The Conundrum of Quality Measures in Health Care

Thursday, March 3, 2016 | Larry Sobal

On February 16th, America’s Health Insurance Plans (AHIP), as part of a collaborative effort with the Centers for Medicare and Medicaid Services (CMS), along with various primary care and physician specialty groups, consumer and employer groups, announced the release of seven core sets of quality measures that will support greater quality improvement and reporting across the health system.

The seven core metrics sets relate to:

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

The stated goals of this effort are to establish broadly agreed upon core quality measures that will allow for less complexity in reporting for clinicians, decrease the overall cost burden to consumers and the health care system, and ensure high-quality care for patients. Fair enough.

It just so happens that my recent travel schedule had me attending two national health care conferences, which collectively included around 1,500 physicians, other clinicians and executives. This gave me a chance to ask a number of people what they thought of the announcement.

I thought the most profound statement came from a cardiologist who professed “I’m too busy focusing on quality to worry about metrics…”

You may not be surprised when I tell you that the majority of the responses fit into one of two categories: “I don’t know anything about it,” and “So What?” Admittedly, there was a third common category, and let’s just say it involved profanity…  I thought the most profound statement came from a cardiologist who professed “I'm too busy focusing on quality to worry about metrics…”

On one hand, I certainly applaud AHIP and CMS for trying to at least standardize some of the hundreds of metrics so there is consistency and simplification in reporting. But on the other hand, I worry that the obsession with quality metrics, now numbering over 1000 reportable metrics being requested (or required) by over 30 different organizations soliciting metric data from hospitals and physicians, is possibly the most challenging conundrum in health care today.

I fully agree that we need measurement to quantify and improve the quality of health care, yet quantifying health care quality is very complex and challenging, almost to the point of being impossible. Furthermore, the value of quality metrics is predicated on having accurate and comparable data. Yet obtaining such data can be difficult and expensive, particularly with the lack of interoperability between information systems, and errors can occur at several levels.

What is my solution?  I strongly advocate three strategies.

First, I would challenge the value of many of the current quality metrics as being too focused on process and not focused enough on the outcomes that matter the most to patients. Many of the current metrics should therefore be eliminated and replaced with more patient-meaningful measures such as mental and social wellness of patients, provision of preventative services, access, adherence to evidence-based care, and improvement in health literacy.

Second, the linkages between metric results and individual physician payment should be closely examined to ensure that we are not incenting the wrong behaviors. When designing compensation plans, there is often a desire by administration to link payments to metrics that physicians don’t have significant control over regarding outcome. This makes these incentives worthless at best, and potentially dangerous if physicians end up being penalized for taking on tough cases. Furthermore, there is scant evidence from behavioral scientists to support the correlation between monetary rewards and achievement of complex, multifactorial outcomes such as treating disease.

Third, we must be careful with the linkages between metrics and the proliferation of public reporting and recognition. I’m not saying that quality metric data should no longer be public, but there does appear to be a growing exploitation of the use of metric data to either bestow awards on organizations or for organizations to tout their superiority versus their competitors. Lest we forget the words of Mark Twain “There are lies, damn lies and statistics…”

I've laid out my point of view – what are your thoughts on quality metrics?

 

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Larry Sobal is Executive Vice President of Business Development at MedAxiom. He has a 35-year background as a senior executive in medical group leadership, hospital leadership and insurance. As part of his current role, Larry consults, writes and presents on topics relevant to transforming physician practices and health systems.

 

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