Quality experts, including the CEO of the National Quality Forum and a former CMS administrator, caution members of the Senate Finance Committee that healthcare quality measures must be better coordinated to be effective.
The nation's efforts to measure healthcare quality has improved in recent years, but that isn't saying much considering how much stakeholders are still in the dark, several quality experts told members of the Senate Finance Committee this week.
Rather, providers, employers and health consumers are increasingly befuddled by more than 1,100 measures used for scoring and payment just in the Medicare program alone, with little understanding of which ones, if any, really drive better outcomes.
"When I asked our members last week how they would describe the value of our national quality measurement efforts to their own companies, they responded with one word: 'abysmal,'" said David Lansky, President and CEO of the Pacific Business Group on Health, which represents 60 companies that buy health coverage for 10 million people and their dependents.
"They're looking for meaningful transparency on price and quality, and neither is available today."
Specifically, he said, "providers should be required to measure and report their outcomes… Improvements in quality of life, functioning and longevity, like after a patient has a knee replacement, is the pain reduced, can she walk normally? Can she return to work? When a child has asthma, can he play school sports? Can he sleep through the night?
"Unfortunately the measurements we use today leave us unable to make many of these vital judgments about the quality of doctors, hospitals or healthcare organizations. "
Christine Cassel, MD, president and CEO of the National Quality Forum, which reviews and endorses quality measures that are the basis for federal and private payment adjustments, added that while there are some examples of decisive improvement, "there's not nearly enough of them."
She said measures need to be "more understandable for consumers and policy makers" and they must be coordinated so public and private payers use the same measures, which they largely do not do today.
"One of the reasons that the employers can't get the information they need [is that] private insurance companies often use different measures or proprietary measures [than federal payers]."
More needs to be done, she said. For starters, considerable funding, specifically for developing quality measures was authorized by the Patient Protection and Affordable Care Act, but has not yet been appropriated by Congress. That money could help develop the kind of measures consumers, and to a great extent providers, want.
"It doesn't just happen by snapping your fingers" and to date, smart people are trying to do the job with "a hodgepodge of support," she said.
"The bottom line is that mistakes, poor care, and complications hurt people and increase costs to workers, families, business and taxpayers. We can and must do better…"
Committee chairman Sen. Max Baucus, (D-MT) called the hearing, entitled "The Path Forward," as a kind of "gut check" to examine the problems in measuring quality going forward as the PPACA changes the way providers are paid. He agreed that with so many multiple measures computed in different ways, there's confusion about who's providing good care.
"It is astounding that we don't have agreement on how to calculate the risk of dying in a hospital," Baucus said. "Three different commonly used measures of mortality produce different hospital rankings. So depending on the measure, a hospital could be at the top or bottom of the list."
Added ranking committee member, Sen. Orrin Hatch, (R-UT) "Currently there is so much marketing around provider quality, particularly with regard to hospitals. Everyone seems to be claiming to be the best at something. Many of these claims are based on proprietary data, making it hard for consumers to have an accurate picture of our healthcare system."
Speakers including former Centers for Medicare & Medicaid Services administrator Mark McClellan, MD, said that CMS and NQF should move more aggressively to measuring outcomes instead of processes.
McClellan is director and senior fellow of the Engelberg Center for Health Care Reform at the Brookings Institution.
"Medicare should take further steps to move away from fee-for-service payments and transition to greater use of person and episode-based payments," McClellan said, adding that such proposals could be enacted this year as part of legislation to address the scheduled Sustainable Growth Rate cut to physician payments. For example, physicians could get some of their payment "based on providing care for a patient, not based on a specific service."
That's not the way doctors are paid today, he said. For example, "Oncologists are only paid based on the volume and intensity of chemotherapy drugs that they administer, and not paid for things like setting a registry for their patients." But that can change, he continued. For example, some oncologists are working on "oncology homes" to devote more effort tracking patients' care to help them avoid complications.
There has been an assumption that meaningful use incentive payments and the push to get all providers using computerized health record would ease the burden on providers. But while electronic health records "do have the have the promise of supporting" quality improvement and reporting, "I think in practice, there have been a few challenges," McClellan said.
First, he told the senators, many systems "have not been very well designed to put together data from a lot of different sources…to track your particular patients in the way you really need to in order to improve their care. A lot of providers are doing add-ons or modifications to systems to help make that happen now."
But second, he said, most of the meaningful use payments "have been tied to whether or not basically you have electronic record systems that are capable of doing things like tracking a patient over time, and maybe potentially reporting on quality measures, but not actually doing it."
It would be better, he said, to move toward payments based on doctors "using their systems to put this data together… Now there are some concerns that may be too big of a leap."
Elizabeth McGlynn, director of the Kaiser Permanente Center for Effectiveness and Safety Research, agreed. "There needs to be more work to make [EHR systems] readily useable and for physicians and individual practices, it's a harder climb because frankly, they're not optimized for this use right now."
At Kaiser, she says, "half of my center's budget goes to making our data useable for research and for clinical decision support, and that's just not something that everybody can afford to do."
Another issue confounding measure developers is that today, unlike in years past, patients are much more likely to have multiple comorbidities.
Quality measurement science, Cassel said, "has understandably focused initially on high prevalence, high yield conditions like diabetes, hypertension and heart disease," looking at one disease across time, "and have not put as much investment into composite measures" that aggregate a patient's outcomes overall.
As a result, an individual quality measure may "kind of backfire because what you might want for someone with diabetes, who doesn't have any other problems, could be very different for a patient with Alzheimer's disease, and is suffering from two or three malignancies and other kinds of issues, perhaps in a nursing home."
Cassel appeared to make the panel uncomfortable when she pointed out the danger of "overpromising" of what a good measure set can actually do because misdiagnosis "is probably 15% to 20%" of what is considered a medical error.
"A big part is making sure patients get the right diagnosis," she said. "We have no measures that tell you. All the measures we have assume that the patient comes in the door with the diagnosis on their forehead."
That prompted Sen. Patrick Toomey, (R-PA), to remark, "It strikes me that we could have a real problem measuring the final outcome of a patient's care if we don't know how well we got the diagnosis straight in the first place."