Providers and health plans should become more involved with the host of public- and private-sector initiatives feverishly working on new measures of health system performance as the industry re-orders its priorities and places a premium on value and population health.
By doing so, providers and health plans can shape the metrics upon which they’ll ultimately be judged. And, they will be able to use those new metrics internally to drive their own performance improvement and externally to demonstrate the value of what they do for payers and patients.
“It is critical to measure because we know what gets measured gets done,” says Peter Long, president and CEO of the Blue Shield of California Foundation.
Long spoke at a seminar in June on quality measures sponsored by the Institute of Medicine. The IOM is forming a study panel charged with coming up with a proposed new set of core measures to assess industry performance.
“The energy is there, the momentum is there, what we need is a force to collate those together,” Long says of the IOM study panel.
Separately, the IOM released a 102-page report last month that outlines a methodology for developing new measures for population health that gauge how well providers and health plans are taking care of the health needs of a designated population base.
In “Toward Quality Measures for Population Health and the Leading Health Indicators,” the IOM said the use of quality measures to improve population health holds great promise but is “…still in its infancy.” The report said effective quality measures to improve population health should meet seven criteria. According to the IOM, the measures must be:
- Reflective of a high preventable burden
- Actionable at the appropriate level for intervention
- Usable for assessing various populations
- Methodologically rigorous
- Accepted and harmonized
What the IOM effectively did was give providers and health plans a standard against which they can measure their own population health metrics and adjust accordingly for both internal tracking and monitoring and external reporting to payers and patients.
Performance measurement has been around for a long time, but it hasn’t been done very well or comprehensively, says Robert Berenson, M.D., senior fellow at the Urban Institute. Dr. Berenson co-wrote a report on the state of performance measurement for the Robert Wood Johnson Foundation.
“One of the challenges with measurement is it is too often retroactive. We’re looking at ways that payers and providers can effectively communicate prior to care delivery. Through shared decision-making tools like our InterQual Criteria portfolio and automated workflow systems, healthcare stakeholders across the spectrum get the actionable, prospective and exception-based information they need to improve patient care and manage administrative burden,” says Matthew Zubiller, vice president decision management at McKesson.
To that end, the Urban Institute report recommends seven steps to better performance measurement, including: measuring outcomes rather than processes; using quality measures strategically; focusing on organization-level measuring rather than clinician-level measures; and measuring patient experience.
Measures today “completely ignore major problems in healthcare,” Berenson says.
For instance, most measurements don’t include how often providers correctly diagnose patients, he says. About 150,000 people are misdiagnosed annually, according to a study published in February in the Journal of the American Medical Association.
“You could have a doctor who is completely incompetent at diagnosing but he is ordering a lot of cholesterol tests so he looks good (from a measures standpoint),” Berenson says.
Well-documented problems with process-focused performance measurements today include “teaching to the test,” where clinicians focus on required measures to reap performance bonuses. Instead, “more system-based outcomes with high public health importance are needed,” according to a June article in the Journal of the American Medical Association written by Patrick Conway, M.D., chief medical officer for CMS, which oversees the Medicare and Medicaid programs, Farzad Mostashari, M.D., HHS’ national coordinator for health information technology, and Carolyn Clancy, M.D., director of the Agency for Healthcare Research and Quality.
The National Quality Strategy, required by the Patient Protection and Affordable Care Act, aims to improve measures in clinical care, patient experience and engagement, population and community health, safety, care coordination and cost and efficiency.
Moving away from process-based performance measures won’t be easy, says Berenson.
“It’s really difficult to do correct outcome measures,” he says. “You have to do case-mix adjustments and account for some providers having a sicker population than another. It takes a major commitment to do it.”
Many clinicians already feel overburdened by the sheer number of performance measures required for participation. When Medicare first unveiled the requirements of its Shared Savings program in 2011, many providers balked at the number of core measurements, and the federal government cut back on the requirements.
But performance measures are important to make sure new payment methodologies like bundled payments and accountable care organization don’t sacrifice quality in order to lower costs, Berenson says.
As the industry evolves, the pressure to develop and implement new measures of health system performance will only increase. Consequently, providers and health plans must seize the opportunity to help design the measures and subsequently use them to drive internal improvement and report value to their customers.