Among the reforms spelled out in the Affordable Care Act is development of two fundamental activities largely absent in health care -- recognizing and rewarding quality care. The first, and possibly most important, step toward those goals is determining how to measure quality -- both in the delivery of clinical care and in the prevention of illness and injury.
The Obama administration earlier this month announced an initial set of quality measures for state Medicaid agencies to use voluntarily for assessing the care of Medicaid-eligible adults.
The HHS measures cover areas such as prevention and health promotion, management of acute and chronic conditions, care coordination, family experiences of care and availability of care.
In California, the Pacific Business Group on Health's Consumer-Purchaser Disclosure Project recently released a report spelling out "Ten Criteria for Meaningful and Usable Measures of Performance."
The report urges policymakers to make consumer and purchaser needs and feedback priorities in performance measurement.
The Affordable Care Act gives states the authority to use federal criteria or establish their own set of measures.
We asked state officials, stakeholders and experts how California should measure quality in health care.
We got responses from:
- Neal Kohatsu, Medical director, California Department of Health Care Services
- Betsy Imholz, Special projects director, Consumers Union
- Bill Kramer, Executive director, National Health Policy, Pacific Business Group on Health
- Carol Havens, President, California Academy of Family Physicians
- Paul Tang, Vice-president, Chief Innovations Officer, Palo Alto Medical Foundation
Consensus, Engagement Are Key
Medical director, California Department of Health Care Services
Quality measurement is critical to achieving the Department of Health Care Services' priorities of improving health, enhancing quality and reducing the cost of care. Thus, we are committed to ensuring that DHCS develops the policy, infrastructure and analytic capacity to collect and use performance data to improve health outcomes.
The recent report, "Ten Criteria for Meaningful and Usable Measures of Performance," developed by the Pacific Business Group on Health, provides valuable recommendations for selecting appropriate quality measures. There are several issues to consider regarding measure development, even with the availability of helpful guidelines.
One issue is the need for vertical alignment. There are multiple efforts at the national, state, local and institutional levels to advance quality through performance measurement. To the extent we can achieve vertical alignment or consensus, we will be able to make more valid comparisons, save time and resources and speed the adoption of quality measurement.
Another issue is stakeholder engagement, including members and patients, as well as those in the health care delivery system. Because there are different needs and perspectives among the many stakeholders, it is essential that there be ongoing dialogue with the stakeholder community. It is this engagement that will help to achieve vertical alignment.
Finally, we must remember that quality measurement is not an end in itself, but is valuable only if it improves health and health outcomes. Kenneth Kizer and Susan Kirsh note in a recent commentary in the Journal of General Internal Medicine -- "The Double Edged Sword of Performance Measurement" -- that performance measurement is, in fact, a "double-edged sword," and that unintended, adverse effects can be generated with the introduction of performance measurement. Therefore, it is important to focus on health, clinical outcomes and patient experience as performance measures are introduced and tracked.
To address the above issues, DHCS is actively tracking performance measurement activities at the state, national and local levels and will be directly engaging with stakeholders to ensure that quality measures that are adopted are relevant and useful. These quality measures will not be selected in isolation, but will be given context as part of a DHCS Quality Strategy that will be developed in consultation with the UC-Davis Institute for Population Health Improvement, directed by Dr. Kizer. A national caliber advisory group will be formed by Dr. Kizer to provide consultation on the Quality Strategy, in addition to extensive stakeholder engagement.
DHCS is excited to work with like-minded partners to advance performance measurement that improves health, enhances care and reduces medical costs for all Californians.
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Leadership From Top Is Critical
Special projects director, Consumers Union
Can Californians find the information they need to choose a good doctor or hospital for surgery or other medical treatment? A wealth of data is collected about the quality of health care in California, mainly on the hospital level. Yet, existing measures don't provide a comprehensive picture, including medical outcomes and the consumer experience of care. Also, few measures are available about physician performance and outpatient surgery centers. And what's available to the public is not easily findable or presented in a clear, engaging way.
Furthermore, Californians don't have one place to access all of the information on a particular provider or for a specific condition or procedure.
For example, a pregnant woman may want to know how to find the hospital or birthing center where she'll most likely get help breastfeeding, avoid a caesarean section or injuries associated with childbirth, and get the best patient experience as reported by other new mothers. Unfortunately, she would be hard-pressed to find that information for all facilities in California, though most of it has been collected. Today, that information is scattered among different agencies and not easy to access by the public.
But the stars are aligning for California to re-invent its quality reporting system to meet consumer needs and improve care. Federally funded information technology upgrades will enable better data collection and sharing. And California's Health Benefit Exchange can play a key role catalyzing collection of measures consumers want and fostering public reporting. The Consumer-Purchaser Disclosure Project, of which Consumers Union is a member, has developed a framework for creating measures that are more meaningful to consumers and more likely to yield systemic quality improvement.
Leadership from the top is critical to push through the structural and substantive changes needed for success. Gov. Jerry Brown (D) has many of the state data collection entities under his jurisdiction. And since state HHS Secretary Diana Dooley chairs the Exchange Board, the link between the Administration and the Exchange is ready-made. Creation of a public process to work through the needed organizational changes and to decide which data to report would assure the best outcome for consumers and garner buy-in. Because the California Exchange will begin enrolling consumers into coverage in 2013 and will start to develop standards for plans to participate in the exchange this year, getting this started should be a top priority on the 2012 "to do" list.
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Fundamental Shift in Thinking Needed
Executive director, National Health Policy, Pacific Business Group on Health
Sometimes it seems like we're overwhelmed with data about health care quality, but I'm often struck by the lack of information on quality that's useful for patients, health plan members and purchasers. We probably have too many measures that are not very useful -- such as simplistic process measures of whether a box was checked on a nurse's work sheet -- and far too few measures of what's really important to patients and purchasers. This lack of useful information is particularly striking, given that the decisions made by patients, purchasers, insurers and providers have very high stakes -- these choices are literally life and death decisions in some cases. And we shouldn't forget that the financial stakes are high, too -- literally millions of dollars ride on these decisions.
We need a fundamental shift in our thinking about quality measurement. First, we need more information about the outcomes of medical care and less about processes. It's good to know whether the doctor gave the patient a pamphlet about smoking cessation, but it's much more helpful to know how many of that doctor's patients actually stopped smoking. Second, we need to gather information from patients in addition to clinical records. It's important to know, of course, whether a knee surgery was done without complications or infections, but that's only half the story. What we also need to know is whether the patient can walk again easily and without pain. Third, we need measures that cut across the continuum of care, not just within the traditional silos of hospital care, physician care, home care, etc. For many patients, especially those with serious chronic conditions, the coordination of care is a critical factor. It's good to know that the hospital care for a diabetic patient was of high quality, but what about the patient's experience after leaving the hospital? Was there a good handoff to the patient's primary care physician? Were other elements of good outpatient care in place? This information is essential to evaluate the quality of care, but it's often missing.
- We strongly recommend that new measures be developed for patient-centered criteria, including the following: Make consumer and purchaser needs a priority in performance measurement;
- Use direct feedback from patients and their families to measure performance; and
- Build a comprehensive "dashboard" of measures that provides a complete picture of the care patients receive.
Additional criteria are described in "Ten Criteria for Meaningful and Usable Measures of Performance," recently published by the Consumer-Purchaser Disclosure Project, a broad coalition of consumer, employer and labor organizations, co-led by the Pacific Business Group on Health.
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High Standards Needed for All Initiatives
President, California Academy of Family Physicians
California Academy of Family Physicians leaders believe that patients, payers and physicians all need more accurate information on health care quality. Such information can help patients choose a physician; payers reward effective physician practices; and physicians continually assess the quality of care they provide. Quality assessment projects designed without adequate methodological rigor, however, can yield deceptive results. In these cases, patients may be misled and physicians unfairly evaluated.
Because quality reporting is so essential, CAFP and the American Academy of Family Physicians work toward improving reporting with state and national entities, including individual health plans, broad coalitions, the National Committee for Quality Assurance, the AQA alliance (formerly the Ambulatory Care Quality Alliance) and others. CAFP supports the AAFP Guiding Principles for Physician Performance Reporting.
Because methodologically lax quality assessment projects can yield invalid findings, it is critical to incorporate a high standard of rigor in each project design. The following challenges must be addressed in any California quality assessment initiatives.
Statistical validity: Individual physicians often have too few patients in a specific disease group to support statistically valid measurement.
Patient attribution: When a patient sees multiple physicians, it can be difficult to attribute her care to a single doctor. A PPO patient, for example, may receive a screening exam from an out-of-network physician. In many quality assessment programs, the in-network physician would be penalized because no claims data would show an in-network exam. This could lead to expensive, duplicative care as physicians tried to protect themselves from negative quality reports.
Claims data insufficiencies: Using claims data to measure performance carries a significant risk of error. Claims data are designed specifically for billing and do not include other relevant clinical information contained in medical charts.
Patient differences: "Process" quality assessment initiatives need to adjust for individual or population-level differences in patient behavior and access to care. Otherwise, physicians who see patients less willing or able to adhere to recommended care may be penalized. Similarly, "outcomes" quality measures must assess the impact of disease severity and the prevalence of co-morbidities. It is critical that reporting initiatives not incentivize physicians to stop seeing patients who may negatively influence quality reports.
Quality assessment initiatives must also ensure that reporting requirements do not impose undue administrative burdens on physician practices and that any data reporting timelines allow adequate time for physicians' review and comment, followed by necessary corrections.
CAFP looks forward to working with other interested parties on improving health care quality reporting in California.
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Quality Measures Should Be Incentive To Do the Right Thing
Vice-president, Chief Innovations Officer, Palo Alto Medical Foundation
America is on the brink of transformation in health care. Not only as a political agenda, but also because of society's conscience to do the right thing -- improve the health and well-being of all U.S. residents. The question is whether we have the right tools, including the right quality measures, to do the job. Unfortunately, we do not have an adequate set of measures to accurately track and reward high performance. Most of the current measures were developed at a time when the only data available were claims data. Consequently, most measures look at processes of care; few are capable of measuring outcomes.
Current quality measures may report on whether a specific task was performed within the past year or what the mortality rate is for certain procedures. What if, instead, consumers knew what percentage of patients were pain-free or could walk again after joint replacement? What if patients with a specific chronic disease knew what percentage of patients being treated by a provider achieved improved control of their disease, rather than reading about population means? In other words, consumers and patients want to know, "what do these quality measures mean to me?" Likewise, patient-centric quality measures would be more meaningful and motivating for providers.
We need to design quality measures and electronic systems that capture the relevant data to answer these types of questions for consumers. Fortunately, the HITECH provision in the 2009 federal economic stimulus package provided incentive funding to implement electronic health record systems and to use them to achieve meaningful improvements in patients' health. As more health care organizations use EHRs, clinical data become available for answering consumers' real questions affecting their health choices. At the request of federal advisory committees, such as the Health Information Technology Policy Committee, new measures that matter to consumers are being developed.
At a time when the country is transitioning from payment-for-volume to payment-for-performance, it is exceedingly important to make sure that the quality measures are accurate and meaningful for patients and providers alike. Relevant quality measures will put important information and feedback in the hands of people who can use it the most. Aligning payment with truly meaningful measures would give the system just the motivation and incentive to do the right thing.
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