Why We Need to Shift Healthcare Quality Measures from Volume to Value

Why We Need to Shift
Healthcare Quality
Measures from
Volume to Value
̶ Jared Capo

© 2016 Health Catalyst
Proprietary. Feel free to share but we would appreciate a Health Catalyst citation.
The Case for Healthcare Quality Measures
Physicians are feeling a time crunch as
never before.
We hear many reasons for physicians’
increasingly hectic schedules: declining
reimbursement that requires them to see
more patients in a day, the added burden
of documenting care in an electronic
medical record.
Now, a new study published in Health
Affairs highlights another significant
contributor to the physician time crunch:
 Quality measures

The study revealed that physicians and staff
spend approximately 15 hours per week per
physician reporting quality measures.
What’s more, providers spend $15.4 billion
annually on quality reporting—as much as
the U.S. spends on healthcare for 1.6 million
people in a year!
Why do providers spend so much time
and money reporting quality measures?
Because they are dealing with an
unmanageable number of them.

Recently, the Centers for Medicare
and Medicaid Services (CMS) and
America’s Health Insurance Plans
(AHIP) announced a major step
toward rectifying this situation.
That announcement marks an exciting
turning point.
But, when it comes to improving the
quality of our quality measures, we
still have a long way to go.

A Bajillion Quality Measures …
and Some Progress toward Alignment
It might be an exaggeration to say
that providers are required to deal
with a bajillion quality measures, but
they do have to deal with at least
1,958 of them.
In truth, not everyone has a clear
scope as to how many measures
are really out there, but the
following are the major ones:

Healthcare Effectiveness Data and
Information Set – HEDIS
Developed by the National Committee
for Quality Assurance (NCQA), these 81
clinically centric measures are familiar
to most U.S. providers.
Health plans generally require providers
in their network to report these
measures. They then use them,
combined with cost data, to identify
high- and low-performing providers.
HEDIS

CMS defines a whopping 1,514
different measures across 22 programs!
To complicate matters further, within
each of the 22 programs, not all
measures apply to all providers equally.
Providers have to figure out which
measures and which programs apply
to them.
CMS

The Joint Commission
TJC previously aligned its measures for
health failure and acute myocardial
infarction with those of CMS—an
important step forward—but TJC also
has 12 other measure sets.
TJC

Providers also have to juggle variations
on these standard measures. Sometimes
health plans tweak standard measures
and add exclusion criteria.
And while most health plans use HEDIS,
they often introduce additional measures
based on the performance requirements
for a specific accountable care contract.
In the past, the industry has seen limited
success in broadly aligning quality
measure definitions.

Some industry collaboration and
consensus has occurred, but not enough.
That’s why the announcement by CMS
and AHIP (as part of a broad collaborative
of health care system participants) is
such a big deal.
These groups announced their intention
to standardize quality measures across
commercial and government payers and
outlined an initial set of quality measures
in seven categories:

• Accountable Care Organizations (ACOs)
• Cardiology
• Gastroenterology
• HIV and Hepatitis C
• Medical Oncology
• Obstetrics and Gynecology
• Orthopedics

Because AHIP and CMS are now leading
the charge for aligning quality measures,
we can expect all payers to jump on
board with this effort.
In the long run, this alignment should
decrease the complexity and frustration
physicians face as they attempt to
demonstrate the quality of care they
provide.

Turning Our Focus to the Best Quality Measures
Even as we celebrate this significant
move toward standardization, we need
to stop and acknowledge an extremely
important issue.
Yes, all providers will soon be measuring
the same things, but are we really
measuring the right things?

The truth is that as an industry, we are
still putting most of our focus on process-
based metrics—on whether a provider
did what the evidence shows was the
right thing to do.
For example, did the physician prescribe
the right antibiotic at the right time?
Did the nurse follow the correct protocols
when inserting a central line?
In short, did they follow the processes
that we believe lead to better outcomes?

While these measures are useful and
appropriate, they don’t measure actual
outcomes.
We can better serve our patients by
retiring some of our process metrics
and focusing more of our limited
resources on measuring real outcomes.
A recent article published in the New
England Journal of Medicine describes
the situation very clearly:
Categories of Quality Measures Listed in the National Quality
Measures Clearinghouse (NQMC). NE Journal of Medicine

[I]n health care we’ve allowed ‘quality’ to be defined as compliance with evidence-
based practice guidelines rather than as improvement in outcomes. Of the 1958
quality indicators in the National Quality Measures Clearinghouse, for example, only
139 (7%) are actual outcomes and only 32 (<2%) are patient-reported outcomes.
Defaulting to measurement of discrete processes is understandable, given the
historical organization of health care delivery around specialty services and fee-for-
service payments. Yet process measurement has had limited effect on value. Such
measures receive little attention from patients, who are interested in results.”
Standardizing Patient Outcomes Measurement
Michael E. Porter, Ph.D., M.B.A., Stefan Larsson, M.D., Ph.D., and Thomas H. Lee, M.D.
N Engl J Med 2016; 374:504-506 | February 11, 2016 | DOI: 10.1056/NEJMp1511701

One body that exemplifies the kinds of
quality measures we should focus on is
the International Consortium for Health
Outcomes Measurement (ICHOM).
ICHOM thoughtfully defines patient-
centric outcomes, with particular attention
on patient-reported outcomes measures.

A brief comparison between cardiology measures from CMS and
from ICHOM illustrates the gap between where we are now in
terms of our quality measures and where we need to be.
Measures for Coronary Artery Disease
CMS measures whether the provider
prescribed an antiplatelet therapy like aspirin
or Plavix, because evidence shows that such
therapies help reduce heart attacks.
The sole focus of the measure is whether the
medication was prescribed or not. We do not
measure whether the patient filled the
prescription, took it correctly, or experienced
better outcomes because of it.
ICHOM doesn’t measure antiplatelet
therapy. Instead, it focuses on patient-
reported health status (angina, dyspnea,
depression, functionalstatus, health-
related quality of life) during the first 30
days after treatment.
It then measures those same factors
annually for five years.

A brief comparison between cardiology measures from CMS and
from ICHOM illustrates the gap between where we are now in
terms of our quality measures and where we need to be.
Measures for Heart Failure
CMS measures the 30 day all-cause
mortality rate following heart failure
hospitalization.
In other words, after hospitalization,did a
patient die within 30 days?
ICHOM measures all-cause mortality for
five years after an index event. Such an
event doesn’t have to be a dramatic
incident like a hospital admission. It
could be a routine checkup when a
physician classifies a patient as high-risk
for heart failure because of hypertension
and high triglycerides.

ICHOM promulgates measures that
center on the patient’s sense of health
and wellbeing rather than on the steps
the physician took in delivering care.
It’s not easy to jump from our current
state to the ideal that ICHOM represents,
but we as an industry should not stop
aiming for it.
As we continue to define how we think of
population health, we must aspire to
meaningful measures that accurately
reflect the state of each individual’s health

For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

More about this topic
Link to original article for a more in-depth discussion.
Why We Need to Shift Healthcare Quality Measures from Volume to Value
Improving the Outcomes That Matter Most to Patients
Caleb Stowell, M.D. and Dr. Sara Sprinkhuizen, ICHOM
Michael Porter and Others Show How to Deliver Better Care in Value-based Healthcare Documentary
Paul Horstmeier, Senior Vice President
Improving Healthcare Outcomes: Keep the Triple Aim in Mind
Michael Barton, Engagement Executive, VP; Tracy Vayo, Director, Knowledge Development
Kathleen Merkley, Clinical Improvement – VP
The Top 7 Outcome Measures and 3 Measurement Essentials
Ann Tinker, Engagement Executive, VP
Why Process Measures Are Often More Important Than Outcome Measures in Healthcare
Tom Burton, Product Development, SVP

Jared Crapo joined Health Catalyst in February 2013 as a Vice President. Prior to
coming to Health Catalyst, he worked for Medicity as the Chief of Staff to the CEO. During
his tenure at Medicity, he was also the Director of Product Management and the Director
of Product Strategy. Jared co-founded Allviant, a spin-out of Medicity, that created
consumer health management tools. In his early career, he developed physician
accounting systems and health claims payment systems.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com

Why We Need to Shift Healthcare Quality Measures from Volume to Value

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Why We Need to Shift Healthcare Quality Measures from Volume to Value