Payment for medical services is shifting from paying for volume (more visits, tests, visits, days = more money) to paying for value (quality of care). Makes sense. But what does value and quality of care mean? It means that physicians get paid an incentive (more money) for certain results (outcomes, process, actions). An example is readmission rates. If a physician’s patients are readmitted to a hospital after discharge more than most physicians, they don’t get the extra payment. There are roughly 1,000 of such quality measures. These quality measures are very important to us – people at the center of care (patients, caregivers, parents, direct care clinicians and staff) – because measurement strongly influences people and organizations who get paid for medical services. Following the money doesn’t necessarily mean better medical care, better health for us, better relationships among our healthcare teams, or better work life for our health professional partners.
I was nominated to sit on a CMS (Center for Medicare and Medicaid Services)/Battelle Quality Measurement Development Technical Advisory Panel (TEP). The TEP had its first meeting in Baltimore last week. I was one of 19 Panel members (and one of two with expertise in all four of the selection criteria -Consumer Perspective, Clinical Content, Performance Measurement, Coding and Informatics). The TEP seeks to improve the process of developing measures. It isn’t trying to develop measures. The good news is that the TEP gelled as a team and the CMS/Battelle leaders seem open to, if not eager for, actionable advice. I am honored to have been asked to sit at this table.
As a Patient Activist and a change catalyst, I appreciate the formidable forces of inertia and the current business realities of the medical care industrial complex. What can little Danny van Leeuwen hope to accomplish? My goal in accepting this appointment is to find one lever that can move the Value-Based Measurement battleship three degrees toward value to people at the center of care. My superpower is to accept what is and go from there. After listening to my esteemed TEP colleagues, my perception of what is is:
- Measures serve to evaluate the performance of individual practitioners (not measure whether patients attain optimal health or how the team is functioning),
- Inertia is heading to further measure specificity by specialty and diagnosis (not toward the patient with more non-medical than medical determinants of health who is more than a sum of their diagnoses),
- Data for measurement exists primarily in claims, diagnostic systems, and Electronic Medical Records (much less patient-generated data and experience/perceptions of people at the center of care),
- Physicians bristle at the idea of being held accountable for anything they deem out of their control (rather than what can I do to contribute to improving whatever?),
- People at the center of care, insurers, and policymakers all feel ill at ease with uncertainty,
- Few, if any, incentives exist for data vendors to integrate their data (So patients, caregivers, and parents using the most health care dollars provide the bulk of communication at transitions in care, if they can do it at all),
- Testing measures in real-life seems to be an almost insurmountable challenge (so the link between measures and what they seek to measure and the link between measurement and value to patients is tenuous),
- Direct care clinicians are stressed and burning out – the proportion of time they spent documenting rather than caring is growing while they feel pressure to increase productivity (rather than technology helping to reverse those trends),
Jeesh. Houston, we have a problem.
At this early stage, I smell two opportunities to shift this battleship and support people at the center of care:
- Consider developing a process to measure clinical decision-making. Clinical decision-making is making informed choices along the medical journey. Informed decision-making by the patient’s lay and professional health team is a new area for clinical quality measurement, yet the body of evidence about Clinical Decision Support (CDS) is growing. Developing the process to measure clinical decision-making makes sense because it:
- Combines medical and non-medical determinants;
- Could make use of patient-generated data that could be integrated into EHRs and PHRs;
- Bridges home, community, and healthcare facilities;
- Includes medical outcomes, workflow and life flow components, and perceptions of people at the center of care;
- Shifts some burden from direct care clinicians to their patient, caregiver, and parent partners; and
- Empowers patients, caregivers, and parents.
- Build the infrastructure for testing measures in real-life. Testing measures in laboratories under narrow, restricted conditions using only claims, diagnostic, and electronic health record data does not reflect the diversity and variation in life. Until the infrastructure supports a shift toward patient-generated data, includes perceptions and experience of people at the center, and integrates the continuum of care, measurement will always do what measurement has always done – Maintain things as they are. There is no evidence without testing. No systemic change can happen without evidence.
I meant it when I said ‘smelled opportunities’. Clearly, these bones need meat. Am I on to something? What are the informing questions that need to be asked? What am I missing? I’d like to go to the next TEP meeting at the end of January/beginning of February with a more mature proposal. I find that groups find it easier to react than create. Please help me create. Use the comment feature of this blog. Thanks.
See my YouTube broadcast of a version of this post here
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