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High-Value Care: The Missing Dimension of Healthcare Quality Measurement

Virtually all contemporary assessments of healthcare value are based on an algorithm whose variables include cost, quality and patient satisfaction.  One benefit of this approach is that once agreement is reached on their specification, measurement of these three variables is relatively straightforward.  

Cost is clear-cut; it’s the price per unit of service times the number of services delivered, the product of which can be readily measured.  Patient satisfaction is marginally more difficult to measure.  CAHPS (Consumer Assessment of Healthcare Providers and Systems) is a CMS family of standardized surveys used to measure the patient experience in inpatient, outpatient and physician practice settings.  (One caveat is that these instruments measure how patients experienced or perceived key aspects of their care, not necessarily how satisfied they were with it.)  In addition, most commercial payers have their own proprietary set of survey instruments.   

Quality as customarily defined is much more of a problem—not to measure, but to first define.  Virtually all quality measures are based on provider adherence to evidence-based protocols and, to a limited extent, patient outcomes.  The problem is there are far too many of them.  There are presently over 1700 provider quality measures presently in use by federal agencies and more than 1300 used by state and regional authorities, of which only 20 percent are used by more than one state or regional program.  Add to this the large number of unique quality measures used by commercial plans, and the number becomes truly overwhelming for providers. 

A major barrier to whittling this down to a manageable number is that different stakeholders want different information.  Patients and employers want information that can help them make informed decisions about buying insurance and selecting providers; physicians need information that will help them improve the quality of their clinical care; hospitals and health systems are more concerned about measures required for external reporting and accreditation; and finally, policymakers want measures that reflect the state of population health. There’s almost certainly no single, manageable set of quality measures that will satisfy all three audiences.  Nevertheless, if a manageable set of measures can be specified for a given situation, measurement and reporting is relatively direct. 

The fourth dimension of healthcare value—and the one most often overlooked—is the avoidance of low-value care, usually referred to as overutilization or overuse.  These are diagnostic and treatment interventions that provide zero or negligible benefit to patients and potentially exposes them to risk of harm.  Overutilization affects millions of patients at an estimated annual cost of more than $190 billion.  A recent JAMA article identified the widespread use of 26 claims-based low-value services in six categories of care.  Eliminating overuse is the quickest route to improving value in healthcare, yet it’s the most difficult dimension to deal with.  Complex, interrelated factors contribute to overtreatment, including patient expectations, misaligned financial incentives, the practice of defensive medicine and a medical culture prone to do more in the name of “being thorough.” 

 Reduction in overutilization requires the ability to first identify high-value services, and in cases where the provider targets specific patient groups, identify which groups would be eligible for services that might otherwise be low-value to a healthy population.  This in turn raises significant legal and regulatory issues around discriminatory practices. 

Beginning in the mid-1990s, the U.S. began trying to restrict unnecessary treatments through policing by insurers: they could refuse to pay for anything that looked like inappropriate care, whether it was an emergency-room visit, an MRI scan, or an operation. It worked for a while, but eventually a public outcry forced insurers to back off, and the incidence of overuse resumed its climb. 

Two decades later, some alternative approaches have begun to emerge.  Once strategy is the “Choosing Wisely” campaign, initiated by the American Board of Internal Medicine, designed to facilitate dialogue between patients and physicians about healthcare choices.  Another is the National Physician Alliances project, “Promoting Good Stewardship in Clinical Practice,” which identifies specific steps that primary care providers can take in their practice to promote the more effective use of healthcare resources.  

Because doctors generally know more about the value of a given medical treatment than their patients, the ultimate burden has to fall on providers to limit low-value care.  This will be encouraged by the emergence of alternative value-based payment models, such as bundled payments and population-based reimbursement.  By limiting total reimbursement for a defined episode of care (bundled payment) or the provision of care to a specified population for a defined period of time (shared savings, shared risk, and capitation), providers will be strongly incentivized to limit the provision of low-value care.  The obvious challenge in each of these alternatives to the traditional fee-for-service model, however, is how to balance the incentive for limiting care, albeit low-value care, against the patient’s need for all appropriate care.  How that will ultimately play out in practice is anybody’s guess.

John McCracken, PhD