201510.09
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Paying for quality in healthcare: easier said than done

All of us involved in healthcare are aware – some painfully so – of government insurers’ desire to pay for quality over quantity of services. The Centers for Medicare and Medicaid Services (CMS) implemented its Five-Star Quality Rating System for nursing homes in 2008, and just this year CMS announced its intention to link 50% of Medicare payments to quality metrics by 2018.

Declaring “We want to reward value and care coordination – rather than volume and care duplication” is a great sound bite, but actually doing it is a whole different ball game. Dr. Aaron Carroll points out the main snag in deciding to focus on quality metrics in the Journal of the American Medical Association (JAMA) Forum:


Of course, such decisions are predicated on the idea that we are good at measuring quality. If we are going to pay [providers] differently based on their performance, then it’s absolutely mandatory that we be able to differentiate between those who deserve higher payments and those who do not. Many are concerned that our ability to do so isn’t adequate.


Several empirical and theoretical studies have been conducted over the last few years, and they all reveal inherent problems in the quality metrics being used. The problematic metrics fall into two main categories: they fail to account for patient characteristics out of providers’ control, and they fail to measure what is actually valuable to patients.


Characteristics unrelated to quality of care include a patient’s income, race, education level, housing situation, and family life, none of which show up on Medicare claims or are taken into account when calculating a provider’s quality measurements. A study published last month in JAMA Internal Medicine concludes:

Patient characteristics not included in Medicare’s current risk-adjustment methods explained much of the difference in readmission risk between patients admitted to hospitals with higher vs lower readmission rates. Hospitals with high readmission rates may be penalized to a large extent based on the patients they serve.

The outcome? Hospitals serving certain groups of patients, often the most vulnerable, are penalized by up to 3% of their annual inpatient payments. As long term care facilities come under increasing scrutiny for hospital readmissions as well, this problem extends far beyond hospitals and threatens a wide range of crucial service providers.


The other set of problems with incentivized quality metrics comes from the lack of patient input in what is being measured. Several doctors wrote an opinion expressing that what is most often left out of of quality measurements is precisely what the measurements are supposed to be promoting: patient well-being!


If the United States intends to pay on the basis of value, it is essential to ask patients what they value, and then deliver on those priorities… Yet almost all current quality metrics reflect professional standards [instead].


Professional standards, like whether appropriate medications are dispensed after a procedure, usually align with patient needs. “However, serious, life-altering, and ultimately life-ending chronic conditions, often in old age, pose a particular challenge for the health care system because traditional professional standards may not effectively address what an individual most wants.” When contending with a terminal illness, a patient may consider comfort, connections to family, control over finances, and other factors to be more important than whether his or her blood test results fall within certain parameters.


“Although professional standards are important, they can fail to capture what matters most to each individual.” Creating and tracking individualized quality goals for each patient is not a practical solution right now, but focusing provider incentives on factors that don’t contribute to patient quality of life is not a good compromise.


Dr. Carroll writes that “too often we use the data that we have instead of the data we need to measure quality.” As we discover with each additional study, the data we have is both inadequate and inaccurate.

Paying for performance, incentivizing hospitals and health care providers to hit metrics, hinges entirely on those metrics being accurate judges of quality. Otherwise, we are pushing the health care system to change its practice in ways that might backfire. This is especially true if the metrics are inaccurate in a way that penalizes those hospitals already caring for the patients who need the most help.


Focusing on high-quality, patient-centered care is a worthy goal, and it is one that patients and healthcare professionals alike can agree on. The problem lies in how to qualify and measure what “quality care” looks like.

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