Health care quality improvement metrics
A science currently in its infancy is changing America’s health care system for the better. That science is performance measurement, sometimes called clinical quality improvement. Via the development of clinical practice guidelines that measure the quality of care delivery against rigorous evidence-based standards, the American health care system will eventually base compensation on the actual quality of care provided, not the amount.
The American health care system is unique in that payment traditionally has been tied to the amount of care provided, not necessarily the quality or effectiveness of that care. Based on the Medicare payment system that emerged in the 1960s, this system worked for a time, but now contributes directly to skyrocketing heath care costs. For example, there is currently a greater financial incentive for many doctors and hospitals to allow patients to get preventable hospital-acquired infections after surgery (because of the associated additional billing costs) than to prevent those infections. Another example includes the fact that Medicare will pay for diabetic leg amputations, but not for preventative wellness care for diabetics that would help avert those amputations.
About 15 years ago, a group of physicians, nurses and allied health professionals saw the disconnect between the American heath care payment system and quality of care, and decided to do something about it. With the cooperation of the Clinton administration, private insurers and consumer groups, the National Quality Forum was created in 1999—the first national organization dedicated to developing and endorsing clinical practice guidelines and performance measures. Other organizations soon followed, including the AMA Consortium for Quality Improvement, a cooperative organization made up of various medical specialty societies and administered by the American Medical Association, which is currently the only organization working to develop evidence-based clinical practice guidelines and performance measures by and for physicians. The federal government also took a more active role in the clinical quality and efficiency movement when it established the Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department for Health and Human Services, in 2000.
As the clinical quality movement continued to grow, it ran up against plenty of institutional resistance. However, in time both private insurers and government programs like Medicare and Medicaid saw the potential benefit in tying reimbursement to the quality of care provided. By linking the health care payment system to adherence to established clinical practice guideline standards, private and public insurers could “pay for performance,” and not for quantity of services. (In other words, quality versus quantity.)
Performance measures are essentially algorithms developed against evidence-based practice guidelines, with targets tied to ICD-9 medical billing codes. These measures are developed and endorsed collaboratively via a variety of national organizations such as the National Quality Forum and AMA Consortium, among others. Large private insurers such as United Healthcare also have systems in place for developing and launching performance measures for their network physicians and hospitals, and these systems continue to grow and develop.
After years of resistance on the part of policymakers, “pay for performance” finally began to gain traction as part of the national health care reform movement. With the passage of The Affordable Care Act of 2010, public payors like Medicaid and Medicare will finally tie payment to performance against nationally endorsed clinical practice guidelines, with a strong emphasis on preventative care. The federal “pay for performance” measures will be rolled in gradually, but will eventually cover most care disciplines. In addition, the Act requires private insurers to cover 100% of standard preventative care procedures like mammograms, colonoscopies and well baby care, with no co-pays or deductibles, and also provides incentives for private insurers to adhere to nationally endorsed performance measures.
While in the past physicians were not compensated well (if at all) for doing preventative care, they now will have an opportunity to increase their potential earnings by doing just that. By shifting payment focus to preventative and wellness-based care, the American health care system is finally moving in the direction most other countries with universal health care have followed for decades.
References
The White House. (2010). The Affordable Care Act of 2010: About the new law.
