"Continuous improvement is better than delayed perfection." You can bet that Mark Twain wasn't thinking about reforming health care payment systems when he spoke these words more than a century ago, but that doesn't mean they aren't relevant to the issue. In fact, "continuous improvement" was the overarching theme at a recent Health Affairs Forum entitled "Envisioning the Future of Value Based Payment."
Several recent laws have strengthened Medicare's incentives for quality improvement and accountability, including MACRA, the Affordable Care Act, the IMPACT Act, and the HITECH Act. Congress passed these laws for the right reasons, and many stakeholders believe they have had a positive effect. But it is time to reassess the programs included in these laws, such as the Hospital Readmission Reduction Program and the Hospital-Acquired Condition Reduction Program, so we can be assured that they continue to promote better health care delivery.
Last month's Health Affairs forum, cosponsored by The Federation of American Hospitals, brought together a broad range of experts to do just that. During the event, participants examined existing and developing Medicare value-based payment programs for hospitals and physicians and discussed how such programs should evolve in a future with seamless integration of electronic health records, big data analytics, and personalized medicine.
Keynote speaker David Blumenthal, President of The Commonwealth Fund, set the tone of the discussion with his remarks about quality measurement in value-based payment programs:
Value and quality are often in the eye of the beholder. It's about what we value, what we choose to consider important. I think that is central to the dilemma we face right now. There is a recognition that the measurement enterprise has slipped out of control, that it's counterproductive, wasteful, burdensome, and not realizing the purpose for which it was conceived and originated.
Congress envisioned the Medicare value-based payment programs as drivers of health care improvement and as immediate or longer-term cost cutting measures. But as many panelists pointed out, some of these programs have resulted in unintended consequences that call for corrective action and a re-envisioned purpose that is patient-centered and focused on the overall health of the population.
Aligning the Purpose of Quality Measurement and Payment
As Dr. Blumenthal noted, there are simply too many measures across the value-based payment programs. In many cases, the scientific evidence to support a given measure's results may be good, but its application in a specific program may be arbitrary and not fully concordant with the program's intent.
Jonathan B. Perlin, President of Clinical Services and Chief Medical Officer at Hospital Corporation of America, puts it another way: "There is a disconnect between what we are doing and how we are measured." The measures in the current programs are… "not getting to the specificity, sensitivity, or predictiveness that are available to us" to improve care.
In addition, there is too great a time-lag between delivering care and reporting on the metrics. Further, the statutory construct of the readmission and hospital-acquired condition programs is aimed only at penalties and is not focused on rewarding improvement in performance and patient outcomes. In fact, in some cases good performers who are improving still may be penalized.
Perhaps more importantly, while the programs aim at discrete and often narrow targets (for example, Meaningful Use Stage 2 Core Objective: Generate and transmit permissible prescriptions electronically), they do not sufficiently promote, and sometimes even inhibit, systemic changes in culture and work flow for hospitals, physicians, and post-acute providers. Such systemic change is necessary to effectively engage patients and providers to continuously strive for greater quality and safety.
Finally, current measure sets do not account for one of the most important, yet difficult to assess, issues: the impacts of socioeconomic factors on health care outcomes. As noted by Cheryl Damberg, RAND Distinguished Chair in Health Care Payment Policy, "There are a number of things that are outside of the control of providers that affect the outcomes of interest. We need to make sure that mis-measurement is not happening, and that we risk adjust for socioeconomic status of patients."
Acknowledging Success and Striving for Improvement
Panelists strongly supported the objectives of current value-based payment programs and agreed that they have resulted in tremendous progress in advancing quality and value for patients. As evidence, some even noted the significant number of measures that have "topped out" due to quality improvement efforts. Yet, in looking to the future, they also agreed on the need for key mid-course corrections to continue on the path of improvement.
Instead of focusing solely on preventing very specific problems, experts such as David W. Baker, Executive Vice President, Health Care Quality Evaluation, The Joint Commission, said we need to find ways to "incentivize a culture of safety across the hospital." For example, Dr. Baker and others noted that under the Hospital Readmissions Reduction Program, ongoing penalties will not necessarily continue to produce significant gains.
"Basically, the juice has been squeezed," Dr. Baker added, indicating that we need to think about systems of care rather than specific processes. However, current programs are not flexible enough to respond to accomplishments made by hospitals and adjust mid-course with new goals or objectives.
What's Next?
Most panelists agreed we must start by defining "value" more precisely. Dr. Blumenthal said, "We have to agree on what we think is valuable. We have to have common purposes to confine the measurement and value-based purchasing enterprise to a manageable administrable enterprise. I think the process we will need to create a set of metrics that will lead to a value-based capability is going to be a consensus-based process that will involve multiple sectors. And we are going to have to create a legitimate way to set priorities that will prove itself over time and gain confidence of key stakeholders."
As Dr. Blumenthal pointed out, data have no value; we derive value from how we use data. The current performance-based payment measurement and data systems are too narrow, and changes are needed. We need to consider how to develop an integrated system of measurement, reporting, payment, and improvement that emphasizes better utilization of advanced analytics paired with good science.
It is clear that reaching these objectives will require adjustments to some of Medicare's measurement programs. The Administration can make some adjustments through regulation, but overall redirection and key fixes will require legislation. In 2017, Congress and the new Administration must engage in a process to review the value of these programs. The Health Affairs forum was a launching pad for that conversation. The Federation of American Hospitals will remain engaged and, as we move forward, will add our ideas to the discussion.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/29XyIsb
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