Healthcare improvement stalls at quality measures

ABSTRACT: Experts from health systems, government, and the insurance industry offer insights into how quality is defined and measured in medicine today.

Very few people will put up a fight against improving quality, but when it comes to paying for quality in healthcare, things get complicated. The need for a definition of quality and a reliable means for measuring it soon muck up the works. Just as it is reasonable to expect that providers be paid more for delivering high-quality healthcare, so it is essential to distinguish high-quality care from lesser quality care.

"We teach our residents and our fellows that it is all about quality. But the hard question is to define what quality is," said Steve Schwab, MD, interim chancellor, University of Tennessee Health Science Center and executive dean of the University of Tennessee College of Medicine. "It is not just what the patient perceives as an atmosphere that is conducive to getting better, but also the hard measurement of an outcome."

Dr. Schwab, along with other policy experts, gathered at the 2009 Mid-South Cancer Symposium in Memphis to offer insight into how quality is defined and measured in healthcare today. The symposium was hosted by the University of Tennessee Cancer Institute.

Hailing from all walks of healthcare–health systems, federal government, academic centers, and policy groups–these roundtable participants put forth some compelling ideas: That patients' definitions of good care are as important as those of medical entities; that quality is the answer to holding down costs; and that healthcare information technology may prove to be quality's greatest partner.

The trouble with surrogate measures

Defining quality depends on perception, which varies with perspective. The patient whose first-person experience involves an intuitive sense of improvement contrasts starkly with the experience of physicians, hospital administrators, and payers whose training leads them to rely on scientific methodology to define improved health.

According to Dr. Schwab, evidence of success often boils down to the most basic of common denominators: Survival. This binary outcome distinguishes only between those who live and those who do not. But survival as an outcome is too basic for most accountings and that leads to surrogate measures, stated Dr. Schwab. And this is where the trouble begins.

An example of these tricky surrogates is hemoglobin A1c, a nationally recognized, standardized tool for assessing blood sugar control in patients with diabetes. "But these measures are limited and they are just point-in-time measures, as opposed to true longevity types of data," said James D. Cross, MD, head of national medical policy and operations for Aetna in Hartford, Conn. Dr. Cross oversees teams charged with developing and maintaining clinical policy as well as reimbursement and coding methodology.

Healthcare professionals fill the void by focusing on evidence-based processes, according to Peter Bach, MD, an associate attending physician at New York's Memorial Sloan-Kettering Cancer Center. These processes, the cogs that make the wheels of an institution go around, can be quantitatively measured. Does an institution have the right number of nurses per bed? Are procedures in place for patient monitoring?

This focus is shared by the Centers for Medicare and Medicaid Services (CMS), which tries to build a quality framework for healthcare by concentrating on the structure of healthcare systems and the process of handling patients, said Dr. Bach, who served as a senior advisor to the CMS Office of the Administrator from 2005 to 2006. Dr. Bach states, "These are used in order to modify payment, as CMS tries to move away from just paying for services to paying for something of value in healthcare."

Quality: The three-legged stool

So quality becomes a three-legged stool of outcomes, process, and structure. For lack of more precise measures of outcomes, government has chosen to focus on the latter two, most clearly in its decision to encourage the adoption of information technology. Simple metrics emerged that not only define quality but support the decision whether to provide reimbursement. An example is the current administration's decision to pay doctors for e-prescribing.

Healthcare IT is a transitional development, one that embodies process yet moves beyond it to embrace structure. Thomas G. Lundquist, MD, lauded the adoption of IT as the means for exchanging data at a meaningful level. But solving the problems surrounding healthcare today, particularly the improvement of quality, requires more than just technology.

"It has to be predicated on trust among government and private payers, hospital systems, practitioners, and community groups," said Dr. Lundquist, vice president of performance measurement and improvement at Blue Cross-Blue Shield of Tennessee in Chattanooga.

Trust comes from adhering to the spirit of healthcare, not just the pieces that lend themselves to measurement. Some of that requires reinvention. "The idea is to focus on the patient to make sure the outcome is not only clinically relevant but relevant to the patient and family," Dr. Lundquist said.

The patient knows best?

A knee-jerk reaction by patients is to want the best care they can get, regardless of cost, according to Mohammad Jahanzeb, MD, national director of care guidelines for Aptium Oncology and medical director for the Lynn Cancer Institute in Boca Raton, Fla. "They have been paying premiums to the insurance company and they don't care if the treatment is going to cost $50,000," he said.

But economics may enter the picture unannounced, particularly if patients have to foot a substantial part of the bill. Even when an insurer picks up 80%, the remaining 20% copay can be financially crippling.

"In making healthcare decisions, patients need to consider their out-of-pocket expenses. And we have to look at them in realistic terms," Dr. Lundquist said. For instance, a 45-year-old man with five children who saved money for his kids' college funds will consider out-of-pocket costs differently than the 65-year-old unmarried man who had been saving money for his retirement, he explained. When quality is defined by patients, healthcare providers have to consider the issues relevant to those patients.

"We have to bring the diagnostic information and the treatment odds [for success] into a package that the patient can understand and use to make informed decisions," Dr. Lundquist said. "And we have to make sure that our own biases as physicians are not leading them down a path they may not have chosen if they had all the information."

Insurers get a better picture of diagnosis and treatment patterns than most participants in the healthcare process, according to Dr. Cross. Aetna's data cover data on all the elements of a patient's care. Claim, pharmacy, and lab data are provided, along with a health risk assessment derived from the patients' themselves. Aetna has built a proprietary "Care Engine" for comparing these data to peer-reviewed literature, he said.

"Millions and millions of pieces of data run through this 'Care Engine,' which spits out what we call 'care considerations' to both providers and members," Dr. Cross said. "It tells us what is happening with that patient and what we should be doing for that patient. Are they missing something from their treatment, or are they getting the wrong things? Are there preventive things they should be doing?"

High quality equals lower costs–most of the time

Controlling medical costs drives much of the concern over premiums and the self-assessment of performance by insurers, said Dr. Cross, who contends that raising quality is the answer to holding down costs. "[At Aetna], we pretty much have committed everything to the idea that quality care is the most cost-effective and efficient way to deliver medical care. If we want to make that happen, we have to be in sync with the practicing community and the employers who pay us to manage their healthcare dollars."

To that end, Aetna promotes preventive care and evidence-based treatments administered in the most efficient manner possible. The goal is to make sure that the money spent on healthcare goes to the right place, he said.

One way to boost quality is by eliminating the wide variance among practices through physician adherence to guidelines. There is too much variability, not only in the choice and administration of treatment but also in patient testing, Dr. Cross stated.

For instance, patient workup often lacks basic information, making it difficult for payers to assess the quality of care. It is not uncommon to find that payers do not know the stage of the cancer that is undergoing treatment, said William T. McGivney, PhD, CEO of the National Comprehensive Cancer Network.

One concern is that the quest for quality will create expenses that healthcare providers cannot afford, said Donna Abney, executive vice president of Methodist Le Bonheur Healthcare in Memphis. Ms. Abney estimates that the Methodist Healthcare Foundation, where she is responsible for information systems, strategic planning, physician services, and marketing/communications, has invested close to $100 million in an electronic medical record system.

"It is not hard to imagine that cost and benefit at some point may get out of whack, but right now I think we're OK," she said. "To date, our investments have made us better and smarter, and I think more scientific. Because of that, we have been able to digest those added costs and continue to meet the needs of the community in the way that we are chartered."

The key to improving quality, as well as measuring it, may be healthcare information technology. HIT can serve as a collection point for patient information and the means for distributing those data to the relevant caregiver. These systems can interconnect the various disciplines from testing to treatment to billing, providing the means for measuring compliance to clinical and efficiency standards, while identifying elements in the care process that can be improved.

In his vision of an electronic medical record system, Dr. Bach describes how a desktop computer screen displays information from the surgeon and pathologist as a patient walks into the office of a radiation oncologist. The pathways and clinical decision support interface pop up, the appropriate doses for regimens are calculated, and the correct drugs are listed for e-prescription to either the onsite specialty pharmacy or a mail-order pharmacy.

Patients are given access to all this information and anything else they need to weigh their choices about treatment, he said, "and the doctor will get to talk to the patient about what is going on in the way that we were all trained to do. The word 'doctor' is derived from the word 'to teach,' not the words 'to bill.'"