Tag: RWJF

6. Invest in the basic science of measurement development and applications.

May 27, 2013

By Berenson, Pronovost & Krumholz

The unfortunate reality is that there is no body of expertise with responsibility for addressing the science of performance measurement. The National Quality Forum (NQF) comes closest, and while it addresses some scientific issues when deciding whether to endorse a proposed measure, NQF is not mandated to explore broader issues to advance the science of measure development, nor does it have the financial support or structure to do so.

An infrastructure is needed to gain national consensus on: what to measure, how to define the measures, how to collect the data and survey for events, what is the accuracy of EHRs as a source of performance, the cost-effectiveness of various measures, how to reduce the costs of data collection, how to define thresholds for measures regarding their accuracy, and how to prioritize the measures collected (informed by the relative value of the information collected and the costs of data collection).

Despite this broad research agenda, there is little research funding to advance the basic science of performance measurement. Given the anticipated broad use of measures throughout the health system, funding can be a public/private partnership modeled after the Patient-Centered Outcomes Research Institute or a federally-funded initiative, perhaps centered at AHRQ. Given budgetary constraints, finding the funding to support the science of measurement will be a challenge. Yet, the costs of misapplication of measures and incorrect judgments about performance are substantial.

5. Use measurement to promote the concept of the rapid-learning health care system.

May 27, 2013

By Berenson, Pronovost & Krumholz

Initiatives to promote performance measurement need to be accompanied by support to improve care. Quality measure data should not only be technically correct, but should be organized such that their dissemination is a resource to aid in quality improvement activities. As such, quality measurement should be viewed as just one component of a learning health care system that also includes advancing the science of quality improvement, building providers’ capacity to improve care, transparently reporting performance, and creating formal accountability systems.

There are several strategies to make quality measure data more actionable for quality improvement purposes. For example, for publicly reported outcome measures, CMS provides hospitals with lists of the patients who are included in the calculation. Since the outcomes may occur outside the hospital for mortality and for readmissions that are at other hospitals, this information is often beyond what the hospitals already have available to them. These data give providers the ability to investigate care provided to individual patients, which in turn can support a variety of quality improvement efforts.

4. Measure patient experience with care and patient-reported outcomes as ends in themselves.

May 26, 2013

By Berenson, Pronovost & Krumholz

Performance measurement has too often been plagued by inordinate focus on technical aspects of clinical care—ordering a particular test or prescribing from a class of medication—such that the patient’s perspective of the care received may be totally ignored. Moreover, many patients, even with successful treatment, too often feel disrespected. Patients care not only about the outcomes of care but also and their personal experience with care.

There is marked heterogeneity in the patient experience, and the quality of attention to patients’ needs and values can influence their course, whether or not short-term clinical outcomes are affected. Some patients have rapid recovery of function and strength, and minimal or no symptoms. Other patients may be markedly impaired, living with decreased function, substantial pain, and other symptoms, and with markedly diminished quality of life. It would be remiss to assume that these two groups of patients have similar outcomes just because they have avoided adverse clinical outcomes such as death or readmission.

In recommending a focus on measuring outcomes rather than care processes, we consider surveys or other approaches to obtaining the perspectives of patients on the care they receive to be an essential component of such outcomes. When designed and administered appropriately, patient experience surveys provide robust measures of quality, and can capture patient evaluation of care-focused communication with nurses and physicians [24]. And while patient-reported measures appear to be correlated with better outcomes, we believe they are worth collecting and working to improve in their own right, whether or not better experiences are associated with improved clinical outcomes [25].

3. Measure quality at the level of the organization, rather than the clinician.

May 26, 2013• 1

By Berenson, Pronovost & Krumholz

Historically, the physician has been viewed as the leader of medicine, with responsibility for the care and outcomes of patients; in iconic photographs and paintings, the physician is seen as a lone, heroic figure. Such a view has led to natural interest in the measurement of individual physicians’ performance. It is therefore not surprising that some information brokers, including the U.S. News and World Report and many city magazines like the Washingtonian, provide ratings of “top doctors,” often based mostly on reputation, warranted or not.

However, this focus on the individual is flawed for most measures of quality and presents substantial technical challenges. Systems-based care is emerging as a key value within health care and a vital component of high-quality care, while the notion that an individual health professional can be held accountable for the outcomes of patients in isolation from other health professionals and their work environment is becoming an outdated perspective. For example, better intensive care unit staffing sometimes mitigates the evidence that surgeons who perform more procedures achieve better outcomes [21].

The communication and coordination of services across providers is required to ensure that patients, many of whom have multiple conditions, are assisted through various health care settings [22]. For some aspects of care, such as diagnosis errors and patient experience, measuring at the individual physician level might be considered. Nevertheless, focusing measurement on an individual runs counter to our goals in promoting teamwork and “systemness” as core health care delivery attributes.

2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.

May 26, 2013

By Berenson, Pronovost & Krumholz

While working to develop a broad set of outcome measures that can be the basis for attaining the goals of public accountability and information for consumer choice, Medicare should ensure that the use of performance measures supports quality improvement efforts to address important deficiencies in how care is provided, not only to Medicare beneficiaries but to all Americans.

CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement [6]. Physicians and hospital clinical staff, if not necessarily hospital financial officers, generally have responded quite positively to the challenge of reducing preventable readmissions.

CMS has complemented the statutory mandate to provide financial incentives to hospitals to reduce readmission rates by developing new service codes in the Medicare physician fee schedule that provide payment to community physicians to support their enhanced role in assuring better patient transitions out of the hospital in order to reduce the likelihood of readmission [7]. CMS recently announced that after hovering between 18.5 percent and 19.5 percent for the past five years, the 30-day all-cause readmission rate for Medicare beneficiaries dropped to 17.8 percent in the final quarter of 2012 [8], simplying some early success with efforts to use performance measures as part of a broad quality improvement approach to improve a discrete and important quality and cost problem.

However, this Timely Analysis of Immediate Health Policy Issues 3“CMS’ current value-based purchasing efforts, requiring reporting on a raft of measures of varying usefulness and validity, should be replaced with the kind of strategic approach used in the national effort to reduce bloodstream infections.”approach is not without controversy.

Improvements have been modest, and some suggest that readmission rates are often outside the hospital’s control, so CMS’ new policy unfairly penalizes hospitals that treat patients who are the sickest [9]. And while readmission in surgical patients is largely related to preventable complications, readmissions in medical patients can be related to socioeconomic status. Also, some have questioned the accuracy of CMS’ seemingly straightforward readmission rate measure, finding that some hospitals reduce both admissions and readmissions—a desirable result—yet do not impact the readmission rate calculation [10]. And one of this paper’s authors (R. Berenson) has suggested a very different payment model that would reward hospital improvement rather than absolute performance, thereby addressing the reality that hospitals’ abilities to influence readmission rates do vary by factors outstside of their control [11].

1. Decisively move from measuring processes to outcomes.

May 26, 2013

Berenson, Pronovost & Krumholz

There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.

Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.

However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting [1]. A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections [2].

The Global Cardiovascular Risk Score: A New Performance Measure for Prevention

Apr 12, 2013• 4

By David M. Eddy, MD

Everyone loves prevention. It may seem strange then, to learn that one of the biggest barriers keeping prevention from reaching its full potential is the current set of performance measures that, ironically, were created to promote them. The reason is that current measures are promoting activities that are inaccurate and inefficient. It is as though explorers who are trying to reach the North Pole have been given a compass that is sending them to Greenland.

This problem is being addressed by a new project conducted by NCQA and funded by the Robert Wood Johnson Foundation. The objective is to evaluate a new type of measure of healthcare quality called GCVR (Global Cardiovascular Risk). The new measure will have an important effect on the prevention of cardiovascular conditions.

To understand how, we need first to understand the limitations of current measures. For reasons that were appropriate when they were initially introduced – about 20 years ago — current performance measures were designed to be simple: simple to implement (e.g. collect the necessary data, do the calculations), and simple to remember and explain. This was accomplished in three main ways. One was to create separate performance measures for different risk factors. Thus there are separate measures for blood pressure control, cholesterol control, glucose control, tobacco use, and so forth.

While a performance measure for any one risk factor might take into account a few other risk factors to some extent, none of them incorporate all the relevant risk factors in a physiologically accurate way. A second simplification is that current measures are based on care processes and treatment goals for biomarkers, rather than on health outcomes. Thus a blood pressure measure asks if a patient with hypertension is controlled to a systolic pressure below 140 mmHG. A third simplification is the use of sharp cut points to determine the need for and success of treatment. For example, patients with hypertension are counted as properly treated if their systolic pressures are below 140 mmHG, otherwise not.

RWJF Call for Proposals: Pioneering Use of Behavioral Economics

Mar 20, 2013• 2

By Lori Melichar, RWJF Pioneer

We have announced our second Call for Proposals in the field of behavioral economics. We’re actively seeking ideas that will help us to better understand how to discourage the consumption of low-value health services — those that provide more harm than benefit or which provide only marginal health benefits. In addition to improving health outcomes, this knowledge could contribute to lowering health care costs for us all.

Behavioral economics is an area of study by which I’ve personally grown increasingly intrigued and in which the Foundation has recently begun to invest. We all know, for example, that we need to exercise, eat right and be actively engaged in our own health care. But we don’t always do what we know we should do; knowing the “right” decision to make does not guarantee that we make that decision. The goal of behavioral economics is to uncover insights that could enable people to make better — more “rational” — choices for their health.

It’s not a given that the behavioral economic-driven solutions that have been shown to, for example, increase 401k savings will prove to be true when applied to the challenges of health and health care. But it’s a risk we want to take because we sincerely believe — if it does — that it could lead to the profound social impact that the Pioneer Portfolio, and the Robert Wood Johnson Foundation as a whole, is seeking.

Transforming Care Through Transparency

Oct 9, 2012• 5

By Anne Weiss

By year’s end, the Department of Health and Human Services will announce plans for making its Physician Compare website into a consumer-friendly source of information for Medicare patients about the quality of care provided by doctors and other health care providers. In doing so, Physician Compare will take its place alongside Hospital Compare and more than 250 other websites that offer information about the quality and cost of health care. More importantly, perhaps, it will send an important signal that transparency in health care is the new normal.

To look at these 250-plus online reports is to see the good, the bad, and the ugly of the public reporting aspect of the transparency movement. Some make it easy for people to make choices among physicians and hospitals, and just as notably, let providers see where they fall short and need to improve care. But others ask too much, forcing users to sort through rows and rows of eye-glazing data and jargon that requires a medical degree to fathom.

The Affordable Care Act calls for Physician Compare to offer information about the quality of care, including what physicians and their practices did and the outcome for patients, as well as care coordination; efficiency and resource use; patient experience and engagement; and safety, effectiveness, and timeliness. That’s a lot of information, and it demonstrates the tall order facing the federal government to make the reports meaningful and accessible, so that physicians and patients will both be more apt to use them.Continue reading…

Is the Center For Innovation Innovating Too Fast?

Jun 30, 2012• 5

By Robert A. Berenson and Nicole Cafarella

One of the few health policy issues that receives bipartisan support is the need to dramatically alter the way providers are paid, shifting from “paying for volume” to “paying for value” to alter the trajectory of health care spending while improving health care quality.

To facilitate this shift, the Affordable Care Act equipped the Centers for Medicare & Medicaid Services with a range of cost-cutting and quality-enhancing tools―the most significant of which might be its new Center for Medicare and Medicaid Innovation. In this blog post, we share insights from recent research funded by the Robert Wood Johnson Foundation on the Innovation Center’s new role, organization, and model selection criteria.

Based on interviews with senior leadership, it’s clear the organization sees its role as two-fold: complementing existing efforts to innovate; and delving into new ideas.

Most of the Innovation Center’s efforts to date have focused on the former―implementing congressionally-mandated demonstrations or ideas that Congress or policy experts have already conceived (e.g., accountable care organizations). More recently, the Innovation Center has begun to seek new ideas from innovators across the country and to promote bottom-up innovation―primarily through its Innovation Challenge.