Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect

Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect


There’s a debate in the United States about whether the current measures of health care quality are adequate to support the movement away from fee-for-service toward value-based payment. Some providers advocate slowing or even halting payment reform efforts because they don’t believe that quality can be adequately measured to determine fair payment. Employers and other purchasers, however, strongly support the currently available quality measures used in payment reform efforts to reward higher-performing providers. So far, the Trump administration has not weighed in.

The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts for the following three reasons:

Even imperfect measurement and transparency accelerate quality improvement. One set of measures often questioned is the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Indicators (PSIs) used by the Centers for Medicare and Medicaid Services (CMS) and others in value-based payment programs. These indicators measure surgical complications and errors in hospitals, which is critical given that one in four hospital admissions is estimated to result in an adverse event.

PSIs remain among the most evidence-based, well-tested, and validated quality measures available. CMS uses many in its value-based purchasing programs. Use and reporting of PSIs through AHRQ’s Medicare Patient Safety Monitoring System has measurably improved quality. For instance, CMS reported a reduction in inpatient venous thromboembolisms (VTEs) from 28,000 in 2010 to 16,000 in 2014, meaning that 12,000 fewer patients had potentially fatal blood clots in 2014.

In addition to using quality measures in payment programs and for quality improvement, making measures public is key to accelerating change. “If transparency were a medication, it would be a blockbuster,” concluded a multi-stakeholder roundtable convened by the National Patient Safety Foundation’s Lucian Leape Institute in 2015. The foundation’s report cited the Leapfrog Group’s first-ever reporting of early elective delivery rates by hospitals in 2010, which galvanized a cascade of efforts to curtail the problem and thus reduce maternal harms and neonatal intensive care unit (NICU) admissions. This was effective: The national mean of early elective deliveries declined from a rate of 17% to 2.8% in only five years.

Using measures improves measurement. Providers and health care executives sometimes point to flaws in their medical-record and billing systems as a main reason certain measures shouldn’t be used. As they see it, their performance on the measures isn’t the issue; it’s their medical records or billing coding that’s the problem. They believe these internal systems should be fixed before measures that use this information are applied in payment formulas or public reporting.

But use of these measures is often necessary to break logjams in correcting the health care industry’s long-neglected weaknesses in data-quality control. Indeed, many of the nuanced imperfections providers criticize were only uncovered by public reporting, which revealed unexpectedly poor performance for some providers, prompting them to research the medical records to find out the reasons.

Even rough measures make a big difference when they are publicly reported. For instance, New York State’s release of surgical mortality data for coronary artery bypass grafting (CABG) procedures jump-started the movement to define and more carefully collect much stronger measures of CABG outcomes, and today we have many advances in cardiac care and its measurement.

In the New York example, the success in generating ever better measures — and more importantly, achieving ever better outcomes for patients — came about because providers made the changes that saved lives, and they deserve all the credit for that. A thorough, respectful process for building scientific and stakeholder consensus around measures has been orchestrated by leaders like the National Quality Forum (NQF) and the National Committee for Quality Assurance (NCQA). Purchasers are committed to partnering in the development and refinement of excellent measures while we advance transparency and payment reform alongside that work.

Returning to fee-for-service is not an optionGiven the widely acknowledged waste, heavy costs, and quality-of-care issues produced by the fee-for-service system, the fact that there are rough spots on the road to value-based payment is hardly a justification for slowing down reform. If converting to a more sensible payment system were easy, it would have been done a long time ago.

The change to performance-based payment and market share requires tenacity and patience. Current quality measures may have rough edges, but stakeholders have worked hard to steadily improve their validity and reliability. Employers and other purchasers, such as those involved in our organizations, must work with forward-thinking colleagues in the health care system to continually improve the measures that publicly signal value. It will be a learning process for providers and purchasers as long as we’re guided by a spirit of transparency.

Whatever the risks of imperfect measurement, America’s first priority must be to eliminate avoidable suffering, mortality, and waste in its uniquely costly health care system. We hope that the Trump administration and lawmakers on both sides of the aisle will continue to recognize what our members see clearly: delaying payment reform is not an option.

This post first appeared in the Harvard Business Review

Leah Binder is is the president and CEO of the Leapfrog Group.

Brian Marcotte is the president and CEO of the National Business Group on Health.  

Annette Guarisco Faldes is president and CEO of the ERISA Industry Committee (ERIC), a national association that advocates solely for large U.S.employers.

Michael Thompson is the president and CEO of the National Alliance of Healthcare Purchaser Coalitions. 


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28 Comments on "Sorry. Health Care Reform Can’t Wait for Quality Measures to Be Perfect"

Nov 18, 2017

Hello, Thanks alot For sharing this wellness information with us. I’m looking to get more information about health from your experience.

Nov 18, 2017

Hello, Thanks alot For sharing this wellness information with us. I’m looking to get more information about health from your experience. maybe you will be interested to read this article too: Wellness Care

Barry Carol
Oct 17, 2017

In a given large group practice, some doctors practice more defensive medicine than others without any identifiable effect on patient outcome but at higher cost to the healthcare system.. Practices that own their own imaging equipment order significantly more imaging studies than those that don’t. It drives revenue for the practice and increases healthcare costs but doesn’t effect patient outcomes at the end of the day. How would we even know any of this without some attempt to measure and track individual physician practice patterns?

By the way, physicians may see patients as their customers, not insurance companies and corporations. Insurers, by contrast, see employers as their customers, not patients, at least for the most part, because its mostly the employers who are paying the health insurance premiums on their employees’ behalf.

Oct 11, 2017

kip, I could not have said it better myself. what a beautiful comment. This is yet another blatant attempt to “ignore the facts” because buzzword care has to be better than the devil FFS. MedPAC has seen the light recently though their solutions are very suspect, still including penalties if you don’t play games with untested unproven programs. As a front line MD, I can tell you that we are living a damaged generation of MDs from all these rapid fire puffery language value programs that penalized the best of us. We are in very big trouble in medicine right now, with the vast majority burned out, and looking for ways to get out. The crisis is now inevitable with a real shortage of practicing MDs

Res Morgan M.D.
Oct 10, 2017

I was hoping you’d comment. We share the same fantasy.

Thank you!

Steven Findlay
Oct 10, 2017

Cheers for this post. Could not agree more with the main thrust. Thanks to Leah, Brian, Annette, and Michael for a clear and crisp statement. Doing Q&P measurement right has proved much more challenging than we all thought it would be 15 years ago. But that can not be allowed to scuttle the aim nor undermine the task, nor be an excuse for pausing or delay. It remains to be seen if the current leadership at CMS, including Trump-appointed crew, will disrupt the ongoing initiatives and process. Indicators are mixed at this point. My only quibble would be that the quality measurement institutions involved in this effort–most notably the NQF–don’t function at peak performance themselves — something not addressed in this short post.

Oct 7, 2017

Hmmmm! Unstable HEALTH begets Unstable HEALTH. In spite of our long-standing acknowledgement of “homeostasis,” we have no well established means to accurately measure its resiliency at any one point in time. The engineering folks have developed statistical means to assess the resiliency of control systems that have been long-ignored in the biological world. Its true that the non-linear, random character of HEALTH makes it difficult, but not impossible. Think Fourier Transform formulated in 1948. The test conditions would most likely involve a defined, randomized low level influence on a basic function, such as fluid intake.
Kudos to Dr. Palmer for the reminder!


Oct 7, 2017

Sorry. No matter what you call them, Quality Measures will kill Health Care.
By the way, as someone pointed out, the chaos that surrounded the treatment of the Las Vegas shooting victims surely precluded any attempt at following quality measures. Nonetheless, I’m sure they received the best care that could be given by those care givers in the overloaded hospitals.

William Palmer MD
Oct 6, 2017

I’m wondering if what we are really doing in health care is actually causing ‘health’ to be increased….whatever that is.

I see health as the ancestral quality of our DNA, the absence of as many mitogens as possible, the faithfulness of our mismatch repair genes, and the accuracy of our RNA polymerase in reaching down into this dense ball of compressed string-like DNA [if a cell is the size of a tennis ball, the DNA is 23 miles long and jammed into its nucleus with barely any room for cytosolic proteins] and reading its exons precisely and fast. In other words, it is tempting to see ‘health’ as the excellence of the biological machine. Just by making the muscles work or fat to be burned up in some fitness program also doesn’t exactly bring excellence to the machine. Crispr-Cas9 editing, contrariwise, gives us a glimpse of what might be true biomachinery improvements.

What we do in doctoring is, rather, fix things….and pretty crudely. You don’t add excellence to the machine if you merely bring a metabolic fuel–glucose–to normal levels or cause the smooth muscles of the heart and arteries and arterioles to work acceptably…as in hypertension therapy. Of course, the patient feels better and may live a little longer but isn’t this like putting new iron shoes on a horse? We haven’t made a Maserati.