Moving from Volume to Value: Part III

This article is the third of three parts.

Why is it Important to Measure Outcomes?

Health outcomes are the results of care delivered. The goal of healthcare is to improve patients’ health and their health-related quality of life. The goal of measuring health outcomes is to ascertain the best approximation of actual health and health-related quality of life that is affected by interaction with the healthcare delivery system. Without measurement and data collection, it is impossible to know whether the first goal—health—is being attained.

Getting a full picture of the quality of healthcare is important, but when it comes to assessing the value of care, outcomes are where the rubber hits the road. This is the measure by which we will be judged by our patients. Quality of healthcare is evaluated by three different types of measures: structure; process; and outcomes. Assessment of structure and process measures provides the understanding of what is happening during the course of care to affect outcomes or to peek under the hood and see the reality of the healthcare that we deliver to our patients. However, the end goal of assessing these three components is to improve health outcomes, and the reason why we even consider the other types of quality measures. Structure and process measures are a means to an end—better outcomes, which means better health for our patients.

Large-scale healthcare policy decisions are centered on achieving the Triple Aim in healthcare: (1) improving the patient experience; (2) improving the health of populations; and (3) reducing the per capita cost of healthcare.(1) Assessing and understanding health outcomes is integral to all three aims of improving healthcare .

Desirable outcomes are what patients care about and the ultimate goal of practicing medicine for physicians. Patients are less concerned about the process of how you practice medicine, and more concerned with how that practice affects them and their health. When choosing a hospital, a patient is less likely to care about the processes in place to prevent infection, and more about their own probability of acquiring an infection during their stay.

Outcome measurement is an essential part of the transition from volume- to value-based healthcare; without knowing the outcomes, we do not know what we get for the money that is spent on care. Insurers and employers are no longer blindly paying for all care delivered even though it appears on a fee schedule. Instead, they are relying increasingly on measuring outcomes in new payment models.(2) Pay-for-performance is one such model, but Accountable Care Organizations, shared savings plans, and bundled payments(3) also are examples of emerging models to assess and improve value—and all require measuring outcomes.

Outcome measures are taking a larger role in overall quality assessment.

As health plans and federal payers (e.g., Medicare) are requiring data on process and outcomes, it feels daunting to record these details. It may feel as if there are endless hoops of paperwork and uncompensated time and energy, rather than a focus on patient care. However, it is important to see that recording outcomes is for the improvement of medicine and for individual physicians so that they can provide the best possible care. Medicine itself, while not perfect, is based on science and evidence, and assessing the practice of medicine should be no different. Decisions regarding what to do for patients and where to allocate resources, from single clinics to national policy, are guided by previous outcomes. These decisions must rely on solid verifiable evidence.

Physicians choose a course of care for their patients based on the probability that any of several different outcomes may occur. Without knowledge of where one is performing poorly or not as well as one should, how can one ever hope to change? The question then becomes what outcomes matter, and how should they be measured and reported?

What Outcomes Should Be Measured?

Currently, most of the quality metrics that are taken into account by policymakers, payers, and accreditors, such as The Joint Commission, are process measures. However, as the age of quality assessment evolves, outcome measures are taking a larger role in overall quality assessment.(4) As the evidence base in quality assessment grows, the process measures that remain in use will likely be those that are most clearly linked to actual outcomes.

Part of the pushback from physicians in measuring outcomes stems from the burdensome nature of the task. To ease the work, administrators and payers would do well to select from a larger body of goals and then prioritize a few actionable areas as early targets. This starts with a common understanding of what is meant by outcomes.

Defining health outcomes may seem intuitive—the effects of care on the health status of patients and populations(5)—but this can encompass a broad variety of measures. In the past, outcomes consisted of survival, length of stay, or readmission rates. Those metrics certainly are important, but now it will be necessary to go beyond those basic outcome measurements and start recording and documenting additional data that will clearly demonstrate superior and meaningful outcomes.

In considering which outcomes are meaningful, you need look no further than the patient sitting in front of you in the exam room. In the past, outcomes were measured from the provider perspective, and most healthcare organizations have been provider-centric rather than patient-centric. For example, doctors treating kidney stones might have been asked what percentage of patients were stone-free at 30, 90, and 180 days following a procedure to remove kidney or ureteral stones. However, the measurement of success arguably should include the patient’s perspective of success, with questions like, “What percentage of patients are free of pain?” or “What percentage of the patients can return to gainful activity at 30 days?” and “What percentage are able to remain stone-free?”.

Michael Porter(6) defines a three-tier hierarchy of outcomes that includes health status as the first tier, the process of recovery second, and the sustainability of health as the third. His examples include five-year survival among cancer patients (tier 1), time to return to work following hip replacement (tier 2), and incidence of second primary cancer (tier 3). Outcomes from one tier may influence those in other tiers. This can provide a useful framework for considering the broad range of outcomes and promotes consideration of the entire process of care delivery.

Value-based care will be the emphasis, and value depends on what matters to patients and how they perceive it. What matters to patients usually revolves around their quality of life, and may include things that physicians do not normally consider, such as, “How long did patients have to wait before being seen?” and “Did someone from the doctor’s office follow up regarding the results of a blood test, x-ray, or other lab work?”. Not only can these nonclinical metrics matter to patients, but they can influence health status outcomes. If a patient with a hernia has to wait three months for an appointment, the clinical outcomes may be negatively affected in addition to having a dissatisfied patient.(7)

Oftentimes, outcomes are organized around provider specialty. However, patients usually are more concerned about the full course of their care for a condition, rather than the isolated care received from a single provider. As Porter points out, in primary care settings, patient populations (e.g., people with diabetes, young women), rather than specific conditions, may be considered.(6) Assessing outcomes by condition, rather than just by medical specialty, can serve patients’ goals, but payers also pay for the whole patient, and not a single provider.

As an example, patients with chronic hip or knee pain may need to see an orthopedic surgeon for consideration of a total joint replacement. But their care will involve multiple other providers, perhaps including a cardiologist, physical therapist, pain management specialist, as well as nursing staff. In order to measure the outcomes that matter to the patient, the full process of care should be considered, by condition, and care teams may help insure the best clinical practices and outcomes for the whole patient.

When teams are involved in patient care, it is not just the surgeon who is held accountable for the outcomes that are deemed important to the patient. Some providers may welcome this more encompassing view of outcomes, as one common complaint is that the results of care are dependent on far more than just what one provider can control. However, to ensure good outcomes, these different providers must work in a coordinated manner towards a common goal determined by the patient.

The International Consortium for Health Outcomes Measurement is developing standardized outcome measurement for disease categories, and has started with those that encapsulate the greatest disease burden. These sets are organized by disease category, rather than by provider specialty. Specific measures will continue to come from specialty practice guidelines, but these cannot be the only measures assessed.

In an era of information overload, it can be useful to start by focusing on outcomes for conditions of high disease prevalence and burden—cancer, diabetes, and heart disease. Another target for outcome measurement is those things that are the easiest to assess and measure correctly. To this end, if an outcome of interest is not readily available through the electronic medical record or other easily recorded place, then a proxy measure may be used until a better alternative is available.(8) For example, it might not be possible to assess prevalence of coronary artery disease, but preventive factors, such as cholesterol values, are accessible. Additionally, outcomes measures should be limited to things that can actually be affected by healthcare, and not those that depend on patient choice or factors completely out of the clinical realm of control.

How Should Outcome Measures Be Used?

Outcome measures can be useful to both insurers and patients to help distinguish providers of high- versus low-value care. Payers can offer incentives to providers to improve outcomes by tying them to reimbursement schedules. Reported outcomes can be incorporated into public “report cards,” or some other type of record, making the information available to patients and allowing them to make more informed choices about what provider they visit. In fact, the CMS is already using outcomes for both efforts, largely in hospital setting and for specific conditions.

Results on the use of payment incentives and public reporting in actually improving health outcomes are mixed.(9, 10) Regardless, there is little indication that either is going away anytime soon. Additional work is ongoing to improve both efforts so that the actual goal of better outcomes can be achieved.

Although reimbursement changes and public reporting may seem frightening at first, the goal is to improve patient care and patient health. Providers can accept these assessments as a means to improve their own practices and to provide better care for their patients, rather than as a pejorative commentary on their work. To the extent that this can be achieved at the same or perhaps lower cost as the usual course of care, everyone wins.

Getting Started in Measuring Outcomes

The first question on how to assess outcomes is: where does the information come from? Often data points already assessed for many patients can be applied, such as blood pressure for hypertensive patients, hemoglobin A1C levels for those with diabetes, and cholesterol levels for patients at risk for heart disease. Claims submitted in billing and medical records contain large amounts of useful information. Measures related to patient satisfaction or timeliness of care would require additional efforts to assess, which may be administered or paid for by outside agents such as accreditors and insurers when they want to track that information.

The end result of improved outcomes should make the efforts worthwhile.

A common worry is that patients with complicated medical conditions can make providers appear to be providing worse care than their peers with a different case mix. These patients should not be excluded from measurement, but appropriate risk-adjustment strategies can be employed to account for different health statuses. Another concern is that reporting may take time away from patient care. As standards change, it is important to make sure that efforts made to assess one type of outcome are not wasted in assessing the next one in the pipeline. In both cases, it may be helpful to keep the end goal of improved patient care and satisfaction in mind. Let’s be honest, change does not often come without some growing pains, but the end result of improved outcomes should make the efforts worthwhile.

The benefits of outcome measurements are that they prevent overuse, underuse, and misuse of healthcare services, and also enhance patient safety. Outcome measurements also drive innovation and research and development, which enhances disease control and improvement in the patient’s quality of life. By tracking outcomes, payers and providers are held accountable for providing high-quality care. When the outcomes are made available to the public or are transparent, patients can make informed choices regarding their care and can select providers who have stellar outcome data. Also, when outcomes are truly measured, there is competition among payers and providers, and with increased competition, prices are certainly going to decrease. Finally, patients with improved outcomes are more engaged in their care, more committed to treatment plans, and more receptive to medical advice.

Providers may feel resistant to measuring outcomes. It can be a chore to do so accurately, and at times difficult to see the benefits. The oath that each physician takes upon graduation is “Primum non nocere,” or “First do no harm.” Every physician we know believes that he or she does an outstanding job caring for patients. However, eschewing outcome measurement, on these and other grounds, is somewhat akin to 19th-century obstetricians taking offense at being asked to wash their hands to prevent infection in women after childbirth.(11) It is time for us to document this outstanding care, or its outcomes.

Summary

The end results of outcome measurement identify patterns and trends and provide the healthcare profession with the effectiveness, or lack of effectiveness, of our medical interventions. By recording outcomes we can maximize favorable outcomes, and can minimize poor ones. Obtaining and recording outcomes enables us to demonstrate the quality of care and hopefully will lead to improved medical care.

Outcome measurement plays a pivotal role in medical decision-making for physicians, payers, and patients who are searching for high-quality medical care. It is outcome measurements that quantify components of quality such as clinical outcomes, patient satisfaction, and functional status of our patients.

References

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2. Burwell SM. Setting value-based payment goals-HHS efforts to improve U.S. health care. N Engl J Med. 2015;372:897-899. doi:10.1056/NEJMp1500445.

3. Rosenthal MB. Beyond pay for performance—emerging models of provider-payment reform. N Engl J Med. 2008;359:1197-1200. doi:10.1056/NEJMp0804658.

4. Centers for Medicare and Medicaid Services. Hospital value-based purchasing. September 2015. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Hospital_VBPurchasing_Fact_Sheet_ICN907664.pdf . Accessed November 7, 2017.

5. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260:1743-1748.

6. Porter ME. What is value in health care? N Engl J Med. 2010;363:2477-2481. doi:10.1056/NEJMp1011024.

7. Katz C, Baum N. Moving from volume to value: part I. J Med Pract Manage. 2018;33:271-275.

8. Proxy Measures. Duke Center for Instructional Technology. http://
   patientsafetyed.duhs.duke.edu/module_a/measurement/proxy_measures.html. Accessed November 7, 2017.

9. Jha AK, Joynt KE, Orav EJ, Epstein AM. The long-term effect of premier pay for performance on patient outcomes. N Engl J Med. 2012;366:1606-1615. doi:10.1056/NEJMsa1112351.

10. Van Herck P, De Smedt D, Annemans L, Remmen R, Rosenthal MB, Sermeus W. Systematic review: effects, design choices, and context of pay-for-performance in health care. BMC Health Serv Res. 2010;10:247. doi:10.1186/1472-6963-10-247.

11. Best M, Neuhauser D. Ignaz Semmelweis and the birth of infection control. BMJ Quality & Safety.2004;13:233-234. doi:10.1136/qhc.13.3.233.