Reforming quality measurement

Image contains square yellow tiles with navy colored letters spelling out “why not try”.

Like many of you I subscribe to a variety of email newsletters, blogs, and Substack’s, including one from Academy Health. Last week they posted a link to “Reforming Medicare Quality Measurement”, written by White, Puthumana, Cram, and Bai, which was published in Health Affairs. In this piece the authors argue that the “quality industrial complex” has hijacked the original intention of the quality movement to create a self-reinforcing loop that developed questionable incentives for providers and health systems, increased compliance burden and scope creep, and has not substantially improved patient outcomes. The authors go on to outline 5 solutions: repeal the Medicare merit-based incentive payment system (MIPS); streamline Medicare’s inpatient quality programs; unburden and empower physicians; engage patients; and identify outliers.

While I’ve had some exposure to the quality system within the pharmacy world, I am by no means an expert in this area, but several of the authors’ comments caught my attention as a researcher. First, they state that more than half of unique quality measures track processes as opposed to outcomes. Second, when outcomes are tracked, they are often surrogate and not focussed on things like mortality or life quality. Finally, the data that is collected often represents a small slice of the patient experience (i.e. with an emphasis on an inpatient admission without accounting for the primary care experience).

For health researchers these critiques are familiar limitations and are not likely to even raise an eyebrow from most of us. As an implementation scientist I spend a lot of my time thinking about what is done, by whom, and how. The evidence supports that process matters. Surrogate outcomes are captured because mortality takes a long time to track and can’t always be tied back to a single medical encounter. Quality of life is squishy, subjective, and hard to capture with fidelity. Cross-sectional data from a single encounter is easy to capture, especially when contrasted with a health system infrastructure where a single hospital can use 2 or 3 different EMRs (none of which are interoperable), and data tracking is primarily for the purposes of billing not patient outcomes.

Now I am sure that a good number of you are nodding your heads at this point, saying something to yourselves along the lines of, “No duh. Tell us something we don’t already know.” Okay, so here’s my pitch, assuming for the moment that improved health and healthcare outcomes are what we are all in the business of achieving, what if we changed what data is collected and how it was tracked?

We know that process can be connected to outcomes in highly controlled, academic medical center settings. So, what if we invested more time and effort in figuring out the give and take for making that translation to community hospital settings? We know that tracking mortality takes time and is very complex. So, what if we built methods and a data infrastructure that allowed us to see those patterns, while also continuing to track surrogate outcomes? We know that patients are responsible for their own health, and when properly engaged can make huge strides in managing their conditions. So, what if found more and better ways to account for their perspectives and gather data directly from them? We know patients’ health outcomes are impacted by more than single episodes of inpatient care. So, what if we found a way to connect patient experiences across providers and the use of other health adjacent resources?

Of course, this likely all sounds very Pollyannaish, especially in a moment when we’re in a federal government shutdown in the US, austerity measures are being implemented in many countries, and outright wars are being waged in others. If this is your thinking, you might be right. However, I also know that nothing changes or gets better unless we start.

So, I am going to continue cultivating partnerships with patients, health care providers, and health systems so I can better understand their specific needs. I am going to continue drawing on expertise from a cross-disciplinary group of researchers to build teams to solve big problems in new ways. I am also going to continue to wear my rose-colored glasses and believe that change is possible and that we can build better data systems to help us determine how we are improving patients’ lives (knowing that it will take time). Who’s with me?

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