Look at how health quality measures have become a jungle

"Pieter Bruegel the Elder - The Tower of Babel (Vienna) - Google Art Project - edited" by Pieter Brueghel the Elder (1526/1530–1569) - Levels adjusted from File:Pieter_Bruegel_the_Elder_-_The_Tower_of_Babel_(Vienna)_-_Google_Art_Project.jpg, originally from Google Art Project.. Licensed under Public Domain via Commons.Some experts view the burgeoning number of quality measures as health care's Tower of Babel.

Pieter Bruegel the Elder – The Tower of Babel (Vienna) – Google Art Project – edited.” Licensed under Public Domain.Some experts view the burgeoning number of quality measures as health care’s Tower of Babel.

Quality measures are good, right? We all want our doctors and hospitals to follow best practices and be held to them.

It’s not so simple.

Put aside for the moment whether the measure is accurate – we don’t always know or agree on what the best thing is in health care (Exhibit A: mammograms).

There’s another quality problem.

There too many quality measures. Oodles and oodles of quality measures.

I first came to appreciate this a few months ago when I was doing some preparatory conference calls before moderating a panel with hospital and health system executives. They came from a variety of organizations – big, small, urban and rural. But all had some kind of accountable care organization or ACO-like value-over-volume arrangement. All were serious about trying to navigate a changing health care landscape. All took part in Medicare and Medicare Advantage and Medicaid (most had Medicaid managed plans). And, of course, they dealt with multiple private insurers in both employer-sponsored health care and the individual market, in and out of the exchanges.

The people I interviewed started talking about how each of these payers had their own quality measures – some overlapping and some mutually exclusive.  I’m not talking about 10 or 20 or 30 measures. They were dealing with 100, 110, 140 or more. They could not possibly meet those standards – or even measure and report their performance in so many sliced and diced ways. I remember wondering – but not getting a clear answer at the time – about how much money and work hours are being spent quantifying quality when the goal was, in part, to use quality to guide us toward a more efficient health care system.

Later, my colleague Erin Mershon of Politico looked into this. Her very good story is behind a paywall so I can’t link to it, but I can quote and describe what she found. It’s real easy for you to do similar stories in your community.

Mershon spoke to Ochsner Health System in Louisiana. They report on 213 – that’s not a typo – different quality measures “some redundant, some just to check a box, and some that are so specific they serve a limited purpose.” For instance, one contract required them report on mammograms for women aged 40 to 75, another on ages 30 to 80. Now, keep in mind that the U.S. Preventive Services Task Force’s latest draft recommendations are for mammograms every other year for women 50 to 74, with a more equivocal “talk to your doctor about whether it’s right for you” for women in their 40s. The American Congress of Obstetricians and Gynecologists recommends annual screening starting at age 40. That’s controversial and confusing enough for both patients and physicians – but neither group recommends routine mammograms for women in their 30s.

“Just that change in the ages means you can’t compare those two metrics across payers, because that makes them vastly different,” Janet Niles, Ochsner’s vice president of accountable care, told Erin. “It’s extremely frustrating.”

The Centers for Medicare & Medicaid Services knows there’s a problem. “Providers obviously can’t focus on 72 different things to improve, especially if they’re doing 72 different things for each separate payer,” Kate Goodrich, CMS’s director of quality measurement and value-based incentives group, was quoted as saying. “(It’s) a lot of noise.”

So you’d think there would be a public-private sector push to streamline the requirements. You’d be right – sort of. CMS is working with private sector partners on that but it’s also proposing new measures. That’s in part because it is preparing to develop a new Medicare payment system for physicians based on quality, which will replace the old Sustainable Growth Rate formula.

Mershon writes:

The reporting requirements are only going to get worse before they can get better. Just this month (July), CMS proposed dozens of additional quality measures for physicians addressing everything from HIV testing to outcomes for stroke patients. Other regulations are adding new measures for home health agencies and other providers. Even more are coming, as the agency starts to implement Medicare’s new quality-focused physician payment system authorized in permanent “doc fix” legislation this April.

The Commonwealth Foundation’s David Blumenthal called it an “excess of good intention … and pretty soon it became a Tower of Babel.”

“(It’s) the Goldilocks criteria,” said Ann Greiner, vice president for external affairs at the National Quality Forum, which vets many of the quality measures used by CMS and private insurers. “It’s both too hot and it’s too cold, and we’re trying to get it just about right.”

A representative at one of the health systems I spoke with said that some providers end up selecting which quality measures to prioritize and which to basically ignore (since they can’t possibly do all of them), based more on which made more practical and financial sense, not necessarily which jived with their own sense of what was really the best care.

This is an underreported story and should be easy to localize. We reporters look a lot at just a few of the big measurements, such as hospital readmission rates. But I haven’t seen a lot of reporting into the quality measurement morass. It should be something that providers and plans are willing to talk about. Judging from the conversations I’ve had, and Mershon’s reporting, the situation may be solving some old problems but potentially creating a whole bunch of new ones.

2 thoughts on “Look at how health quality measures have become a jungle

  1. Avatar photoLeah Binder

    There are many measures, but only a small percentage are publicly reported. (Ask Ochsner how many of the 213 measures they cite are reported publicly by hospital or by physician). In addition, too few measures are directly relevant to consumers; many are process measures, such as the timing of medication administration prior to surgery. Consumers want to know the track record of individual surgeons, the overall infection rates of hospitals, etc. That’s difficult and often impossible to find. Providers have begun talking with journalists about the morass of measures, suggesting we need to pare them down. However, consumers–and journalists– do not have enough good data on hospitals and physicians and beware the movement to restrict measures even further.

  2. Avatar photoMichael Millenson

    The phrase that comes to mind is “crocodile tears.” Providers have resisted measures bitterly, whether they were good (some of the measures of CABG mortality) or not-so-good. The AMA wouldn’t even use the term “guidelines,” preferring “practice parameters.” And, in turn, physicians ignored educational materials on topics such as beta blockers post-MI for, literally, more than a decade. So: we got measures. Lots of measures.

    What journalists should be doing is holding providers accountable for not reporting even well-understood measures in a way that would benefit consumers. This spring, I wrote a post for WBUR saying the way to honor Betsy Lehman’s memory would be for hospitals to take a “zero preventable errors” pledge and be as transparent as Norton in Louisville has been for more than a decade.

    The provider community, and Harvard academic types, ignored that call. As did local media. But take a look at Norton or Beth Israel Deaconess in Boston or a few others and demand that your local hospital that runs great ads meet that standard.

    We can’t lead all the pressure to ProPublica.

Leave a Reply