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Physicians See a Gaping Hole in the Safety Net

 |  By jcantlupe@healthleadersmedia.com  
   June 27, 2013

Government quality metrics fall short in meeting the needs of safety-net healthcare providers, who complain that such measures force them to divert their resources into lower priority programs.

Safety net physicians are calling for new measurement criteria to replace existing government quality metrics, saying the status quo isn't suited for the "real world."

Martin Serota, MD, chief medical officer of Alta Med Healthcare Services in Los Angeles, the largest independent federally qualified community health center in the U.S., is one of those docs seeking change. Current quality measurement scores don't address the basic healthcare needs of urban at-risk patients, and, as a result, funding is redirected elsewhere, says Serota. AltaMed is a team that delivers services in 43 sites in an affiliated Independent Practice Association of contracted physicians in Los Angeles and Orange Counties.

"With health reform stressing accountability, efficiencies and patient-focused care, it's important we address real world issues for our safety net patients," Serota said in a statement. His call to action is the latest among those having concerns about changing quality metrics for safety net hospitals.

Quality ratings, which are a key element of the Patient Protection and Affordable Care Act, influence how hospitals are paid. The quality scores for safety net hospitals have been generally lower than for other hospitals. The safety net hospitals provide a significant level of care to low-income, uninsured and vulnerable populations.

Trying and failing to meet the benchmarks for government quality programs often leaves healthcare safety net programs in the lurch for funding, Serota says.

Serota is blunt in his call for reform, telling me that existing government measurement for quality hasn't been "about truth."

"As we should be moving toward more patient-centered care and population health, we need to be thoughtful about what we measure and why we measure it," Serota told me. "There [are] a lot of reasons for our current quality measures. They were based on several criteria, things that can be measured easily, and measured by claims data and not by truth."

Serota and co-authors expressed their concerns about quality target measures for population health management of the at-risk population in a June commentary in the Journal of the American Medical Association.

While traditional quality measures may be suitable for the commercially insured population, they may not be suitable for patients who need safety net care.

For instance, Serota says that traditional quality measures such as colon cancer screening are legitimate in mainstream hospitals. But healthcare facilities serving impoverished patients have difficulty enrolling patients in such programs because the patients have more pressing concerns, such as chronic illness, or drug and alcohol addictions.

Over the years, Alta Med has invested large sums in putting together quality programs, especially through expensive IT platforms to improve data collection for higher quality and improved reimbursements. Yet Alta Med sees differences in data points it views as important compared to the government, when it comes to a needy population.

When physicians sought to increase screenings for colon cancer, Alta Med struggled. The screening rates were almost 20% below target, according to Serota's report. The doctors tried different ways to attract patients to screenings, such as outreach campaigns and electronic reminder systems. As healthcare officials struggled with screening targets, they wondered about the ROI – financially, and for patient care, Serota says.

"Although we fully appreciate the value of colon cancer screening (one of us had almost 100% compliance rates previously in private practice,) we weren't certain that focused outreach to improve our rates was the best use of staff time," Serota wrote in the JAMA commentary. "In order for our case managers or referral specialists to dedicate efforts to promote colon cancer screening, they would need to spend less time doing something else."

Too often, traditional quality measures such as cancer screening rates and process measures for diabetes care, are "non-patient centric and may result in the redirection of precious resources away from the services patients most need and toward services that are tracked in quality reports," Serota and his colleagues wrote.

In our conversation, Serota recalled that when he was in private practice, his insured patients got colon screenings "and it did reduce the incidence of colon cancer in my population, at an incredible cost."

"At a much lower cost we can be immunizing people in the inner city, and doing other things for them, such as feeding them or housing them at a much lower cost," he says.

Alta Med has a substantial investment in IT, but officials wonder if the group is tracking the proper quality metrics to improve their patient population, Serota says.

"We had to build a quality department, to collect data and build the informatics infrastructure," Serota told me. "We run a skinny margin" in profitability, he adds. "If we are going to spend that much money, we want to go for the right things for the right reasons," Serota says. "That's the biggest issue."

In his JAMA report, Serota and other authors call for a "new platform" to address quality measurement that they say is more "outcomes-based, simple and adaptable to local circumstances" than existing measures.

While patient satisfaction scores should be maintained, significant changes for the government's quality metrics would be fairer to safety net hospitals, Serota wrote.

Serota added that there is a need for "risk adjustment emergency department and hospitalization utilization." Too many ED and hospital visits are often described as a "failure" of the healthcare system. But instead of being penalized, hospitals serving at-risk patients, who often use the ED, should be rewarded for providing "intangible services," such as preventative care, social support and educational resources.

In addition, hospitals should be given compensation for providing "enabling services"—including transportation, social and counseling programs, including an obesity prevention focus.

"One quality measure the government doesn't address is obesity," Serota says. "Having reduced obesity is not a quality measure, and that's the biggest health issue facing our country. Yet there's no quality measure around it."

By changing its focus, the government would help "better align quality improvement with what brings value to patients," the Serota commentary states. "Without such a shift, quality measurement—and the ensuring improvement efforts—may continue to shift resources away from where they are most needed. This is something we surely cannot afford."

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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