Part 1: The Missing Link in Current Quality Measures

Part 1: The Missing Link in Current Quality Measures

By Susan Butterworth, PhD and Amanda Sharp, MPH

Introduction
Quality improvement measures are intended to provide standardization across the gamut. A case can be made that they have been simplified to procedural processes and, despite their title, may not adequately or accurately regulate patient-centered quality care.1 We explore the concept of moving more strongly in the direction of a patient-centered orientation in our blog titled “A New Way of Thinking About Quality Improvement in Healthcare”. Because we live in a world where claims can be deceiving and fact-checking is imperative, let’s unpack the complicated details of how the US healthcare system’s well-intentioned quality measures may be missing the mark in their execution.

Programs with Broken Promises
In 2009, the American Reinvestment and Recovery Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) initiated steps in the right direction for healthcare reform. 2 They allocated more funds for Medicaid and targeted healthcare initiatives for underserved populations, as well as funding improvements in healthcare technology. 3 And, for example, the use of electronic health records does contribute to easier patient access of their health records, as well as allow for more collaboration between providers.4 However, these acts also serve as examples of ostensibly laudable bills that have distracted administrators from also tackling meaningful solutions and interventions that engage and activate patients. Specifically, large portions of these bills focus on incentivizing electronic health records for improved population health; amid strategies devoted to defragmenting data collection, assisting with coordinated care, and breaking down boundaries for access to full patient and population profiles, the bigger picture that includes patient engagement and activation has gotten lost. Although patients generally have positive attitudes towards electronic portals, they are not well-utilized among the most underserved populations. To boot, a recent review of the literature indicates that we lack evidence that electronic medical records actually improve health outcomes and cost. 5

Moreover, quality measures have become inconsistent and often incomprehensible due to sheer numbers and varied focus.6 Rather than contributing to clinical meaningfulness, procedure and internal decisions are influenced by external reports that drive consumers and finances.7 We’re forced to consider whether current quality improvements enrich person-to-person interactions, or merely simplify them to a robotic, rote process.

Considering What’s Behind the Quality Curtain
Healthcare value is based on a relationship between quality and cost. Not only is the US ratio disproportionate, we spend more money on healthcare and have more health care disadvantage relative to all other high-income countries.8 The measures used to determine quality are not reflective of what matters most to patients.

For example, the Quality Payment Program (QPP)9 is one incentive program that is, again, allegedly a step in the right direction but falls short when it comes to meaningful quality measures.By its own proclamation: “The Quality Payment Program improves Medicare by helping you focus on care quality and the one thing that matters most — making patients healthier.” Ostensibly, this is a noble cause. With a bit of digging though, we see that the “quality” requirements for clinicians to meet their scores and qualify for payment are one-dimensional. Due to standardized procedures, sometimes our quest to meet measures causes clinicians to provide less than ideal care. They end up abandoning an approach that would prioritize the individual and circumstantial needs of patients because the procedures created to meet these standards require a blanket approach to all patients that fall within specific characteristics, circumstances, and categories.

This qualification process puts the clinician between a rock and a hard place. Do they treat the patient based on their own best judgment with a patient-centered perspective? Or do they succumb to the regulations pseudo-mandated by these bills and programs? If they choose the former, they risk losing eligibility for these incentive programs. If they do the latter, they risk unnecessary tests, treatments, and costs with the potential to cause harm.10, 11

Within the QPP, consider the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) – both introduced in 2014 and enacted in January 2017.12,13 Both offer a multitude of quality measures associated with incentives and penalties, with provider performance accounting for up to 60% of their overall score.12,13 Since healthcare organizations are likely to be swayed by financial opportunities, it is natural for management to modify their delivery systems to meet these required measures. In this way, payment schemes become deeply influential, with care delivery skewed towards a checklist-type of mentality – ignoring patient-centered interventions and creating opportunities for low patient satisfaction, low treatment adherence, poor clinical outcomes for chronic disease management, and even malpractice.15-17

Good Intentions Gone Wrong
As mentioned, requirements for passing quality measures can tie the hands of clinicians; forcing them to consider patient management pathways that seem arbitrary, wasteful, or even harmful. We are not suggesting that we shouldn’t incorporate electronic medical records into our system or ignore best practice guidelines. However, these should be used within the context of the patient’s most pressing needs. Consider the following case study in Figure 1 below that provides an example of when the pressure to check off quality measures can cause a provider to neglect a patient-centered
approach.  

Modifying Quality Measures to Ensure They Support a Patient-Centered Approach
There is ample evidence that one of the strongest impacts on both patient satisfaction and clinical outcomes is the care provider’s interaction with the patient – one that emulates a caring, empathetic partner with the goal of empowering the individual to take charge of one’s health.15-17 And yet our current quality improvement measures do not effectively support such an approach.

Regardless of your position in your organization, there are active steps you can take to be part of the solution. In their presentation10, Drs. Sawin and Adler presented resources on ways to provide feedback and get involved in the process of reforming our quality measures. Some of our favorites from their list are:

- Right Care Alliance of the Lown Institute

High Value Care at the American College of Physicians

Annual Call for Measures and Activities through CMS

Whether you ultimately choose to act through informing yourself or colleagues, sharing resources with stakeholders, or expressing your opinions and experiences with decision-makers, your efforts can make a difference. With healthcare payment reform on the horizon, we must not miss the opportunity to ensure that future measures are blended with best practice gleaned from behavior change science. We must first redefine our characterization of “quality” to incorporate meaningful outcomes along with measurable standards. There are essential aspects of patient-centered care that should inform healthcare delivery and the prioritization of value. Ideally, the next stage of quality metrics will represent a patient-centered skill set and be aligned with values like collaboration, empathy, and support for autonomy. In the meantime, in our next blog article, we suggest ways to meet current quality standards while remaining patient-centered.

References

1. Blumenthal D, McGinnis M. Measuring Vital Signs: An IOM Report on Core Metrics for Health and Health Care Progress. JAMA Intern Med 2015;19;313(19):1901–2.

2. American Recovery and Reinvestment Act - ARRA. HITECH Answers: Meaningful Use, EHR, HIPAA News. Accessed on: August 15, 2017. Available at: https://www.hitechanswers.net/about/about-arra/

3. Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) | Federal Privacy Council. Accessed on: August 15, 2017. Available at: https://www.fpc.gov/health-information-technology-for-economic-and-clinical-health-act-of-2009-hitech/

4. Smydo J. No One Left Behind: Technology can be used to cut health care disparities. Pittsburgh Post-Gazette. Sep19 2015. Accessed on: August 14, 2017. Available at: http://www.post-gazette.com/healthtoday/2015/09/20/No-One-Left-Behind-Technology-can-be-used-to-cut-health-care-disparities-Vital-Signs-forums/stories/201509200003

5. Goldzweig CL, Orshansky G, Paige NM, et al. Electronic Patient Portals: Evidence on Health Outcomes, Satisfaction, Efficiency, and Attitudes: A Systematic Review. Ann Int Med 2013;159(10):677-687.

6. Blumenthal D, McGinnis JM. Measuring Vital Signs: An IOM Report On Core Metrics For Health and Health Care Progress. JAMA Intern Med 2015;313:1901–2.

7. Lindenauer PK, Lagu T, Ross JS, Pekow PS, Shatz A, Hannon N, et al. Attitudes of Hospital Leaders Toward Publicly Reported Measures of Health Care Quality. JAMA Intern Med 2014;174:1904–11.

8. Woolf SH, Aron LY. The US Health Disadvantage Relative to Other High-Income Countries: Findings From a National Research Council/Institute of Medicine report. JAMA Intern Med 2013;309:771–772.

9. Modernizing Medicare to Provide Better Care and Smarter Spending for A Healthier America. The Quality Payment Program. Accessed on: August 15, 2017. Available from: https://qpp.cms.gov/

10. Sawin G, Adler R. Volume to Value: How Do We Sustain a Patient Focus? Lecture presented at; 18th Annual Summit on Improving Patient Care in the Office Practice and Community. Orlando, FL. Apr 21 2017. Accessed on August 23, 2017. Available at: http://app.ihi.org/FacultyDocuments/Events/Event-2823/Presentation-14980/Document-12177/Presentation_B9_Patient_Focus_Volume_to_Value_v2_standard.pdf

11. Saver BG, Martin SA, Adler RN, Candib LM, Deligiannidis KE, Golding J, et al. Care that Matters: Quality Measurement and Health Care. PLOS Med 2015;12(11): e1001902.

12. FAQs about the Merit-Based Incentive Payment System (MIPS) [Internet]. SA Ignite. Accessed on August 15, 2017. Available at: http://www.saignite.com/industry-expertise/quality-payment-program/mips-education/10-faqs-about-mips

13. Centers for Medicare & Medicaid Services. CMS Quality Measure Development Plan: Supporting the Transition to the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Accessed on August 15, 2017. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Final-MDP.pdf

14. Welch HG, Passow HJ. Quantifying the Benefits and Harms of Screening Mammography. JAMA Intern Med 2014;174(3):448-454.

15. Ann Weinacker. Press Ganey Again? Strategies for Improving the Patient Experience. Stanford Health Care. Accessed on August 28, 2017. Available at: https://stanfordhealthcare.org/health-care-professionals/medical-staff/m...

16. Manary MP, Boulding W, Staelin R, Glickman SW. The Patient Experience and Health Outcomes. N Engl J Med 2013;368:201-203.

17. Johnson DM, Russell RS. SEM of Service Quality to Predict Overall Patient Satisfaction in Medical Clinics: A Case Study. Qual Manag J 2015;22(4):18–36.

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