Guest Blogger Andrey Ostrovsky, MD – Quality Measurement: Catalyst or Killer of Health Care Reform?
February 25, 2016 · Andrey Ostrovsky
v Dr. Andrey Ostrovsky is a Quality Talks veteran, a practicing physician and co-founder of Care at Hand, a digital health company. Read his blog and comment below.
Quality measurement: catalyst or killer of healthcare reform?
Over $500 Billion in Medicare spending is being overhauled due to the Medicare and CHIP Reauthorization Act (MACRA) and its Merit-based Incentive System (MIPS). Shifts in Medicaid are equally as dramatic with a growing number of states diverting their Medicaid dollars from state-administered fee-for-service to managed care organizations. The unprecedented increase in financial drivers of more efficient and higher-quality care is leading to a rapid evolution in delivery processes redesign. Hospital CFOs are finally, albeit begrudgingly, shifting budget allocations toward investments that will grow revenue by keeping patients out of the hospital rather than driving them in. In this historic time of healthcare change, there is more need than ever to effectively gauge if we are moving closer to or farther away from achieving the Triple Aim.
As these healthcare financing and delivery model innovations take off, we are using antiquated instruments to measure their impact. Not only is it hard to improve what can’t be measured, but there are billions of tax-payer dollars and millions of the peoples’ well-being at stake if these innovations don’t pan out.
The disconnect between measurement and delivery innovation is partly attributable to a narrow focus on medical quality measures. Health has a wide spectrum of determinants and measurement should take into account this breadth to adequately measure and improve overall care delivery. That is not to say that existing measures should be adjusted for upstream determinants as NCQA eloquently pointed out. Measure-level adjustment for upstream determinants would obscure the true differences in quality even if they are influenced by confounders like SES. Rather, new measures and measurement processes need to evolve while preserving medical care quality. There are promising efforts underway at the National Quality Forum to broaden the types of measures that are developed to include domains of care such as home and community based services.
But measures alone are not the problem. The failures in the process of measurement are even more egregious. It can take millions of dollars and years to create, validate, ballot, and approve a quality measure before it ever gets used at scale. The current processes for measurement development and evolution cannot keep up with the pace of innovation that is happening in healthcare financing and delivery. Sadly, there are too few significant efforts underway at scale to change this slow pace. During each 2-year measurement development cycle, 5 million people will die.
Among the important barriers to overcome in improving measurement processes is recognizing that academic validity and business viability of measures are not the same thing. In other words, a measure may be validated through rigorous psychometric research to be reliable, but if that measure does not take into account the constraints of healthcare financing and delivery model malleability, then the insights from measurement may not be actionable. And action is everything when deciding to make major investments in scaling or squashing an improvement project.
Quality measurement leaders should be charged with improving quality measurement by changing how we measure. The basics of improvement science can serve as a guide by making measurement more iterative, rapid, and adaptive to local context. By breathing new life into the old ways of measurement, we can catalyze achievement of healthcare reform.
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