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.