Quality of Healthcare

Healthcare quality (IOM) is defined as the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes consistent with currrent professional knowledge. Elaborating further, care delivered should be safe, effective, patient-centered, timely, efficient and equitable.

Right care in the right place at the right time at an affordable cost(as per the Australian Institute of Health )

The Institute of Medicine defines health care quality as “the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

The Agency for Healthcare Research and Quality  (under the Department of  Health & Human Services ) states the goal from providers’ perspective:  “Care delivered should be safe, effective, patient-centered, timely, efficient, and equitable.” This underscores the crucial role of healthcare professionals in ensuring the quality of care.

More importantly, the following statement summarizes well the goals that are relevant for healthcare consumers: 

Consumer Perspectives

The IOM’s framework plays a pivotal role in comprehending consumer perspectives on healthcare needs. It offers a holistic view of healthcare needs, with reporting categories developed based on Foundation for Accountability (FACCT) research that elucidate how consumers perceive their care. These categories include:

• Staying Healthy. Getting help to avoid illness and remain well.
• Getting Better. Getting help to recover from an illness or injury.
• Living with Illness or Disability. Getting help with managing an ongoing, chronic condition or dealing with a disability that affects function.
• Coping with the End of Life. Getting help to deal with a terminal illness.

The Australian Institute of Health and Welfare states the following: 

Right care in the right place at the right time at an affordable cost.

This simplified version by The Australian Institute of Health is the only one which addresses the issue of healthcare costs.

Among the various quality measures, safety and effectiveness of treatment stand out as the most critical. This is not just a viewpoint, but a consensus among all healthcare experts. Let’s delve deeper into this: All healthcare experts agree that care delivered outside the hospital can significantly reduce the risks associated with hospital-acquired infections and other safety concerns, such as errors in a highly complex hospital system. For instance, during the COVID-19 epidemic, the most suitable care setting for an elderly patient was outside a nursing home or assisted care facility. Prompt care, or care delivered at the right time, should be easily accessible, especially for emergencies or urgent health issues. There should be no cumbersome barriers when a patient facing a medical crisis needs urgent care.

Effective care implies care delivered to those who need it based on scientific evidence. It involves accurate diagnosis, knowledge of the natural history of a disease or prognosis, targeted treatment, and, importantly, avoiding the overkill of multiple therapeutic agents trying to “cover all bases.” 

 Practitioners should ensure that Equitable healthcare is not compromised on the grounds of gender, ethnicity,race, or sexual orientation.

Another challenging facet of health care is multidimensional integrated care for patients with chronic conditions and facing increasing infirmities of aging. It involves a team of professionals and support staff who address the challenges that patients with multiple impairments and disabilities have to endure. The thorniest part of the above discussion is the issue of cost of care, particularly for patients with health coverage with high deductibles, co-payments, co-insurance payments, and substantial out-of-pocket expense exposures. 

CMS (Centers for Medicaid and Medicare Services ) is pushing for payment reform based on performance and outcome criteria. A bewildering array of quality criteria is being employed to monitor and assess these criteria. The whole thrust is the development of alternative payment models for providers based on the value of care to replace the existing system of payment based on the volume of care.

As per the Bloomberg Law Article of September 2021 by Allie Reed, providers paid by the CMS are incentivized to report specific metrics about the quality of care they deliver, which determines whether they gain or lose funding. The 729 measures that providers must report back to the agency as part of quality programs reflect the healthcare industry’s significant shift from payment for quantity of services to value-based payment for quality of services. This shift has significantly increased the administrative burden on healthcare providers, as they now have to spend more time and resources on reporting and documentation, which could otherwise be utilized for patient care.

In an article published in Health Affairs in March 2016,  healthcare experts evaluated four practices in Family Medicine, Internal medicine, and Cardiology. The following is the summary of their findings:

Practices spent 15 hours per MD per week reporting on quality data; out of these, MDs spent 2.6 hours per week. The financial implications of this reporting were significant, with the average cost for the organization being $40,000.00 per MD per year. The total cost for reporting for all organizations amounted to a staggering $15 billion dollars in 2015, underscoring the financial burden on healthcare practices.

It’s not surprising that four out of five physicians in the surveyed practices didn’t feel that the quality of care was being enhanced. They were not only frustrated with the time, effort, and expenses involved in reporting, but it was also leading to burnout for some physicians. This aspect of the quality reporting process highlights the need for a system that not only measures quality but also supports the well-being of healthcare professionals.

 In a JAMA Forum on 7/4/2017,  Dr.Ashish Jha, Dean of the Brown University School of Public Health and Biden Whitehouse Covid-19 coordinator, offered the following critique about quality measures:

-Too many quality measures of dubious value

-Let patients decide what comprises high-quality care

Lawton Burns and Mark Pauly, economists at the Wharton School, published a detailed analysis and sobering critique of APMs  ( Alternative Payment Models )  in the following article in the March 5, 2018, edition of the Milbank Quarterly.

“Transformation of the health care industry: Curb your enthusiasm.”

Their conclusion: “The transformation from ‘volume to value’ in health care … appears to be driven more by ideology and aspiration than by evidence. To date, APMs  (alternative payment models) show limited improvements in quality and even more limited cost reductions.

Sara Heath, the managing editor of Xtelligent Healthcare Media Network, writes a website called PATIENT ENGAGEMENT HIT.

On 12/4/2017, she reports as follows:

“Patients and providers don’t always see eye to eye in terms of what constitutes “value” in healthcare, leaving a gap in what providers can deliver to meet growing industry demands for patient-centered care, according to a report from the University of Utah Health.” 

This report surveyed seven hundred providers and over 5000 patients.

Just focussing on patient perspectives, she points out the following salient points: 

• *No two patients are alike. Ninety percent of patients picked different combinations of value statements than providers!
• *Patients have individual priorities from one another and also different from the physician’s viewpoint 
• *Unlike providers, patients were mainly concerned with cost and said they were unlikely to pay more for care even if the care met all value expectations per expert guidelines.
• Researchers noted that consumers are behaving as they do in almost every other industry—as individuals with different views of what comprises value.

As Sarah Heath’s article alluded to above, patients were particularly concerned with the cost of care (which they would be responsible for) and thus likely to avoid care even for urgent issues except in dire circumstances. 

To summarize, there is a lot of NOISE in the provider community regarding improvements in healthcare quality by APMs to providers.

These measures may help individual groups of patients with specific diseases, such as diabetes, in disease management programs, but they are unlikely to help most patients.

What should matter to patients is how they can receive safe, accessible, affordable care without medical or financial harm (by avoiding unnecessary tests or treatments ) in a timely manner. 

The sad reality (as noted earlier in Burns and Pauly’s critique of the current provider payment reforms) is that most patients and families will have to work hard to seek safe, effective care that they can afford ( in terms of copays, deductibles, etc.) in accordance with their own values and preferences. 

Let us look at innovative payment models being tried out by providers to reward high-value care and reduce low-value care. This will add to our insight into educating patients about how they can minimize low-value care and thus reduce the financial burden they face in the system.

At the University of Michigan Center for Value-based Insurance Design ( V-BID), Drs. Mark Fendrick and Michael Chernew describe the concept of providers adopting payment policies and models as the “peanut butter “on the supply ( provider ) side and patients embracing the avoidance of low-value care as the “jelly” on the demand ( Consumer) side.

Oregon Public Employees Benefits Board has instituted lower premiums and lower cost-sharing for high-value services and increased cost-sharing for low-value services. For example, there is a copay of $100.00 plus coinsurance of 15% for MRIs, CT scans, PET scans, sleep studies, spinal injections, EGD endoscopies, bunionectomy, and knee joint viscous supplementation injections. Also, there is a copay of $500.00 plus coinsurance of 15% for Total Hip Replacement, Total Knee Replacement, Arthroscopies, bariatric surgery, spine procedures, and sinus surgery. As patients have the utmost fear of cancer, the Oregon Board did not enforce co-payments on employees for low-value cancer care received. It is tough to implement high deductibles (“penalties”) for low-value cancer at an organizational level.  At an individual level, though, the patient is free to make rational choices in avoidance of procedures and treatments in cancer care that are of marginal value.

At Mayo Clinic in Rochester, Minnesota, the health plans for their employees have zero copays for primary care and a $25.00 copay for specialist care. For procedures, there is a coinsurance of 10% to 20%. This policy has reduced specialist visits and testing procedures for Mayo employees. I should note that  Mayo Clinic is a world-class healthcare institute that draws prominent international and US dignitaries seeking care in Mayo Clinic. 

For State of Connecticut employees, members are encouraged and incentivized to adhere to evidence-based services; those who were not willing to accept these guidelines had to pay a $100.00 surcharge premium per month and a deductible of $350.00/member annually. There was a similar surcharge for using Emergency Department Services if a reasonable alternative existed. If the ER visit resulted in hospitalization, the surcharge was removed.

The state of Connecticut’s policy for the coverage of its employees is a good innovation. There is a great need for a nationally available affordable health insurance plan (based on the principles in the Connecticut plan)  that would cover only evidence-based care without surcharge. Some bright professionals and actuaries in the Insurance industry can perhaps devise an affordable plan that could provide immense relief to millions of Americans and their families. 

In his book “Priced Out”, Uwe Reinhardt , offers some advice about setting up a plan that would satisfy the Libertarian traits in a good number of Americans. If a reader is interested , he can read the details of the program in his book.