IoM's new report on quality metrics says that just 15 core measures, which it calls "vital signs," should guide or replace the many, many existing metrics. But should providers be accountable for high school graduation rates?
As just about everybody in healthcare knows, there are too many goldarn quality measures.
Just count 'em.
- The Centers for Medicare & Medicaid Services has about 1,700 measures for various provider settings, many tethered to payment.
- Nearly all health insurance plans are scored on about 81 HEDIS measures (Healthcare Effectiveness Data and Information Set) vetted by the National Committee for Quality Assurance.
- The Joint Commission imposes another 57 measures of inpatient care for hospitals.
- Medicare's Physician Quality Reporting System offers dozens to hundreds of measures that clinicians must meet to receive full payment.
There will be more measures set by the Secretary of Health and Human Services under the new Sustainable Growth Rate law, H.R. 2. And efforts are underway to measure outcomes for nearly every surgical and medical procedure for every type of patient.
The National Quality Forum, under CMS contract, endorses, sometimes unendorses, sometimes alters, and then re-endorses measures, with more than 630 currently endorsed.
I could go on, but you'll be relieved that HealthLeaders Media imposes a 1,200-word limit for this column.
Along the road, there are numerous measure data checkpoints. For example, the HCAHPS survey on patient experience asks patients whether their hospital bathroom was always, usually, sometimes, or never clean.
Some measures are basically the same, but criteria and definitions often differ just slightly depending on the setting. Clinicians and hospital staff also have varying strategies for interpreting what they should measure and whether to report it.
Somebody should do something about all this mess because it's wasting valuable time.
That's why last week's Institute of Medicine report on core metrics sounded like an army of reason coming to the rescue, trumpets blaring. It said, in more dignified terms, that our measurement system is out of control, run amok, and bordering on insanity.
In the report's 353 pages, the 21-member IOM panel of healthcare luminaries, chaired by Commonwealth Fund president and former HHS National Coordinator David Blumenthal, MD, extensively detail what should change.
"We're saying we have too many measures, they're not defined the same way, they're getting in each other's way, they're creating inefficiency, they're costing money without return, and they're ultimately not all serving the purpose of improving quality," Blumenthal summed up in a telephone interview.
"We need to simplify and prioritize, and prioritization almost always means giving something up."
I like measures because I'm the quality editor at HealthLeaders, and measures help me write stories about care quality. But frankly, I wouldn't like to be a care provider and have to comply with each and every one to a T. Simplification does sound like a good thing.
The IOM committee highlights just 15 core measures—the report names them "Vital Signs"—and says these should guide the development and efforts to whittle down what quality measures providers and others use.
The committee uses the words "parsimonious" or "parsimony" 64 times. "This report presents a parsimonious set of core measures for health and health care identified by the committee, and describes how their focused implementation can contribute to reducing the burden of measurement on clinicians; enhancing transparency and comparability; and most critically, improving health outcomes nationwide," it says.
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Some core measures might make hospital officials and physicians squirm. They include goals that most providers today would say are irrelevant to what they do. These are society's problems, and not really not under their control—like whether their patients' children will graduate from high school, which the report says is the best way to measure the health of a community. Poorly educated patients are likely to be sicker.
Here's the full list:
- Life expectancy, measured by expectation at birth
- Well-being, measured by self-reported health
- Overweight and obesity, measured by body mass index
- Addictive behavior, measured by addiction death rates
- Unintended pregnancy, measured for teens
- Healthy communities, measured by high school graduation rates
- Preventive services, measured by childhood immunization rates
- Care access, measured by unmet care need
- Patient safety, measured by hospital-acquired infection rates
- Evidence-based care, measured by preventable hospitalization rates
- Care matched with patient goals, measured by communication with clinicians
- Personal spending burden, measured by high healthcare spending relative to income
- Population spending burden, measured by per capita healthcare spending
- Individual engagement, measured by health literacy rate
- Community engagement, measured by levels of social support
The point of these vital signs is to look at the big picture about what we want healthcare to do for communities, and work back from there, says Timothy Ferris, MD, vice president of population health management for Partners HealthCare in Boston and a member of the committee. They won't replace existing measures right away, but gradually, over time, he says.
"You might hear that it's going to be hard to make a hospital or a doctor think in terms of being accountable for a graduation rate," he told me. "But my answer is, 'Yes, maybe. Someday.' Because we don't want to rule out the possibility that high school graduation is a very important determinant of health, and physicians and hospitals can influence this."
Maybe, he says, the topic of a high school student's threat to drop out might come up when teenager visits the doctor. "I wouldn't want to pay my doctor based on high school graduation rates of his patients, but we're always coming up with things we do internally, and if our doctors said they'll satisfy practice requirements by giving high school lectures, or getting an at-risk dropout to work in the office, that would be a contribution."
Blumenthal provides more perspective, acknowledging that some providers might find this population-scope thinking "out of the box."
"It is out of the box only in the sense that people haven't consciously made the linkage between day-to-day work of health professionals and the communities where they work. The family history taken by an internist, which I've done a thousand times, often stops with questions, 'Do you have children? How old are they? And do they have illnesses?' to indicate any hereditary disposition.
"But what this suggests is that it might be fair to ask an internist to be thinking how their patient's health is affecting the likelihood that the patients' children will graduate from high school. I'm not saying for attribution that I support that, but I'm telling you I think it's a question this report raises that deserves examination."
Likewise for obesity, as measured by BMI.
"Hospitals are core members of communities they serve, and if BMI is a measure of hospital performance, it will focus hospitals' attention on schools, what's served in schools, the weight of their own workforce. It will focus the attention of an absolutely critical institution for the health of a community on the health of that community more generally, starting with their own patients, but pretty soon on the performance of their community," Blumenthal says.
Clearly the IOM report sets lofty, perhaps elusive, goals. No one is thinking this population health improvement will be accomplished anytime soon, Blumenthal says. "It's best to see this as a continuous process of simplification and improvement.
"But," he says, "it needs to begin right away, and continue indefinitely."