“We really don’t care about whether a patient got a beta-blocker, or did a patient get an aspirin. What we really care about is did the patient live or die, or is able to walk a block or a mile,” Wachter says. “But we use process measures instead because there are fundamental problems with using outcomes: They take too long to accrue, you might lose those patients to follow-up, and the risk-adjustment problem is really tricky.”
For example, regarding those discharge instructions or any measure using a checklist, Wachter says, “There’s a decent chance that what [a clinician] will do is the least possible work, and then document that they did it.
“I’m not convinced that any of them are lying and not doing it at all, but I am convinced that discharge instructions can be anything from an hour of a nurse coordinator’s or physician’s time, sitting down with the patient, talking with them, making sure they say back what they were told. Or, it could be no more than handing someone with poor health literacy a brochure, and then checking the box saying we gave discharge instructions.
“Those are two fundamentally different acts, and right now, there’s no good way for the system to score them as being different,” Wachter says.
Mitchell, whose hospitals are located in Arkansas, Texas, Kansas, and Missouri, would rather be judged on the basis of outcome measures, three of which are set to be added to the VBP formula in 2014. And many more ways of measuring outcomes are destined to come eventually, shifting the weight of the scores away from processes.
Outcomes aren’t being scored right away because of questions about whether 30-day mortality for acute myocardial infarction, heart failure, or pneumonia, can be adequately adjusted for a patient’s comorbidities.