We're trying to fix a profoundly dysfunctional healthcare system. We need a way to incentivize quality. To do that, we have to find a way to measure quality and safety. Why is it taking so long to get this right?
I've been at this for a long time.
I remember sitting at a Washington D.C. press conference about Medicare's release of hospital mortality rates—30 years ago. Back then, what we now know as the Centers for Medicare & Medicaid Services was called the Health Care Financing Administration (HCFA). Ronald Reagan was president. I was young. And data was small.
The effort was a first pass at measuring hospital quality. Consumer groups welcomed the move; hospitals opposed it, saying the measures didn't adjust for severity of illness. HFCA admitted it was a crude first step and needed to be refined.
They tried, but within five years, they had given up.
Last week, that scenario replayed in miniature. Hospitals complained, members of congress lobbied and CMS decided to delay its planned update of hospital star ratings.
But CMS is no longer the only organization rating hospitals. On Monday, the Leapfrog Group released its latest patient safety report, complete with mortality measures.
So, the long journey to measuring the quality of care continues, and promises to stall once again, for better or worse. My Twitter stream, inbox, reading list, and, thus, this column have been filled with complaints about the relevance and volume of quality and safety measures such as mortality rates.
Related: Processing Quality Measures Costs $40K Per Physician Per Year
There are too many; they produce conflicting results; they are redundant; they vary from payer to payer; they're not based on science and they make measure compliance, such as zero readmissions, the goal, not better care. And they add to costs. Two people I talked to last week made the case that value-based payment programs should be put on hold until we figure out how to accurately measure value.
Driven by Politics, Money
Many of these complaints are valid. Still, the cliché that keeps crossing my mind is this: No good deed goes unpunished. We're trying to fix a profoundly dysfunctional healthcare system. We need a way to incentivize quality. To do that, we have to find a way to measure quality and safety.
Why has this been so hard to get right?
Let's go back to D.C. Despite their halos, many of the players in the healthcare reform debate are driven by politics and money, not good policy. Lots of people are making money off the way the healthcare system is now, including most hospitals.
Since Medicare and federal programs drive so much in healthcare, providers and their suppliers have armies of lobbyists on Capitol Hill. Their goal is to protect their share of the more than $1 trillion dollars [not a typo] that the feds will spend on healthcare this year.
Politics also played into last week's CMS decision to hold back on releasing its hospital data, data that critics say punishes hospitals that serve low-income patients. Leah Binder, the head of the Leapfrog Group, noted that 60 members of the Senate, who can't agree on anything else, agreed that they "need to be nice to hospitals. So they sent a letter and they put a lot of pressure on CMS, and that works in Washington."
'No Measures are Perfect'
The entire federal health quality enterprise has felt pressure from Congress over the years. Last summer, a version of the federal budget with no funding for the Agency for Health Quality Research made it to the House floor, but never passed. (Health policy types know how to lobby too.) And, for years, some Republican lawmakers have fought anything related to evidence-based guidelines, arguing that medical decisions best be left to doctors.
Now, it seems that objections to the proliferation of quality measures are more widespread, industry-driven, and bipartisan. Binder will have none of it. Her group chastised CMS for holding back its quality data.
"The measures are not perfect," she told me. "No measures are perfect, but they are very good. Consumers are entitled to know what we know about the relative performance of hospitals."
That is what Leapfrog, an organization started 15 years ago by large employers tired of paying high premiums, tries to deliver. It uses its own survey of hospital performance and combine that with data from the AHRQ, the Centers for Disease Control and Prevention (CDC), CMS and The American Hospital Association's Annual Survey.
Different Ways to Keep Score
This year, the Leapfrog Group took us back to mortality. The headline on its press release reads: "Selecting the Right Hospital Can Reduce Your Risk of Avoidable Death by 50%." Before you never set foot in your local B-rated hospital again, note the details. Ranking hospitals with letter grades, the report calculates that the rate of avoidable deaths per 1,000 admissions was
- 5.13% in "A" hospitals
- 5.56% in "B" hospitals
- 6.93% in "C "hospitals and
- 7.68% in "D" and "F" hospitals
That last number is what produces the 50% increase in relative value cited in the press release. If you slice off the D & F hospitals, which only represent 6.5% of all admissions—the relative odds of dying in the hospital are narrowed. But the accompanying analysis from a Johns Hopkins researchers puts another number on it: 33,495 patient deaths each year could be avoided if every hospital had earned an "A" rating from Leapfrog.
Much has been made of the fact that hospitals that do well on Leapfrog may not do well on the other widely referenced rankings from U.S. News & World Report and Medicare's Hospital Compare. So, I asked Binder why she thinks Leapfrog's rankings are better than the others. They're not, she told me, they're different. Leapfrog focuses on safety while the others look at a broader range of measures.
Her group's research found that consumers are not confused by conflicting ratings; they are used to them. On that point, hotel searches and restaurant ratings come to mind. Lots of critics disagree on the same movie. Check out the Rotten Tomatoes website sometime. Now Yelp and Facebook allow users to rate hospitals. Reportedly, they do a pretty good job.
Binder disagrees with the notion that conflicting ratings suggest that the measures are imprecise. She's also the only person I've talked to in weeks who is troubled by the growing complaints about quality and safety measures. Binder agrees that providers are burdened by measures. She says there needs to be some "strategic alignment" to make sure hospitals are not asked to account for six different measures from six different payers for the same procedure.
But is the outcry about precision or about money? She thinks that all this complaining began when payers started linking quality measures to reimbursement. She calls it a panicked reaction from providers who are worried that suddenly their pocketbooks are going to be affected by their own performance.
"I don't think it's an accident that we come to that pinnacle point, and suddenly we are hearing the backlash," she says.
Pinnacle point? Well, one pinnacle point of many, Binder says. She agrees that we are still not where we should in using measurement to reward good performance and change the way people seek healthcare. She suggests that providers step back and take a more measured response.
"We've got to [get to] a pinnacle because we have a movement for value and we have CMS behind that movement," she says. "We have a real effort to, in a meaningful way, tie payments to health systems to their performance on certain key measures."
Like mortality rates.
Binder says Leapfrog's findings are alarming. Want to another opinion? If you're looking to cross-reference the group's ratings with up-to-date data from the CMS Hospital Compare website, you'll have to wait.
The agency suggests the wait will be 3 months, not another 30 years.
Tinker Ready is a contributing writer at HealthLeaders Media.