Time to relook at value and quality programs — Part 1

I recently spoke on a panel regarding actions that the new administration or Congress could propose to reduce provider burden and improve patient care. Another panelist had a list of 90 items, and he was trying to figure out which to discuss. For me, a key priority is clear: reform value and quality reporting and payment regulations that, while well intentioned, are not achieving the intended goals in the current form.

This isn’t a new topic. In fact, we discussed it on the Hill when I was there more than 20 years ago. We know we need to move from volume to value. We know we need to move toward a system that focuses on improving patient care to reduce costs. But when we pause to consider where we have done over the past 20 years, we must ask: Have we moved the needle?

Not to be a total Debbie Downer — meaningful improvements have happened. For instance, avoiding incidents from the “never events” list (e.g., leaving a sponge in a patient and preventing patient falls) is a win for the patient. Each avoidance also prevents unnecessary spending. Overall, however, we must look at the bigger picture, the sum of all of the initiatives. We must ask, “Are costs down? Are patients actually receiving the highest quality of care from each provider? Is the return on the investment positive?” 

Reviewing the numbers

A June 2023 study in The Journal of the American Medical Association shared the annual cost to an acute care hospital for measuring and reporting quality metric data:

• 162 unique quality measures for a hospital to track
• More than 100,000 person-hours to manage
• More than $5,000,000 in personnel costs
• An additional $6,000,000+ in vendor fees to administer

This is a lot of time and effort — and the study only reflects acute care hospitals, not other provider settings, doctor offices and more. A 2022 Stat article stated that “tens of billions of dollars – perhaps hundreds of billions” have been spent on value-based payment programs that “have done little to improve Americans’ health or lower health care costs.”
 

Reflecting on regulatory process measures

So, what should we do? Well, I would never advocate dropping efforts entirely — the goals are critical. But, we need to change our approach. I give credit to former Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma — she recognized this when she joined CMS and focused on patients over paperwork. She targeted frustrations with process reporting measures and made efforts to reduce some of them. Yet they continue to proliferate today — and the regulatory use of process measures needs to be addressed. 

Process measures provide valuable direction from specialty societies and clinical experts on best practices for providers. The “Aspirin at Arrival” measure — giving aspirin to patients presenting with chest pains – is good policy for an ED. The “Pain Assessment and Follow-Up” measure that ensures patients receive a pain assessment and follow up plan if needed – another good measure. But, these are process measures that direct the provision of care and require documentation and new reporting initiatives. Completing these steps does not necessarily mean the patient’s care was truly managed effectively, if the quality was high or low, or if potentially traumatic and costly additional preventable healthcare events were averted.

Redirecting focus to preventing adverse events

So, let’s go back to the initial intent and focus on improved patient outcomes and reduced costs. Specifically: 

• Has a potentially preventable healthcare complication – whether in the inpatient setting or the ever-growing ambulatory space – been prevented?
• Has a potentially avoidable hospital admission or readmission been avoided?
• Have potentially unnecessary avoidable (and costly) ED visits been averted with better patient management?

Let’s turn our attention to these critical outcomes that are really important to patients, like avoiding a visit to the ED. If we do that, we can move the needle on better care with lower costs. And, if we reduce potentially avoidable admissions, complications, readmissions and ED visits, healthcare expenses should decrease – without denying care or cutting physician payment. 

Importantly, a true outcomes-measured approach focused on preventing avoidable events should reduce reporting requirements because outcomes could instead be tracked with claims data, lab data and other data already being collected. We have so much data today. We need to use it effectively – not keep asking for more of it.

There’s more to come! Stay tuned to Inside Angle for part 2 where I’ll touch on how individual states are looking at quality programs. 

Megan Carr is the head of the regulatory and payer solutions team at Solventum.