Over the past 15 years there have been major changes in the measures we have at our disposal to assess the quality of care. We have gone from decentralized disorganization to measures that have been “standardized” through various multi-stakeholder consensus processes, including that of the National Quality Forum. And where there was a dearth of standard quality measures, some now argue we have too many (600-plus and counting), but not the right ones.
This has led to initiatives like the Measure Applications Partnership, the Institute of Medicine’s report “Vital Signs: Core Metrics for Health and Health Care Progress,” and the America’s Health Insurance Plans Core Measures Collaborative. Each of these efforts has sought or continues to seek, for different purposes, a carefully selected subset of measures.
Currently, the consensus processes around quality measures are dominated by the supply side of the market; physicians, hospitals, and health systems have greater expertise and resources to bring to the table than their buy-side counterparts, other than large public purchasers such as Medicare. This has created an unfortunate tilt in the commercial market toward provider-centric measures instead of patient-centric ones. While employers and other health care purchasers, along with consumer representatives, are usually invited to join the discussion, they often lack the bandwidth and know-how to balance the conversation and center it on the patient.
What would be different if employers and other purchasers chose which measures we use to define the quality of patient care? By encouraging the use of measures that hold providers accountable for the cost and quality of the care they deliver, and basing health care purchasing decisions on quality performance, purchasers could stimulate a market imperative for improvement and accelerate the transition to payment models designed to improve quality and affordability.
But to design and evaluate health care delivery and payment reforms, and to provide the most important and salient information to consumers when they face important health care choices, health care purchasers need to know which quality measures matter most. If employers and other health care purchasers determined which measures the industry uses, they would examine where they spend the most money on health care services and then ascertain within those areas where their populations experience the greatest variation in the cost and quality of that care — a clear sign of poor reliability and value in the marketplace.
It is at this intersection where purchasers would aim to create incentives for improvement and track progress over time. And that’s what we’ve done.
Priority Areas For Quality Measurement, Health Care Delivery, Payment Reform, And Transparency
It turns out, based on a CPR-commissioned analysis of commercial claims data by the Health Care Incentives Improvement Institute (HCI3), there are 12 clinical areas where the most spending occurs and where the greatest variation lies in quality, safety and costs. Many of these (listed alphabetically) are obvious and familiar: arrhythmia, asthma, breast cancer, coronary artery disease, depression, diabetes, gastrointestinal endoscopy, hypertension, low back pain, osteoarthritis, pregnancy, and upper respiratory infection. Some of these clinical areas are consistent with those that matter to Medicare, but others aren’t. The good news is that there are measures available today – though some still rarely used – that could make a difference in these priority areas. They simply haven’t been emphasized enough by those who dominate the measure debate.
Together with Discern Health, CPR identified the best available quality measures for these priority areas, along with the best measures to assess the performance of the health care system in broader ways such as care coordination, prevention, patient experience and safety measures. The CPR Employer-Purchaser Priority Measure Set consists of a total of 30 measures. We selected the measures with attention to alignment with other programs to the extent that it makes sense given our focus on the commercial population. We also identified the measure gaps that remain.
Now that we have identified these 12 priority clinical areas and associated measures, we can’t help but wonder if the numerous payment reform efforts throughout the country are paying them adequate attention? What about quality improvement, consumer transparency and other efforts? Given that we identified them, in part, due to the uneven quality they represent, I think we know the answer. We hope shining a spotlight will get the attention of the commercial market and also point out where its interests diverge from Medicare’s, which rightly focuses on an older population.
We can be proud of what we’ve accomplished since the turn of the century, when we still lived in the wild west of quality measurement. The process to define measures is better, but the dominance of the process by large public payers and provider organizations threatens to crowd out the interests of the majority of Americans who are covered by commercial insurers. We therefore hope our Priority Measure Set will start us on a course of more meaningful measurement.
We’re interested in hearing your views on this topic. What do you think?