What Does Quality Mean in Health Care?

In this Breaking Down Health Care conversation, John Hennessy, MBA, and Michael Kolodziej, MD, examine how to measure quality in health care and the current challenges with the existing methods.

Read the transcript:

John Hennessy, MBA: Welcome to Breaking Down Health Care, where we'll be discussing evolving topics on health care in the United States. I'm John Hennessey; I'm a principal at Valuate Health Consultancy. And for this video series, I'll be in conversation with Michael Kolodziej, an oncologist and currently an advisor to ADVI and Canopy, an electronic patient-reported outcomes startup.

We're also talking about his new Substack, Decoding Healthcare. And we're using our expertise to dive into some nuances of the health care industry in the United States.

So, Mike, we've talked about the FDA in previous conversations. As part of that, we talked about quality in health care and how we measure it. And when we want to talk about quality, it's a lot more complicated than we might think at the first glance, sort of a 3D chess kind of thing. So, can you summarize the main ways we measure health care quality in the real world?

Michael Kolodziej, MD: Yeah. So, first, I think we should probably start with the observation that a lot of people, both in and out of medicine, have this thought that quality should be self-evident, and I don't think anything could be further from the truth. I think being able to articulate quality means that you have to have some agreement on what constitutes quality and you have to be able to measure it.

So, I jokingly begin this the Substack on quality with the observation that everybody thinks they're doing a darn good job, just like Garrison Keillor’s Lake Wobegon where every child is better than average. And I swear to God, you cannot go to a large metropolitan area without seeing a billboard saying, “Our hospital is top 10 whatever.” Those drive me crazy, because I don't know how the heck they decided they were going to claim superiority, because there's no agreed upon rules.

So, I think we need to talk a bit about the history of quality measurement. And I specifically cite Dr Donabedian, who is the sort of the father of health outcomes research in America, especially quality measurement, and he decided that we should break down quality into three major domains: structural, process, outcome.

Structural means, do you have the right stuff in your practice or your organization? Are the nurses trained, certified; is the ratio good? Do you have all the things that you need to do to succeed? So, when we think about, for example, U.S. News & World Report quality measurements, those are structural, right? Those are structural. You need them to succeed, but in and of themselves, they're not adequate for what you and I would agree is success in terms of quality.

Then there's process measures. Do you do the right things? If a patient has breast cancer, do you measure HER2 and ERPR status, for example?

And then there's outcomes, and outcomes speak for themselves. Do you have low rates of hospital-acquired infections? That's an outcome. And I think as we discuss quality in medicine, we need to be very particular, very precise in what kind of quality measure we're talking about. And then we need to be sure that we're measuring it accurately and reporting it, particularly in the context of how others are doing.

That serves several important functions. Number one, it helps patients know whether they're getting quality. Number two, as we move forward with the alternative payment models, which we've discussed, it gives us sort of safety lanes in terms of making sure that as you reduce the cost of care, you don't compromise on these quality measures. And the third thing, of course, is it allows practices to get better, lets doctors get better. And I think all three of those are important reasons that we need to measure quality.

Hennessy: So, as we think about measuring quality, there is no sort of, you know, national standard of quality here. There are a variety of agencies who've put quality metrics out there from the National Quality Forum to CMS. And to your point, U.S. News & World Report has some sort of gravitas in defining what quality is.

So, what's the challenge of measuring quality? And maybe add on to that, translating that to patients so they know what to do with that information.

Dr Kolodziej: Yeah, so I would say that the kind of the ultimate arbiter of quality in health care has been Medicare, has been CMS. And the reason for that is that CMS has linked physician payment, to some extent, to quality measures.

So, the old timers who are listening to this remember the SGR, the Sustainable Growth Rate. SGR was introduced as part of Medicare funding to try to reign in cost inflation. So, it was indexed to what the consumer price index [CPI] was. And if medical inflation exceeded the CPI, cuts were put in place.

And the SGR would have been devastating to providers of health care in America because, as we well know, the medical cost inflation far exceeded the CPI many, many years. And so, every year at the end of the year, Congress had to pass a law that basically said, “Not so fast. We're not putting those cuts in.” So, every year, the end of year, we had this sword of Damocles. We're going to chop your head off. And it got to be ridiculous.

So, a law was passed during President Obama's administration that basically eliminated it. And in its place, we got something called the MIPS program, MACRA and MIPS: merit-based incentive payment system or something like that. And the MIPS program basically said your Medicare professional reimbursement was going to be tied to your performance on quality measures. And those quality measures were supposed to be specialty specific.

The only problem was that Medicare decided they'd index those quality measures to what the National Quality Forum [NQF] had said were the quality measures. Now the NQF, again, was created by the government as being a not-for-profit, nonpartisan clearinghouse of quality measures. But the problem was they were given an impossible task, which was measuring quality across all of medicine.

Look, what's quality in oncology is different than what's quality in OB/GYN or peds. It's just different. It's a huge task. And so, it got to be so cumbersome to update quality measures. Somebody had to sponsor the quality measure, they had to put in a lot of data, it became very expensive.

So, as I wrote in the Substack, there were 9 or 10 quality measures in oncology. Most of them were quality measures when I was a fellow for crying out loud. I mean, there was so little movement in quality measurement and reporting compared to the incredible explosion of what we learned about cancer over the 20 years.

So, we got stuck into this vicious cycle where we wanted quality to be rewarded but we had a hard time modernizing and applying all the things that we learned about cancer care. And that happened in every specialty, every specialty. So, we continue to be handcuffed a little bit in that the people with the real influence—Medicare, and then, by extension, commercial health plans—who have taken ownership of this quality issue, have really just not delivered on it.

Now, that's not the only people who measure quality. You mentioned a number of others. The one that I call out in the Substack is QOPI [Quality Oncology Practice Initiative]. QOPI was started by Joe Simone and Doug Blayney 20 years ago, where it was really to try to improve how well an oncology practice was taking care of patients. And the quality measures there, they resonated more, I think, with practices. But the problem with QOPI is it just got too big and too complicated.

And so, the process of quality measurement reporting by practices was voluntary; it was manual. ASCO [American Society of Clinical Oncology] knew this was going to be a problem; they tried to build CancerLinQ to solve it, but CancerLinQ was never adequately powered, staffed, funded to execute on this. And so, CancerLinQ actually has now been sold to a for-profit data company, and we still have this issue about oncology practices can get a handle about whether they're doing a good job or not. So, we're in a we're not a good place with quality, not a good place.

Hennessy: I have not necessarily fond memories of the QOPI process, but I have fond memories of beginning to measure quality and the importance of recognizing that in the practice. And we certainly learned things, but it was a very expensive learn number one, but I think sort of outside the capabilities of many small practices. And that doesn't mean they weren't delivering high-quality care, it just means they weren't able to measure it.

And that's I think always one of these sort of tensions we have is, are we delivering quality care or just measuring and producing data that suggests we're delivering quality care? How do you balance that? Or is it something that's just not balanceable? You have to measure it at some point to have some sort of balance in terms of, to your point, the billboard that says it's high quality versus is it actually high quality?

Dr Kolodziej: Yeah, so, the answer probably is that artificial intelligence is going to make all this discussion about what measures and how hard they are to validate them,I t's going to make it irrelevant, right? Artificial intelligence will allow us to get all that information from the electronic medical record [EMR], from the claims data, from everything.

And so, one of the very real and I would think short-term opportunities for artificial intelligence is to go into the EMR, take that unstructured data, extract it, and then generate these kinds of comprehensive reports. Now, whether or not you can still have billboards that say that, “Our ER has the shortest wait times,” that's a whole different question.

You know how I feel about advertising in medicine—I’m not a fan. But I do think that when we get a much easier way to measure, it'll be easier for us to start thinking about how to improve. And then we start talking about, which I bring up in the in the Substack: Deming, and the Deming cycle of observe, measure, and then improve, which is now commonplace in industry—that's the way industry looks at quality improvement—will actually be something we can embrace in medicine. And I think that's going to be to the benefit of just about everybody.

Look, you can claim anything, right? But I think when we get to the point where you can actually measure it and start looking at ways to make things better, it'll benefit all of us a ton.

Hennessy: As we think about quality, from a patient perspective, obviously we hope that the medical care that's being delivered is of high quality, but things like wait times, things like out-of-pocket costs, contribute to that quality equation for patients.

Do we integrate those two or are those two separate pillars that somehow have to stand together? Those are both elements that we have to be working on in health care to deliver what patients might expect to be calling high quality.

Dr Kolodziej: Oh yeah, absolutely. So, yeah, I think, you know, proving that your doctor is treating according to best evidence-based medicine, and making sure that the patient's satisfaction measures around things like wait time, those can be done, they're not mutually exclusive, right? They will provide a profile.

I think what's more of a challenge is how do we ensure that what we learn becomes transparent? That is that we are able to allow patients to see this kind of information. We haven't done so great on transparency in health care if you think about it. And it's something that we're going to have to put our mind to.

Hennessy: Thank you for watching this installment of Breaking Down Health Care. We hope you enjoyed the conversation and learned something you didn't know about health care and how it works in the United States. If you have questions or topics you'd like Mike and I to discuss, you can use the Contact Us feature on the website. Tune in for future conversations because we're just getting started.