While healthcare's finest minds continue to wrestle over how to measure quality, the National Quality Forum lit a match near another potential powder keg by taking the first steps toward defining how to measure “value.”
Looking at value
NQF backs effort focusing on resource use, costs
Last week, the NQF released a set of four endorsed “resource use” measures that included two developed by the National Committee for Quality Assurance and two from Bloomington, Minn.-based HMO HealthPartners that address the costs of diabetes and cardiovascular care along with total primary-care costs and primary-care total use of resources. Similar measures being considered involve asthma, chronic obstructive pulmonary disease, hip and knee replacement and pneumonia.
“I find the NQF action fascinating,” Dr. Robert Wachter, University of California San Francisco professor and Department of Medicine chief, said in an e-mail. “Over the past decade, national organizations like NQF and healthcare delivery organizations such as hospitals have invested heavily in trying to improve safety, quality, access and patient satisfaction. Now that everyone is consumed with the imperative to bend the cost curve, it is still an open question whether these efforts will be on their own axis or will be somehow blended into existing efforts. When the latter course is chosen, the resulting action is sometimes placed under the heading of ‘value.'”
Wachter added that there is a risk that some will be confused and will think an NQF measure is about quality when it's actually about cost savings.
Dr. Helen Burstin, NQF senior vice president for performance measures, said she is unaware of any confusion so far. Burstin referred to the measures as “building blocks” toward defining value while also adding more transparency, and she added that the new measures should not be viewed in isolation but rather in tandem with quality measures.
“Cost and quality need to be reported together,” Burstin said. This point was echoed by Susan Pisano, spokeswoman for the America's Health Insurance Plans trade association, who said her group supported the new measures.
Those who oppose the measures have until Feb. 29 to file an appeal asking NQF to reconsider its endorsement, but Burstin said NQF “did not get a great deal of pushback on the concept” of resource-use measures. Dr. Dan Blue, president of Sanford Clinic, Sioux Falls, S.D., said they shouldn't.
“We shouldn't fear this, we shouldn't resist it,” Blue said. “It's a mirror, and it's a reflection of what we do.”
Blue said the new measures will provide data needed for continuous improvement, and Dr. Rhonda Ketterling, chief medical officer of Sanford Health Fargo in North Dakota, called the measures “good preparatory data” in the move toward accountable care organizations and other healthcare reform-related business models. While smaller, independent practices may not appreciate the measures so much, she said, they will help show the value of care provided by integrated systems such as Sanford.
Dr. Bruce Bagley, the American Academy of Family Physicians' medical director for quality improvement for and a member of the NQF Consensus Standard Approval Committee, said for some small practices or for individual physicians with a few diabetic or cardiac patients the measures may not be statistically viable. But, if a primary-care doctor always prescribes brand-name drugs or always orders more tests or consultations, Bagley said “that will show up” with the new measures for total costs and resource use.
Dr. Lyle Swenson, president of the Minnesota Medical Association and an interventional cardiology specialist with East Metro Cardiology in St. Paul, said his organization is “all in favor” of measures that allow more transparency, help educate the public on the true costs of healthcare, and provide “standardization instead of a chaotic Wild West” situation where different organizations are all asking for something different from physicians.
On the other hand, he is concerned about reducing everything to a number as medicine adopts more big business practices.
“Our main focus is the patient in front of us, but big organizations look at large populations over time and ask, ‘How did we do last year? How did we do last month?'” Swenson said. “But we don't just provide a service. There's judgment involved, there's the patient-physician relationship, empathy and taking care of people in difficult times.”
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