcomes Measurement (ICHOM). ICHOM thoughtfully defines patient-centric outcomes, with particular attention on patient-reported outcomes measures. A brief comparison between cardiology measures from CMS and from ICHOM illustrates the gap between where we are now in terms of our quality measures and where we need to be.

  • Measures for coronary artery disease
    • CMS measures whether the provider prescribed an antiplatelet therapy like aspirin or Plavix, because evidence shows that such therapies help reduce heart attacks. The sole focus of the measure is whether the medication was prescribed or not. We do not measure whether the patient filled the prescription, took it correctly, or experienced better outcomes because of it.
    • ICHOM doesn’t measure antiplatelet therapy. Instead, it focuses on patient-reported health status (angina, dyspnea, depression, functional status, health-related quality of life) during the first 30 days after treatment. It then measures those same factors annually for five years.
  • Measures for heart failure
    • CMS measures the 30 day all-cause mortality rate following heart failure hospitalization. In other words, after hospitalization, did a patient die within 30 days?
    • ICHOM measures all-cause mortality for five years after an index event. Such an event doesn’t have to be a dramatic incident like a hospital admission. It could be a routine checkup when a physician classifies a patient as high-risk for heart failure because of hypertension and high triglycerides.

ICHOM promulgates measures that center on the patient’s sense of health and wellbeing rather than on the steps the physician took in delivering care. Now, obviously it isn’t easy to jump from our current state to the ideal that ICHOM represents, but we as an industry should not stop aiming for it. As we continue to define how we think of population health, we must aspire to meaningful measures that accurately reflect the state of each individual’s health.

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