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. 


28 replies »

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  3. 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.

  4. Thanks for your posts, and subsequent posts. We need more untested/unproven quality metrics like we need more untested and unproven board certification requirements (ie MOC).

  5. Art Caplan may actually have the best insight into the problem.

    In 1981, he co-edited an excellent volume of essays about the concept of health and disease (http://amzn.to/2zfzKIF) . The range of opinion about what those terms mean was edifying. In 2004, he co-edited another excellent volume on the same question (http://amzn.to/2gwO2NE) . Needless to say, not much progress had been made in the interim, and not much progress has been made since then. We are as confused now as we were then.

    So why do we have to blame either the experts or the doctors? Why not blame both? How can doctors justify receiving a medical license from the state when they are incapable of defining the main object of their profession? How can experts justify offering solutions to health care when they are equally incapable of articulating what the endpoint of their efforts must be?

    I made a brief editorial comment in that regard a few years ago. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709242/) I quoted CS Lewis for saying ““health is a great blessing, but the moment you make health one of your main, direct objectives you start becoming a crank and imagining there is something wrong with you.”

    Perhaps we are all past beyond the point of being called cranks…

  6. This comment by Binder et al. reveals ignorance born of arrogance. They tell us they represent employers, which is supposed to cause us to sit upright and listen to them opine about medicine. And they would have us believe that the only opposition to “quality” measurement is from “some providers.”

    Let me start by announcing I am not a health care professional. My training is law and economics. Ergo, my contempt for Binder et al.’s arrogant piece cannot be written off as the self-interested ranting of a greedy “provider.”

    When I find some time, I will write a longer comment about Binder et al.’s diatribe. Here I’ll note two of its more important defects — the language is inscrutable, and the authors reveal a distaste for evidence that is typical of managed care advocates — and then I’ll suggest a remedy for these defects that I often dream about.

    First, this article illustrates the role that managed-care-speak plays in making a productive debate about managed-care nostrums impossible. Binder et al. tell us we should “support the movement away from fee-for-service toward value-based payment,” and we should join them in condemning “some providers [who]advocate slowing … payment reform efforts.” I realize all of you who follow the meandering health care reform debate have heard these vacuous phrases a million times, but once in awhile those of us outside the managed-care movement would like to interrupt and ask: What the hell does “movement away from FFS toward value-based payment” mean? Note all the flabby words — “away,” “toward,” “value-based,” “reform,” “efforts.”

    Binder et al. don’t tell us what they mean. We’re just supposed to know what their flabby lingo means. The implied attitude is, “If you have to ask us what our manipulative jargon means, you’re too stupid or too blinded by self-interest to participate in this debate with enlightened people like us.”

    Second, this article illustrates the half-century-old practice within the managed care movement of never backing up an opinion with research. Binder et al. failed to cite a single peer-reviewed paper documenting their unarticulated assumption that “quality” measures in use today do more good than harm, and, even worse, they ignored a large body of peer-reviewed literature demonstrating that nostrums often called “pay for performance” (P4P) and “value-based purchasing” (VBP) have at best mixed effects on quality, raise costs, exacerbate racial and income disparities, burn out doctors, and accelerate the consolidation of the insurer and medical sectors.

    And now for a little fantasy of mine about how to fix this problem. When I’m czar, I will roll back all “quality” reporting on doctors and hospitals that was never shown to be safe and effective before it was unleashed on society, and I will subject Binder and others who promote “quality” reporting to quality reporting. I will insist that some third party review every article written by those who promulgate P4P and VBP and grade them according a criterion I will call “evidence-based health policy.” I will require a reduction in the incomes of those who get lousy grades (which will be nearly all of them). I will do this without the slightest concern for what my quality-measurement crusade will cost. A billion dollars? I don’t care, because the proponents of P4P and VBP never cared. According to Binder and the measurement buffs, cost consciousness is for the doctors and the other little people, not the health policy aristocracy.

    In fact, I’ll make Binder et al. pay for some of that cost. I’ll make them buy clunky computers upon which to write their fatuous sermons, and if they have to hire clerks to handle the new data-entry chores for my P4P auditors, so be it. The illuminati don’t care what scribes cost, or that patients might not like sharing an exam room with scribes. What’s good for the goose ….

    When Binder and their ilk complain about the inaccuracy of my “quality” measures on them, I will publish irritable sermons, totally devoid of endnotes, accusing “some quality measurement mavens” of wanting to “slow or even halt” the movement away from consequence-free pontificating by the illuminati and toward “efforts” to hold the illuminati accountable. I will imply in my passive-aggressive way that there’s something wrong with them — that their greed motivates their kvetching.

    End of fantasy. Back to work. I hope to post soon some comments on the damage the measurement craze is inflicting on our sicker and poorer patients.

  7. I’ve been struggling with the question Niran asked for many years. Why are so many health policy “experts” incapable of comprehending the practice of medicine they claim they want to improve?

    In seeking an answer to that question, I have focused on the manipulative and abstract language managed care proponents use and the habit of asserting opinion without evidence (and often in the face of contrary evidence).

    Those three habits of thought — use of manipulative language, a love of abstraction over concreteness, and love of opinion and a casual attitude toward evidence — are lethal in any field, especially when the culture that promotes those habits attracts big money from Fortune 500 companies and foundations like RWJ.

    Daniel, I don’t know if you would call yourself a managed care proponent (or a proponent of any particular managed care nostrum, like ACOs), but your last email illustrates the abstractness I complain about in the statements of managed care proponents. You essentially offered us several truisms: Our system is awful, doctors must admit to its “shortcomings” in order to fix them. Is that not the dictionary definition of a truism, a platitude. Therefore what? What can any of us say in response to such a truism other than, yup, you got a point?

  8. Niran: Very heartfelt words. They are obviously true. The burden on PCPs of all these non-evidence based quality/cost incentives became clearer to me when I gave several grand rounds recently to PCPs (on PfP) at the Cambridge Health Alliance, the Boston VA and Brigham and Women’s Hospital. Great and nationally renowned institutions. Virtually all the docs said they were burned out by all the poorly targeted policies.

    For example, they said that they cost their hospitals millions in penalties for early readmissions that they couldn’t possibly prevent based on CMS’ pathetic determinations of predicted numbers of admissions from claims data that don’t get at the root causes of the problem. They said the rules don’t account for language problems, spousal abuse, low SES and non-English speaking patients who get readmitted more often than patients with fewer social problems. They are great docs with great stats but are frustrated by CMS. They wondered if I could influence the government to stop investing in useless pay or penalize for performance and, instead, put the money directly into reducing the social problems that account for a much greater proportion of the “quality of care” problems.

    I wish I could. Best, S

  9. Daniel-

    I agree with everything you said. There are absolutely shortcomings. However, I don’t see those being addressed. I see lots of non-physicians suggesting what they “know” will save money. Yet their theories don’t hold water.

    Right now “quality” metrics penalize me for expensive studies ordered by specialists. The IT people can’t tell who ordered tests so PCPs are dinged for all of them.

    I would LOVE to see a breakdown of what I cost the system, not just in office visits, but hospital days saved, fewer tests ordered, and Er visits saved by seeing them at my home. These number crunchers can’t seem to calculate the important stuff, but can provide reams and reams of useless data.

    They stare blankly when I ask them to produce the helpful data and say things like “statistics cannot do that.”

    Yes. Let’s start looking at the shortcomings so we can make helpful changes. Let’s stop physician-shaming and start working together.

  10. Niran, I can understand your frustration and have experienced it in my own practice.

    Although our colleagues are largely outstanding and caring physicians, as I’m sure that you are, we work in a frankly dysfunctional system. Most of us do great work in that system. Nevertheless, the system as a whole does not serve the country well enough. We spend a third more than other developed countries without apparently greater benefit. We may be 10% of the costs but our decisions account for the overwhelming bulk of it. Again, most of those costs are incurred with good intent.

    In order for the system to evolve in a positive direction (“reform” probably being too strong a word, given the likely pace of change) we need to acknowledge the shortcomings of the system so that we can address them.

  11. Jim-

    I do hear what you are saying as to your concern, but in all honesty, most physicians ( I am one of them) are offended that those who have not set foot in our clinics are trying to mandate how we treat patients using oddball, nonsensical mandates with no scientific basis. Furthermore, what offends me to an even greater extent is the fact that those of you who are not familiar with clinical care can actually become very knowledgeable if you would spend a week with a primary care doc, but for some reason do not even think it necessary to do so.

    I wish someone had been here today in my office. I am trying to cap at seeing 20 patients between 9am and 2:30pm so I can pick up my children from school each day. That means dictations finished, paperwork complete, and all referrals etc plus questions from patients who call in. I ended up seeing 24, am here later than I should be and could not turn the patients away if I tried. I simply don’t understand how FFS is “physicians trying to make more money.” It is paying me per visit for the time I spend on a childs’ new problem each day.

    I saw one last week for an illness, who returned because she got mad and sustained a boxers fracture after punching a door. I saw a kid for a sports physical last week (totally healthy) and today he came in with a tib/fib fracture. Ortho thinks he needs surgery. I intervened, called Children’s Hospital, texted the photos and was told “leave the leg in a cast only, no surgery.” Yes, I saved the patient money and helped a growing child, but by NOT paying me to do this, these children will NOT be provided the care and will have unnecessary surgeries anyway.

    As far as your point about the four “purchasers” you describe, they are in fact, NOT physicians’ paying customers, they are unnecessary third party payers who are skimming money off the top by paying me NOT to do my job. It makes absolutely no sense. I don’t care if they believe they are paying too much; they are dead wrong. And, no, we do not have to listen to them if we decide not to.

    You can’t mandate all the do-dads like EHR (useless) and other time-wasters to our profession and then penalize us when costs go up. Physicians’ fees are less than 10% of healthcare costs. Why are so many people after us? I will tell you why. We are too busy saving lives to bother with fighting back. I have had enough of the bashing, trashing, and arguing that my lean, mean medical office machine costs too much. Personally, I cannot wait for employers to decide to get out of the insurance business and when people pay for the care out of pocket, it is cheaper, easier, and a cleaner transaction. I have many cash paying customers on top of the regular insured ones. They come in when they need me and I help them when they do.

    Right now, because I am so overloaded and cannot find another physician to join me, I am having to contemplate dropping government insurance/Medicaid altogether being that it is the lowest payor. I only have 300 patients on that type of insurance. It is a terrible dilemma I am facing. These people need care and there is not enough of me or any other primary care docs to go around. Instead of pinching pennies, “policy and economics experts” should spend time ensuring we are paid what we are worth. Your life is actually worth a lot.

    My solution is quite simple… go back to simplifying the medical system. Let us use dictation, charts, electronic, or whatever is best for the PHYSICIAN. Eliminate metrics which make no sense. I have written five posts about solutions…. but they aren’t jazzy enough to generate money for the “purchasers” who are in actuality, greedy and rich. My customers are my patients, not the “purchasers”. It is a physician-patient relationship, not a physician-insurance-purchaser relationship.

    BTW, Your focus on the “healthier lifestyles requiring less treatment” is actually not a scientifically proven statement. Its like saying “drowning risk decreases when children take swim lessons.” Sounds like heaven on a stick, unfortunately the statement is simply NOT true, no matter how much we want it to be. Physicians are scientists. Science is really important to us. This touchy-feely “paying for performance” idea is pie in the sky, and it doesn’t work , no matter how much many of those on this thread want to pound the square peg through the round hole.

    Again, spend one or two days in a clinic with a busy rural primary care physician. You will not only lose weight (from no time to eat) , but you will understand what is is like when trying to get a drink of water out of a fire hose and you will learn a heck-of-a-lot more than you could ever imagine.

    …And if ANY of you actually did it for 10 days, well, then our healthcare problem would probably be much easier to fix.


  12. Folks, I’m deeply troubled by both the substance and tone of many of the comments Those of us who are not physicians (usually) accept the fact that we are not clinicians and bow to the superior knowledge of physicians when it comes to treatment. What seems to have been lost is the fact that the four purchasers (Binder et als) are physicians’ paying customers, and they believe they are paying far too much for what they get in return. They must be listened to and not be arrogantly dismissed as greedy and rich. They want value and don’t think they are getting it. They do have a point. And the cost of care IS the issue. It’s become unaffordable and lacking in commensurate value. To do nothing invites a host of troubles. Employers (aka rich greedy corporations) at some point will have had enough and will stop providing employer based health insurance (depending on the status of federal law and the ACA). Should that occur, either individuals will have to buy their own coverage (and finally become both payor and user) or the federal government will take over as single payor. Individuals won’t be able to afford it and would have to start acting like the consumers they are by being very disruptive. And if it’s the feds, physicians might compare what they are paid by private insurers vs. what they are paid by Medicare and Medicaid.

    It appears to be exceedingly difficult to do rigorous studies to prove what “works” and what doesn’t in terms of best practices or payment modalities. That should not mean a default of continuing the unacceptable status quo of outrageous cost and relatively poor quality. And if best practices (developed by clinicians of course) are truly “best,” there should be a direct causal relationship with better outcomes. Michael Porter of Harvard Business School, not a physician but very smart nonetheless, defines “value” in his and Tom Lee’s article Providers Must Lead The Way In Making Value The Overarching Goal as”the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”

    Perhaps the same degree of vigor might be better used to come up with better solutions. We ignore the consumer/customer at our peril.

    I’m actually focusing on the other half of the equation: improving individuals’ health through healthier lifestyles requiring less treatment. Also wicked hard.

  13. I would actually like to applaud the honesty and sincerity of the authors for admitting once and for all that “quality measures” are not about quality of medicine, but are instead a purely financial tool used to keep more money in the pockets of “employers and purchasers”, i.e. corporations and wealthy individuals, and as such “quality measures” need not be clinically valid, accurate or meaningful.
    Unlike Kip, I have no desire to turn the sharp end of the “quality measures” weapon on these small minded servants of the corporate exploitation machine. I just want them gone. I want them all to be fired, their think tanks and non-profits to be shut down, and the principals to be indicted for knowingly and willfully defrauding the public.

  14. Kip-
    Well said. As usual, you have a knack for writing a rebuttal that explains your position (and mine) in a way I never could. Thank you.

    The more important question is why are some policy experts capable of understanding the world of medicine in which they are not necessarily an integral part and others unable to “walk in our shoes”?

    Do they lack empathy? Or do they really see the world as being full of “greedy” physicians? Are they just incapable of understanding such a difficult construct as practicing medicine?


  15. 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

  16. You lost me at “The four of us, leaders of organizations that represent large employers and other purchasers of health care, reject any delay in payment reform efforts.” Actually, I almost cannot stop laughing at the notion that four leaders representing employers and purchasers of health care believe they understand anything about the practice of medicine.

    Metrics are STUPID. Period. They will not improve quality of care, however, they will improve the “documentation” of the care provided, resulting in higher costs overall.

    As my piece on immunization rates says, I score low because I believe ALL children should have health care no matter their station in life and refuse to cherry pick. I have the BEST number in the state for tracking BMI of children. The only reason I have the top number is because I picked up this tip in one of the meetings. I always tracked it but didn’t necessary bill or code for having completed it. Now that I do — I look amazing on paper, computer, or whatever documentation method is ‘the rage’ these days.

    The children I care for are not better or worse , the medical care quality is exactly the same as it was before I coded for BMI, and well, I think all the time and money that went in to getting physicians to track the number in the first place is a huge WASTE when we could use our time to see ill patients who need us. But what do I know? Right? I am just the hamster on a wheel, like the other primary care docs.

    The proper slogan for Quality Metrics should be…. the wheel is turning but the hamster is dead.

  17. Ha!

    You have your work cut out for you! Because it’s like a Sisyphean (or Promethean?) curse.

    My dad and many of my friends are GPs in England, unhappy about the targets imposed upon on them. One said to me – “we must rise above the metrics.” That sort of sums up everything.

  18. Please, this is a dead horse but you keep flogging it in the unrealistic hope that you might revive it. How many systematic reviews of the best evidence, RCTs, and longitudinal studies-from the US, Europe and around the world- will it take for us to dispense with this fuzzy thinking? Pay for performance is attractive in theory, but doesn’t work.

    It can even result in unintended consequences that lead to patient harm, lack of treatment and discrimination against people with social deficits who don’t “perform” as well.

    The authors should study the following document. There are dozens of additional well-controlled studies over decades that beg to differ with this opinion.


  19. “Returning to fee-for-service is not an option”

    Fair enough. But “fee for X” will eventually bring out the lunacies of X, which will lead to “fee for Y” which’ll bring out the lunacies of Y, resulting in “fee for Z,” by when the glaciers would have fully melted.

    Reminds me of the movie, Devil’s Advocate. John Milton keeps nailing Kevin Lomax for vanity, in different forms.

    Over to you Dr. Koka – be gentle.

  20. 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.

  21. 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!

    see http://www.nationalhealthusa.net/innovaton/innovation/

  22. 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.

  23. 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.

  24. No amount of calling process indicators “clinical quality measures” (CQM) will make them so.

  25. So, we apply our economic and improvement efforts primarily to the 5-10% of the population who comprise 50-70% of our nation’s health spending. It is highly unlikely that the economic requirements for unstable HEALTH in this population could be reduced by 30%. The current focus on reporting data is long over-due and will produce meaningfully, but minimally, improved efficiency. However, eventually the power law distribution curve will prevail. Without a strategy to improve the level of Stability earlier during a person’s life- time, the healthcare industry paradox will continue unabated. Given the Power Law Distribution curve verification, our nation’s health spending devotes only 5% of its total to 50% of our nation’s citizens. This is further aggravated by the severe decline in the level of Social Capital in many communitys that further aggravates their HEALTH and for which our nation’s health spending is eventually augmented.
    Let’s see: Hurricanes, mass murders, rising sea levels, stagnant economy, a likely impending flu pandemic, forest fires, homicide/suicide ‘epidemic’ among adolescents and young adults, dramatically decreasing social mobility from within low income families AND a continued annual worsening in our nation’s maternal mortality ratio. All of this is occurring as I write, and the excess cost of our nation’s health spending was $1 Trillion 2016. In 2016, health spending represented 18.2% of our nation’s GDP. The other 34 OECD nations clustered around 12% for their economies. The difference between 13% and 18% for 2016 amounted to, yes, $1 Trillion.
    I wounder if you would all consider spending a day with a primary physician located within a rural or inner-city metropolitan area who has been located in the same clinic for 10 years or more. The most important attribute for health care is its ability to establish , TRUST , and to a certain degree its level of cooperation and reciprocity. You will see what that means as a basis to improve each person’s Stable HEALTH and its resiliency.
    As a final note, health spending within our nation’s economy was 5.0% in 1960. The increase through 2016 at 18.2% amounted to 2.33%, compounded annually, over and above economic growth. The only time it did not was from 1995 through 2000 (the HMO years). See Health Spending Briefs at http://www.altarum.org