As a means to improve outcomes and control costs, insurance companies and other health care payers in the United States are increasingly using metrics to rate providers and health care organizations as well as to structure payment. However, payers should be careful not to impose quality measures that prioritize time- and cost-effectiveness over principles of patient-centered medicine, evidence-based interventions and transparency, according to a policy brief authored by eight UMass Medical School family medicine & community medicine faculty members and published in PLOS Medicine Nov. 17.
Barry Saver, MD; Stephen Martin, MD; Ronald Adler, MD; Lucy Candib, MD; Konstantinos Deligiannidis, MD; Jeremy Golding, MD; Daniel Mullin, PsyD; and Stefan Topolski, MD, are co-authors of “Care that Matters: Quality Measurement and Health Care.” They argue for a fundamental change in the approach to quality measurement and propose a set of five principals that might help shape quality measures and ensure that they reflect meaningful health outcomes.
“While we appreciate the importance of measuring quality in health care, there are many devils in the details of doing so. Only a small subset of the quality measures employed in primary care are supported by evidence that they correlate with better health for patients,” said Dr. Adler, associate professor of family medicine & community health. “Quality measures in health care must be evidence-based and correlate with better health for patients; in other words, with the care that matters.”
The authors argue that evidence connecting quality measures with improved health outcomes is modest, and metrics may be chosen because they are easy to measure rather than because they are evidence-based. They also warn that with payment at stake, clinicians and organizations may be tempted to game the system by devoting disproportionate effort to patients barely on the “wrong” side of a line rather than focusing on those at highest risk. For example, it is more beneficial to help a patient who has already had a heart attack and whose systolic blood pressure is 180 to lower it as much as possible, than to prescribe medication to a healthy patient whose systolic blood pressure is 141 in order to lower it to 139.
“Measuring what is easily measured leads to focusing too much on those items, even if the measures are all valid, which many are not, and neglecting what is not measured,” said Dr. Saver, professor of family medicine & community health. “Patient preferences virtually always should have a role in decisions, so eliciting and respecting those, along with providing information and guidance, is what we should be doing to provide quality, patient-centered care, but it is not what we measure.”
Pointing out that substantial resources are invested in public health quality efforts, the authors propose five core principles to guide the development of quality measures that reflect and enhance the quality of care provided. The Core Principles for Development and Application of Health Care Quality Measures call for measures that:
- address clinically meaningful, patient-centered outcomes;
- are developed transparently and supported by robust scientific evidence linking them to improved health outcomes in varied settings;
- include estimates, expressed in common metrics, of anticipated benefits and harms to the population to which they are applied;
- balance the time and resources required to acquire and report data against the anticipated benefits of the metric; and
- are assessed and reported at appropriate levels; they should not be applied at the provider level when numbers are too small or when interventions to improve them require the action(s) of a system.
“The heart and soul of the work we do is in the close personal relationships we develop in the exam room, striving to understand each human being as an individual,” said Dr. Golding, clinical professor of family medicine & community health. “Current measures do little to actually enhance the quality of the care I provide. We can and must do better.”
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