The newest movement in healthcare is the quest for “value,” paying for the best outcomes at the best price. Nearly everyone agrees this is a good idea.
But our $3 trillion delivery system is not built on ideas, it's built on dollars, most of which still come from fee-for-service. So “value” has its opponents.
Nonetheless, the value movement is progressing rapidly, and will succeed where prior reforms stalled. Its momentum comes from three main triggers.
The first trigger is the force of law. “Value” is enshrined in the Affordable Care Act, with the CMS now tying almost 6% of hospital Medicare reimbursement to performance and Congress replacing the sustainable growth-rate system with a value-based formula.
The second trigger is the market. Already 40% of commercial payments may be linked to value—surging from 9% a year earlier. Consumers are paying more out of pocket, so they are sensitive to value as well.
The third trigger is measurement. Thanks to big data, good research and nimble leadership by the National Quality Forum and others, we can defensibly measure the quality side of the value equation.
Value opponents can't do much about the first two triggers: Try convincing a politician or a restless market to exempt healthcare from accountability. But the third trigger, measurement, does offer opportunities to delay the move toward value.
As a result, never before have we seen such emotional fervor, sometimes outright vitriol, in negotiations about measures. At the NQF, provider stakeholders now segregate “higher stakes measures”—those affecting provider pocketbooks—for especially raucous debate. (For patients, all measures represent the highest stakes imaginable).
Advice to clinicians: Beware of arguments made in your name to denounce measures. Many of those arguments might depress you—a risky proposition in an era when nearly 50% of physicians report burnout and a third of nurses want to quit. Two recent publications that ostensibly discredit specific measures illustrate this hazard.
The first, in the journal BMJ, questioned the “standardized mortality ratio.” Through chart review of inpatient deaths in the United Kingdom, the researchers observed that the vast majority of those deaths (85% to 95%) did not directly result from a “problem” in care, clinician error or omission. So the researchers conclude clinicians have little impact on the standardized mortality ratio, and it's unfair to hold them accountable for it.
Here's the damaging assumption in the study: The only way physicians or nurses improve patient survival is by avoiding killer mistakes. Surely clinical skill impacts mortality more than that.
Another recent study in JAMA similarly minimized the impact of clinicians. The researchers compared how U.S. hospitals did on a tested and validated composite of safety measures used by the CMS to determine how they performed on two untested and unvalidated composites the researchers invented.
One of the invented composites credits certain hospital characteristics toward its quality score, such as Level 1 trauma or teaching status, while the other credits quality processes.
The study finds that some hospitals excel on the invented quality composites but fail on the CMS safety composite. Illogically, the researchers conclude that the CMS safety composite is flawed. One might just as well conclude that the researchers' composites are flawed.
Ultimately, this paints a dismal portrait of the potential of individual clinicians. If you practice in a hospital that's not a teaching hospital with a Level 1 trauma certification, then—try as you might—you will not deliver the highest-quality care. If you excel on some but not all measures, the measures are wrong and you don't excel at anything.
While thoughtful critiques of measures are important, politically motivated denial of measures is destructive in unintended ways. It often follows the unfortunate pattern of these studies in assuming that providers perform at essentially the same level of quality and/or their actions can't be linked to patient survival or healing. If all physicians and nurses believed their work had such modest impact, the burnout problem might be even worse. People who choose a career in healthcare tend to be bright, competitive and caring, and they won't last long if they believe their talents make virtually no difference.
I salute the many physicians and nurses who courageously insist on transparency and accountability for their patients. For them, the patients come first, not some institution's finances or politics. Clinicians have a choice: Seize the momentum of the value movement to finally get rewarded for excellence, or recite tired political talking points that minimize your life's work. Value will succeed either way, but it will be so much better infused with the knowledge and gifts of practicing providers.
