What you don't measure, you can't improve. But if you measure everything, you are at risk of sending false signals about what's important and what's not.
This is especially true when measuring healthcare quality, a movement that began in earnest in the late 1990s and now has exploded into a mini-industry. Quality measurement helps determine physician and hospital reimbursement, Medicare star ratings, insurer networks and more.
The field has long been criticized for emphasizing process measures over outcomes measures. Why continue asking whether you gave an aspirin to every heart attack patient that arrived in the emergency room when what really mattered is whether that patient walked out of the hospital alive?
The Government Accountability Office piled on in a report last week that chastised the measurement industry for its dispersed decisionmaking and lack of coordination. Private insurers each have their own reporting requirements, and those are different from government agencies.
Each uses different measures and data collection methods, the report noted. And in some cases, payers allow providers to determine what they'll report to accommodate the fact that different providers have different electronic health records.
Payers have traditionally depended on groups such as the National Quality Forum and the National Committee for Quality Assurance to approve measures. But those groups operate through a stakeholder-driven, consensus-building model, which makes it almost impossible for them to make the difficult choices that might offend one of their constituencies—whether its payers, hospitals, physician groups or consumers.
The result is cacophony.
A recent report that looked only at 48 state and regional healthcare quality measurement programs—primarily used by Medicaid agencies—identified “a staggering 1,367 (measures) in use.” Medicare's proposed Merit-based Incentive Payment System, or MIPS, whose final rule must come out by Nov. 1, included about 300 potential measures that physicians could use as part of their payment formula—and they get to choose which ones they'll use.
While the mini-industry behind measurement has heard the criticism and responded, changes are coming at a snail's pace. The CMS, working closely with America's Health Insurance Plans, convened a Core Quality Measures Collaborative to focus on outcomes, not process-based measures, which have little meaning for consumers or payers. Their goals included establishing a more limited set of reporting requirements for all government and private payers.
Clearly, a common understanding of what's important to measure would go a long way toward limiting the administrative burden on reporting organizations. According to a recent survey in Health Affairs of physician practices that are members of the Medical Group Management Association, practice staff spent an average of 15.1 hours per week for every employed physician collecting and reporting various measures.
But the Collaborative's work has received little backing from Congress. The Medicare Access and CHIP Reauthorization Act included a scant $15 million a year to support work in identifying core measures that would paint a more accurate picture of provider quality, and serve as benchmarks that providers could use on their journey to better outcomes.
In their despair, some thought leaders in the field have called for the equivalent of a Securities and Exchange Commission to establish rules of the road for creating and reporting quality measures. But others are skeptical about launching another government healthcare bureaucracy. It makes more sense, in their view, for the government to invest in rigorous research to determine the most significant measures in each specialty. Public and private payers could then adopt those common reporting standards and tie them to payment policy.
The best path forward would be a fit subject for hearings in the next Congress. Given the lax reporting standards that the CMS has created for MIPS to dampen physician opposition, it's now clear that improving the nation's healthcare quality reporting system needs to be near the top of the next administration's agenda.