Evaluating Physician Quality, Efficiency, and Value – Dr. Raymond Fabius
Medical Director on Demand call – 2.14.19
US ranks 37th in healthcare systems performance among developed countries. Part of the issue relates to quality of care. In a noteworthy paper in the New England Journal of Medicine, Elizabeth McGlynn showed that among all types of care, the US was only about 55% compliant with recommended services from a quality standpoint, with a range of between 10-78% in different care types. While these values may have more recently increased into the 60-65% range, significant opportunities exist for further improvements in care.
Value of care = Quality / Cost. Alternatively, Value of care = (effectiveness + experience) / efficiency
Another way to look at this is through the lens of the Triple Aim (Berwick), and in particular, how does the quality of care compare across the spectrum of individuals who are healthy, those at risk, those with chronic conditions, as well as those with catastrophic conditions.
Health status = effectiveness (across the care continuum, peer comparisons, over-time trending)
Cost per capita = efficiency (cost per episode, cost per case)
Perceived value = patient experience (net promoter score, likelihood of recommendation)
- Highest reward /recognition, demonstrating continuous improvement, minimizing errors
- Measurement approaches – funnel analysis, error rates, quality improvement, benchmarking
- Performance outliers relative to peers
- Preventable high-cost care
- Bundled payments vs. total cost of care as measure of efficiency
- May need to adjust for severity of illness
- Lower cost for an episode of care should be recognized
- Patient satisfaction – net promoter score, recommendation. Can use surveys to gather patient perspective
- Staff satisfaction – expands triple aim to quadruple aim to recognize provider satisfaction, which is associated with better outcomes. Surveys can also be used to evaluate staff satisfaction.
- Key question for patients – would you recommend this practice to others? If yes, these practices should be recognized and possibly rewarded. Trends in improvement should also be recognized.
Severity adjustment – multiple associated/complicating factors, which should be considered in the analysis. A number of factors should be considered in the overall evaluation, to more fairly/equitably compare across different clinicians.
Balanced scorecards can be used to provide an overall approach to quality, efficiency and cost outcomes.
Alternative payment methodologies should increasingly be used to more meaningfully align quality and outcomes with cost. Need to transition from fee-for-service to performance-based compensation, using the above approach. Incorporate a base payment with a quality payment that’s based on the measures as discussed above.
How can coalitions at a regional level be successful in their efforts to understand these measures in their respective regions?
- Understand the three dimensions of quality, interface with providers and payers in the community, and evaluate current data. Consider starting with a single category, such as oncology care or other service offering.
Wichita – movement toward direct primary care: Not necessarily the best at tracking outcomes in those practices, but with support, working fairly well
NEBGH – looking at cancer care from a quality standpoint – quality of life, high-cost treatments an important consideration.
Fabius: Three E’s as described above appear to be broadly applicable, including this setting.
Maine – using Archway Health (Massachusetts) to evaluate service provider quality metrics to identify high quality providers. Had difficulty in aligning metrics across different entities – and anticipating that state-level approach has great potential. Previously, tiered network approach developed by multiple stakeholders, use of metrics to stratify quality, including Leapfrog. Maine now has greatest number of high-quality rural hospitals. Primary care – pushback from providers about data; efforts previously internally driven, now using a third-party entity to evaluate quality.
Smart Shopper app to be used to steer individuals to lower cost sites of care (e.g., infusions), with incentives to steer individuals to higher value care. In place in New Hampshire with favorable responses.
Fabius – target high-volume practices to improve quality as a way of not pushing patients to change clinicians.
Hays – market dynamics are impacting healthcare services use, with dominant systems taking patients away from the independent practices. End of the day, how do we create a market to increase competition and lower pricing? In NH, Quest labs offering cost-saving alternative to hospital labs – as another example.
Conard – Physician networks exist, where high quality providers may often refer to high quality specialists. Network construct may be important to take into consideration.
Fabius – Important to engage individuals in primary care practices – as medical homes, they can support patient compliance with recommended services. Target high volume primary care practices for referrals as well as quality improvement efforts.
Hays – are medical home supplemental payments yielding value? Is it worth employer efforts to try to improve clinical practice quality?
Fabius – in general, the more investment the employer makes in healthcare services, the better the results. Evidenced by greater direct involvement (direct contracting) of employers with practitioners. Still room for improvement, even in level 3 patient centered medical homes, though overall quality appears to be higher in those practices. Best opportunity for cost containment – ensure all have primary care.