When Garrison Keillor of “Prairie Home Companion” fame welcomes his radio audience to Lake Wobegon, his fictional Minnesota town, he describes it as a place where, “all the children are above average.” When one of us or our loved ones goes to a hospital for care, we expect that facility to be “above average” too. Sometimes we are able to choose the hospital where we seek care; sometimes, due to an emergency, we have no choice. Either way, we depend on the professionalism of the hospital and its clinicians to provide high quality care and keep us safe.
Reports by the Institute of Medicine (IOM) and other research surfaced a decade and a half ago indicating that patients could not always be confident in the quality or safety of hospital care, and that too frequently in America hospital care was wanting. The IOM made a strong case that American hospitals needed to improve performance and put greater effort into preventing harm to patients. The IOM also made it clear that clinicians and providers were not sufficiently accountable for the services rendered, or the safety of their hospitals, and that the provision of care and its outcomes were not generally transparent.
The root notion underlying IOM’s recommendations was that performance measurement and reporting of the results would fuel needed improvement. Much progress has been made since these troublesome reports. However, to expand and sustain progress, efforts that have been taken by the public and private sectors need to be properly targeted and refined.
Establishing The Hospital Quality Alliance
A key turning point for meeting the challenges facing American health care was taken when the American Hospital Association, the Association of American Medical Colleges, and the Federation of American Hospitals partnered with the US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to establish the Hospital Quality Alliance (HQA) in December 2002. The HQA was developed as a private and public multi-stakeholder partnership with a mandate to lead an initiative to improve hospital care through performance measurement and reporting. The HQA’s leadership focused action on Medicare resulting in important steps forward in the care and safety of Medicare beneficiaries and other patients.
Initially, the HQA encouraged hospitals to join in a nationwide voluntary effort to gather and report on available clinical process metrics. This effort focused on measures for three conditions, heart failure, pneumonia, and acute myocardial infarction (AMI) with specific reporting on such questions as whether or not a patient received comprehensive discharge instructions for heart failure, a timely initial dose of an antibiotic for pneumonia, or an aspirin at the time of arrival and discharge for suspected AMI. Eventually, the HQA’s initiative became more sophisticated, helping to spark Congressional legislation and administrative action by HHS and CMS to further the use of performance measures. Policies resulting from these initiatives culminated in the quality and pay-for-performance provisions embedded in the Affordable Care Act (ACA) in 2010.
Medicare’s Quality Payment Programs
The development and implementation of hospital performance reporting and ACA’s expanded Medicare mandates has yielded material, though mixed effects on hospital care. A new article, published in the August issue of Health Affairs by myself and colleagues, explains that there have been key successes and impacts as three core Medicare quality payment programs have taken hold: the Hospital Readmissions Reduction Program, the Value-Based Purchasing (VBP) Program, and the Hospital-Acquired Condition (HAC) Reduction Program. The 10 percent drop in the hospital readmissions rate is emblematic of that success, and reflects the investments hospitals have made to retool care delivery.
On the other hand, there are issues with these policies that limit their potential and present obstacles for hospitals to achieve all-important improvement in quality, safety, and performance. Initiatives must be re-calibrated so hospitals can meet the three goals, characterized by former CMS Administrator Don Berwick as the Triple Aim: improving the individual experience of care, improving the health of populations, and reducing costs.
Examples of the concerns tied to these three Medicare programs include the redundancy and relevance of measures that are used in both the VBP and HAC programs; the arbitrary, musical chairs-like HAC penalty that punishes a quarter of all hospitals every year regardless of how well those institutions have improved, or even potentially of how well they actually performed; and, the silence of the readmissions measure on the critical socio-economic factors, which studies show are likely to influence readmissions of low-income patients for reasons beyond the hospital’s capacity to affect.
It is clear we have work to do to improve quality and performance measurement in these Medicare programs. It is imperative that we get these revisions right. At the same time, we must also pursue improvements to those Medicare and Medicaid initiatives that use these measures to support value-based payment.
Effective and relevant measurement is critical to the effort to improve hospital care. It is important now to focus on the current form of metrics for corrective action. A roadmap for policymakers and researchers alike to redirect our performance evaluation is provided by the latest report on quality from the IOM. The “Vital Signs” report recommends a set of “core metrics” (including measures such as life expectancy, patient safety, and healthy communities), which will provide an infrastructure that can be used to concentrate assessment on what is truly most essential for health care delivery.
Beyond adopting the principles in “Vital Signs,” over time, hopefully, performance measurement will evolve with use of “big data” that, when accessed and analyzed, will enable more effective, efficient, and timely use of measurement and will offer better support care for decisions.
Well-honed clinical and performance measurement now and “big data” analytics in time should drive quality improvement, value purchasing, and meaningful transparency. We must assure patients and their loved ones that when they choose a hospital or find themselves in an emergency room, that every facility is considered, as Garrison Keillor would say, “above average.”
No comments:
Post a Comment