The Failure of “Quality” in Health care
"What gets measured, gets managed." This is an accepted truism throughout the business community. But what if we are consistently measuring the wrong things? In health care we place an increasing faith in codified Quality Measures, but what if we are just forcing providers to "manage" reimbursement rather than patient care? If so, we need to reevaluate our understanding of Quality, because this is not a harmless re-prioritization.
Take, for example, this case exposed by ProPublica about a patient that suffered brain damage during a heart transplant surgery. He was kept alive, in a vegetative state, for the express purposes of avoiding a ding to the hospital's 12-month transplant survival rate. His family was intentionally not counseled on hospice options and were left to hope that he could recover. Oh, and it turns out that the hospital may have defrauded Medicare & Medicaid to get paid for the privilege of keeping the patient alive solely to pad their numbers. This is an example of a department staff that was effectively, and proactively, managing care to the measures they abide by. And so, the patient had to “take one for the team,” as one member of the surgery staff put it. (Chen, 2019)
And this gross disjuncture between optimizing payment opportunities--and/or avoiding quality performance dings--and acting in the interest of patients is not limited to hospitals. It is common, if not ubiquitous, across the entirety of the health care industry. This horrifying case is only remarkable because the providers were so candid in openly transmuting the subtext into the text; and the fact that they were recorded in their candor.
This disjuncture is in large part a symptom of the fact that we don’t really understand how to evaluate--or even measure--quality in health care.
Let’s look at Primary Care measures.
In 2014 CMS, AHIP, the quality measure developers, and all the leading societies of organized medicine formed the Core Quality Measures Collaborative to “reduce, refine, and relate” (Conway, et al., 2015) quality measures across the industry by clinical domain. This Collaborative put forward what was identified as the twenty-two defining measures for Primary Care.
Given that pedigree, can we assume that those twenty-two measures provide a robust framework for predicting and improving desired clinical outcomes? Sadly, no.
A comprehensive analysis conducted in 2017 from the Congressional Budget Office (CBO), quite effectively titled Issues and Challenges in Measuring and Improving the Quality of Health Care, found that “... existing measures tend to focus attention on conditions that are easily measured or clinical processes that are widely considered appropriate—a phenomenon sometimes called ‘looking under the streetlight.’” (Hayford and Maeda, 2017)
Hayford and Maeda’s (2017) report also raises the concerns that:
The use of a specific set of measured “aspects of care may result in the neglect of other aspects of care that are not being measured.
The use of some measures may have unintended consequences. Including--but not limited to--a wave of overprescription for opioid painkillers starting in the early 2000s.
The self-reported nature of quality measures will result in providers and institutions working to game the system. Please re-read the ProPublica article referenced above if you forgot how this can look in real life.
Most damningly of all, though, the CBO’s report frankly states that: “... the current set of quality measures cannot evaluate various complex clinical decisions and processes… Existing measures also cannot assess physicians’ ability to manage patients with multiple chronic conditions, nor can they capture other aspects of care, such as providers’ technical proficiency...” (Hayford and Maeda, 2017)
But how does this relate back to primary care?
Primary care, by definition, happens to be a specialty that is defined by, “various complex clinical decisions and processes.” It is, therefore, beyond the technical ken of the current set of quality measures to evaluate. So our faith in the power of Quality Measures to improve the technical, clinical aspects of primary care delivery are entirely misplaced.
And it gets worse.
Healing is a fundamentally human (and humane) endeavor. No primary care doctor will succeed in healing another human being if they cannot manage to win their patient’s trust and navigate the often turbulent dynamics of the patient-physician relationship. Given that reality would it surprise you to learn that of the twenty-two Consensus Core Set Measures for Primary Care precisely zero actually assess the patient-physician relationship?
But there is hope.
We are starting to see the tentative percolation of an alternative approach to understanding and valuing (as opposed to evaluating) primary care. In May 2018, the New York Times Magazine published a groundbreaking piece, Trying to Put a Value on the Doctor-Patient Relationship, which gave a narrative voice to the need to understand the power of relationships in primary care.
Then in 2019, the Larry A. Green Center released the free-to-field Person-Centered Primary Care Measure set. It is even validated! Which is more than can be said of ~60% of CMS’ measures related to primary care. (McClean, et al., 2018)
So maybe, just maybe, we are at the precipice of developing measures that will assist us in better understanding how to improve primary care delivery. But making the most of this opportunity will require us to take a huge leap of faith. We are going to have overcome overwhelming inertia and challenge the conceptual basis of “pay for performance” programs and so-called “value-based care” models. So it might, ultimately, be a slim hope.
But given the current state of the American health care industry, I will happily take any hope at all. No matter how slim it may be.
An avowed health policy geek, Joe co-founded Grundy Consulting to end the tyranny of the 15-minute doctor visit in primary care. He does this by empowering thought leaders and disruptive innovators like you to address the challenges of health care transformation from as many angles as possible. Book a free call to accelerate your impact in the broken system. We can do this. Together.
[1] Chen, C. (2019). “It’s Very Unethical”: Audio Shows Hospital Kept Vegetative Patient on Life Support to Boost Survival Rates — ProPublica. [online] propublica.com. Available at: https://www.propublica.org/article/audio-shows-hospital-kept-vegetative-patient-on-life-support-to-boost-survival-rates [Accessed 7 Dec. 2019].
[2] Patrick H. Conway the Core Quality Measures Collaborative Workgroup. “The Core Quality Measures Collaborative: A Rationale And Framework For Public-Private Quality Measure Alignment." Health Affairs Blog, June 23, 2015.
[3] United States, Congress, Congressional Budget Office. Hayford, T.B. and Maeda, J.L. “Issues and Challenges in Measuring and Improving the Quality of Health Care.” Issues and Challenges in Measuring and Improving the Quality of Health Care, Congressional Budget Office, 2017.
[4} Maclean, Catherine H., et al. “Time Out — Charting a Path for Improving Performance Measurement.” New England Journal of Medicine, vol. 378, no. 19, 2018, pp. 1757–1761., doi:10.1056/nejmp1802595.