Quality was a key element in the ACA and when it was being bantered about I expressed significant concern. Mainly because it is illusive. No one can define or measure quality. I wrote extensively about it in mid 2009 as the ACA was raising its evil head. I then detailed it in my Health Care book in 2010. Thus when I see articles now regarding the ACA I am not surprised about anything.
One paper in NEJM states[1]:
... the Affordable Care Act (ACA) created the “value-based
payment modifier,” or “value modifier,” a pay-for-performance approach for
physicians who actively participate in Medicare. By 2017, physicians will be
rewarded or penalized on the basis of the relative calculated value of the care
they provide to Medicare beneficiaries….
The value modifier is meant to provide differential
payment to a physician or physician group under the Medicare Physician Fee
Schedule on the basis of the quality of care furnished as compared with the
cost; it will result in a reward or penalty amounting to 1 to 2% of payments
for groups of 100 physicians or more in 2015 and for all physicians by January
1, 2017. CMS anticipates increasing the percentage of payments at risk as
positive experience accrues. To reduce the burden on physicians, CMS has based
the value modifier on the Physician Quality Reporting System (PQRS).
As usual the problem is the term quality, or worse the value
of care. Quality is the term which drove the main character in Zen and the Art
of Motorcycle Maintenance stark raving mad. Value on the other hand should have
a quantitative measure, but in the context of the CMS one will wonder. But here
we have a confluence of Quality and Value, as in the last sentence, thus the
creation of a true schizophrenia.
The author then states:
The challenge of accurately assigning costs to an individual
physician is similarly daunting. Current methods for case-mix adjustment do not
adequately capture variations in patients' illness severity, complicating
coexisting conditions, or relevant socioeconomic differences — differences
beyond the physician's control that affect the cost of care. And we currently
don't know how to attribute to an individual physician the costs that Medicare
beneficiaries generate across the health care system.
The observation is spot on. As the authors state in their
opening:
the practical reality is that the Centers for Medicare
and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure
any physician's overall value, now or in the foreseeable future. Instead of
helping to establish a central role for performance measurement in holding
providers more accountable for the care they provide and in informing quality-
and safety-improvement projects, this policy overreach could undermine the
quest for higher-value health care. Yet the medical profession has been
remarkably quiet as this flawed approach proceeds.
That is absolutely correct. Not only cannot they measure an
individual physician’s value they cannot do so with quality, and even more so.
In contrast there was a second NEJM article praising this
program[2]. They praise the ACA and CMS and its efforts as demonstrated by the chart below from the article.
(Note: The above is from this article and demonstrates "Medicare's
Quality-Incentive Programs Leading up to Hospital Value-Based
Purchasing, as Compared with Those before the Launch of the Physician
Value-Based Payment Modifier." )
They state:
The PVBM reward formula is a simple, relative system in
which performance is assessed in two dimensions (quality and cost), with
payments accruing to physicians who have above-average performance along both
dimensions. Physicians who perform worse than average or choose not to be
involved will be paid less; physicians with average performance will experience
no change. The maximum bonus is about 2% of Medicare fees, and the maximum
penalty is approximately 1%. For CMS, scoring physicians relative to one
another achieves budget neutrality. For physicians, it eliminates the effects
of common shocks to performance, such as an influenza epidemic or vaccine
shortage. The key disadvantage of this incentive structure is the inherent
uncertainty for physicians about the amount of improvement that will be
necessary to receive a bonus or avoid a penalty.
How does one make such a comparison? For example, an
Internist and an upscale area versus a poor community GP, what is there to
compare.
They continue:
The lack of experience with physician-level measurement
and reporting has important implications for the PVBM. First, far greater
numbers of physicians will need to become engaged in reporting of quality and
cost performance. This challenge should not be underestimated: there are nearly
150 times as many physicians who bill Medicare as there are hospitals, the
physician population includes physicians of all types (primary medical,
surgical, and subspecialists), and many of these physicians work in a wide
array of smaller practices that are still acquiring the basic infrastructure
(e.g., health information technology) or organizational affiliations (e.g.,
independent practice associations) needed to measure and improve the quality
and cost of care.
We have asked physicians to expand record keeping, billing,
Electronic Health Care Records, and no we demand they measure quality. Re-read
Zen and the Art of Motorcycle Maintenance, quality measurement and definition
will drive one insane! What will happen are more costs related to gaming the
system.
One area that could improve health care would be balancing
patient expectations with outcomes. All too often the patient’s dissatisfaction
is based upon an outcome that they were not expecting because they were not
informed. Questionnaires which measure patient psychographics as well as other
factors and them assist them in matching treatments, holistically, may help.
But that is delimited by not including family expectations. For example for a
man with prostate cancer there may be several options. How would we best treat
that patient? It would be critical to understand his psychographic profile.
That all too often is not done. Then on a post basis we verify that the proper
choice is made and we can create a good Bayesian methodology to maximize
patient satisfaction, namely they had no surprises.
Thus quality and value are just more terms that confuse
rather than enlighten. To paraphrase Osler, “If all else fails listen to the
patient.”
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