“How Can You Tell If You Have Good-Quality Health Care?”

The blog title is a quote from Avedis Donabedian, a pioneer in the study of health care quality.

L Rosenbaum. NEJM 2022; 386: 1663-1667. Reassessing Quality Assessment — The Flawed System for Fixing a Flawed System

Background -Cost: “The Centers for Medicare and Medicaid Services (CMS) spent about $1.3 billion on measure development and maintenance between 2008 and 2018.3 Hospitals’ QI investments vary with their size, but data from the National Academy of Medicine suggest that health systems each employ 50 to 100 people for $3.5 million to $12 million per year to support measurement efforts…[and] if good care is the goal, the greatest cost of all this activity may be wasted time.”

Key points:

  • It is hard to know if health care quality is improving after early successes in “reducing nosocomial infections,8,9 improving surgical outcomes,10 and improving processes of care for patients with pneumonia, heart failure, or myocardial infarction.”
  • One study found only 37% of CMS’s Merit-Based Incentive Payment System for internal medicine were valid.
  • “Once a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure… a tremendous amount of resources are directed toward the appearance of quality rather than its substance… QI has become more a box-checking exercise for billing purposes than a meaningful act to improve care.”
  • Even if QI measures are important, there has not been adequate “consideration of whether the movement’s costs are justified by its benefits.”
  • Lost in the grumbling: “doctors want the best care for their patients.” However, there are considerable documentation burdens tied to demonstrating quality.
  • “Using internal performance standards to motivate better care — which many physicians embrace — differs starkly from using external financial incentives to improve quality.”
  • Quality metrics remain hampered by faulty risk adjustment.

Paradoxical Effects of Quality Improvement Efforts

  • Since ” better-resourced hospitals can afford administrative support to optimize billing, value-based payment initiatives can also worsen inequities…after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties…Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.”
  • Also, there is “the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices.”

My take: It is worthwhile to try to improve quality and value in healthcare, but, not surprisingly, quite difficult to achieve. Unintended associated consequences of current efforts include an epidemic of burnout and workforce demoralization.

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