Jan. 30, 2015 6:47 p.m. ET
The Obama administration’s goal of tying more Medicare payments to the quality—not the quantity—of health care by 2018 has intensified the debate over how “quality” is defined and measured.
Many doctors, hospitals, insurers and cost experts want to move away from the myriad quality metrics that largely measure process—from tracking the percentage of patients with chest pain who get an aspirin in the ER, to how hair is removed from ambulatory surgery patients—toward broader measures that assess patient outcomes.
On Friday, the National Quality Forum, a nonprofit advisory group, submitted recommendations on 199 performance measures for Health and Human Services to consider in 20 federal programs. Christine Cassel, the group’s president and chief executive, said many of the proposals seek to better align measures among various programs and replace narrow process-oriented metrics with “measures that matter.” For example, one recommendation would replace individual metrics on the percentage of diabetes patients who get foot exams, eye exams and blood-glucose checks with a composite measure of diabetes control.
But some doctors question whether the measures that exist can adequately measure quality. And there is little agreement on what measures matter most or are more likely to produce good value. “In many areas of patient care, we do not yet have high-quality outcome measures with enough specificity to drive improvement,” American Medical Association Executive Director James L. Madara wrote in a letter to the quality forum earlier this month.
Some doctors complain that whether patients get better is often out of their control; that outcomes measures take more work, not less; and that being held accountable for outcomes could prompt doctors to avoid treating the sickest patients.
“Measurement fatigue is a real problem in hospitals,” said Scott Wallace, a visiting professor at Dartmouth’s Geisel School of Medicine. “But, to me, the only metric that matters is, did you get better?”
As of last year, 33 federal programs asked providers to submit data on 1,675 quality measures, according to a government count. State, local and private health plans use hundreds more.
This year, many of the federal pay-for-performance programs carry financial penalties. Hospitals and doctors stand to lose millions in Medicare payments for missing filing deadlines or improvement benchmarks in programs that track hospital-acquired infections, readmissions and electronic-record use.
In all, about 80% of traditional Medicare spending is already tied to such pay-for-performance programs. HHS Secretary Sylvia Burwell said Monday the agency wants that to increase to 90% by 2018. She also set a goal of having 50% of Medicare spending in alternative payment models, in which providers are accountable for quality and the cost of care for groups of patients.
Patrick Conway, deputy administrator for Innovation and Quality at the Centers for Medicare and Medicaid Services, said CMS also wants to move toward more quality measures “that matter most to patients and clinicians,” and that some had already had an impact on outcomes. Central-line bloodstream infections have dropped by 50% since hospitals were required to report them, and 150,000 fewer Medicare beneficiaries were readmitted to hospitals within 30 days of discharge in 2012 and 2013 under a federal program holding them accountable as part of a pilot with the quality forum.
More than 2,600 hospitals will see their Medicare payments cut between 1% and 3% this year—a total of $428 million— for not reducing 30-day readmissions sufficiently, according to a CMS report. Some have complained that safety-net hospitals are being unfairly penalized because low-income patients may be sicker and have less support at home. Dr. Conway said CMS is considering adjusting some measures for socioeconomic status.
Critics contend that some quality metrics are removed from consideration when a high percentage of physicians score well on them. Some 50 measures were “topped out” from the Physician Quality Reporting System—one of several programs that require doctors to submit quality data for 2015—including the percentage of patients with back pain being given a physical exam, assessed for over-the-counter anti-inflammatories and advised against bed rest.
To fulfill PQRS requirements, doctors in large practices must submit data on at least six out of over 200 quality metrics for at least 50% of their Medicare patients in 2015, or see their 2017 Medicare payments cut by 2%. The requirement extends to all doctors treating Medicare patients next year.
Many of the current quality metrics are being made public in tools such as CMS’s Hospital Compare and Physician Compare websites, though metrics that would let patients compare, for example, how often an orthopedic surgeon’s knee or hip replacements encounter complications, are not yet available.
Developing that would require capturing data across multiple hospitals. “When people have surgical complications, they are unlikely to go back to the same hospital where they had the surgery done,” says Nicole Latimer, a senior vice president in the performance technology division of the Advisory Board Co., a consulting firm.
Write to Melinda Beck at HealthJournal@wsj.com
The Obama administration’s goal of tying more Medicare payments to the quality—not the quantity—of health care by 2018 has intensified the debate over how “quality” is defined and measured.
Many doctors, hospitals, insurers and cost experts want to move away from the myriad quality metrics that largely measure process—from tracking the percentage of patients with chest pain who get an aspirin in the ER, to how hair is removed from ambulatory surgery patients—toward broader measures that assess patient outcomes.
On Friday, the National Quality Forum, a nonprofit advisory group, submitted recommendations on 199 performance measures for Health and Human Services to consider in 20 federal programs. Christine Cassel, the group’s president and chief executive, said many of the proposals seek to better align measures among various programs and replace narrow process-oriented metrics with “measures that matter.” For example, one recommendation would replace individual metrics on the percentage of diabetes patients who get foot exams, eye exams and blood-glucose checks with a composite measure of diabetes control.
But some doctors question whether the measures that exist can adequately measure quality. And there is little agreement on what measures matter most or are more likely to produce good value. “In many areas of patient care, we do not yet have high-quality outcome measures with enough specificity to drive improvement,” American Medical Association Executive Director James L. Madara wrote in a letter to the quality forum earlier this month.
Some doctors complain that whether patients get better is often out of their control; that outcomes measures take more work, not less; and that being held accountable for outcomes could prompt doctors to avoid treating the sickest patients.
“Measurement fatigue is a real problem in hospitals,” said Scott Wallace, a visiting professor at Dartmouth’s Geisel School of Medicine. “But, to me, the only metric that matters is, did you get better?”
As of last year, 33 federal programs asked providers to submit data on 1,675 quality measures, according to a government count. State, local and private health plans use hundreds more.
This year, many of the federal pay-for-performance programs carry financial penalties. Hospitals and doctors stand to lose millions in Medicare payments for missing filing deadlines or improvement benchmarks in programs that track hospital-acquired infections, readmissions and electronic-record use.
In all, about 80% of traditional Medicare spending is already tied to such pay-for-performance programs. HHS Secretary Sylvia Burwell said Monday the agency wants that to increase to 90% by 2018. She also set a goal of having 50% of Medicare spending in alternative payment models, in which providers are accountable for quality and the cost of care for groups of patients.
Patrick Conway, deputy administrator for Innovation and Quality at the Centers for Medicare and Medicaid Services, said CMS also wants to move toward more quality measures “that matter most to patients and clinicians,” and that some had already had an impact on outcomes. Central-line bloodstream infections have dropped by 50% since hospitals were required to report them, and 150,000 fewer Medicare beneficiaries were readmitted to hospitals within 30 days of discharge in 2012 and 2013 under a federal program holding them accountable as part of a pilot with the quality forum.
More than 2,600 hospitals will see their Medicare payments cut between 1% and 3% this year—a total of $428 million— for not reducing 30-day readmissions sufficiently, according to a CMS report. Some have complained that safety-net hospitals are being unfairly penalized because low-income patients may be sicker and have less support at home. Dr. Conway said CMS is considering adjusting some measures for socioeconomic status.
Critics contend that some quality metrics are removed from consideration when a high percentage of physicians score well on them. Some 50 measures were “topped out” from the Physician Quality Reporting System—one of several programs that require doctors to submit quality data for 2015—including the percentage of patients with back pain being given a physical exam, assessed for over-the-counter anti-inflammatories and advised against bed rest.
To fulfill PQRS requirements, doctors in large practices must submit data on at least six out of over 200 quality metrics for at least 50% of their Medicare patients in 2015, or see their 2017 Medicare payments cut by 2%. The requirement extends to all doctors treating Medicare patients next year.
Many of the current quality metrics are being made public in tools such as CMS’s Hospital Compare and Physician Compare websites, though metrics that would let patients compare, for example, how often an orthopedic surgeon’s knee or hip replacements encounter complications, are not yet available.
Developing that would require capturing data across multiple hospitals. “When people have surgical complications, they are unlikely to go back to the same hospital where they had the surgery done,” says Nicole Latimer, a senior vice president in the performance technology division of the Advisory Board Co., a consulting firm.
Write to Melinda Beck at HealthJournal@wsj.com
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