Measuring Value in Healthcare to Improve Quality
Medicare is poised to incorporate new quality metrics as a guide for payments. At ASH 2015, Helen Burstin, MD, MPH, Chief Scientific Officer, National Quality Forum, Washington, DC, discussed the need for measures and reporting systems that reflect patient care and care coordination.
“The purpose of measurement is to improve healthcare quality,” said Dr Burstin. “We want to focus on measures that provide value for both patients and oncologists and may ultimately drive systematic change.”
To this end, Dr Burstin and colleagues considered the use of measurements based on episode of care rather than costs reflected in individual claims.
“How do you move from a population at risk all the way through the acute management of illness to postacute care and secondary prevention?” Dr Burstin asked. “What kind of outcome measures could be used to describe that space?”
Although measures such as functional status, quality of life, costs, and advance care planning are a component of that, a more comprehensive set of measures is needed, according to Dr Burstin. At the same time, as consumers and purchasers seek out better data, tensions between system-level measurement and individual assessment arise. Metrics are therefore needed for different specialists and settings.
Hematology-specific measures can be divided into the following categories:
- Testing (eg, cytogenetic testing on bone marrow)
- Treatment and documentation (eg, the pathology report in the chart confirming diagnosis and a documented plan for chemotherapy)
- Symptom and function assessment.
Health behaviors, such as smoking status, can also be reported as a cost-cutting measure. Also important are the very significant set of measures for advanced directives: hospice enrollment, death from cancer in the intensive care unit, and chemotherapy administered in the last 2 weeks of life.
Although such measures are a good start, Dr Burstin believes the key to measuring value is moving away from process measures toward outcome measures.
“Outcomes are the reasons patients seek care, and why providers deliver care,” she said. “Outcomes are integrative, reflecting the result of all care provided over a particular time period. In addition, measuring performance on outcomes encourages a ‘systems approach’ to providing and improving care rather than narrow process measures.”
In addition, “measuring outcomes encourages innovation in identifying ways to improve outcomes that might not previously have been considered modifiable,” she added.
An underutilized example of this is patient-reported outcomes. “Researchers have developed an elegant set of tools for patients,” said Dr Burstin. “These are well-validated patient-level instruments.”
And yet, there are challenges to using patient-reported outcomes for accountability and performance improvement, she said, because little is known about how to aggregate this information.
Despite the upside to measuring outcomes, persistent measurement gaps have been identified. “There is a real concern around potential for unintended consequences,” Dr Burstin cautioned. “We don’t want to be incentivizing bad medical decisions.”
There are also challenges with accountability, as patient selection can lead to significant differences across physicians or hospitals. Furthermore, outcomes reflect a variety of factors, not all related to the care provided. “Some of these factors are patient-related,” she said. “Some of which are modifiable, and some of which are not.”
These factors include genetics, demographic characteristics, clinical factors, psychosocial factors, socioeconomic, and environmental factors. There are also health-related behaviors and activities (eg, tobacco, diet) to consider. Finally, risk adjustments can be made for socioeconomic status, too, although this remains controversial.
Discussing her study, she said, “There was a huge dichotomy of opinion between those who thought adjustment for socioeconomic status was necessary for the sake of comparative performance, and those who thought it would mask disparities and not move us forward.”
While acknowledging that the move toward more episode-based, value-based purchasing is not going to be easy, Dr Burstin was encouraged by support from multiple stakeholders.
“We are hearing a great deal of interest, not just from the public side, but from the commercial side, and health clinic world, as well,” she concluded. “It’s a move that needs to be made.”