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Medicare Doc Payment Bill May Be Vehicle to Tighten Quality Measurement

By John Reichard, CQ HealthBeat Editor

Medicare and other insurers should sharply reduce the number of measures they use to assess the quality of care so that they focus on a few pivotal outcomes of treatment—not on how care is delivered.

That was the message delivered in testimony last week before a Senate Finance Committee hearing that included sometimes blistering criticism of the state of the national quality improvement movement.

Chairman Max Baucus, who described the hearing as a "gut check" on national efforts to improve quality over the past decade or so, appeared strongly interested in winnowing down the number of measures. More than once he broached the possibility of including such changes in legislation addressing Medicare physician payments.

Medicare "uses 1,100 different measures in its quality reporting and payment programs," the Montana Democrat said in his opening statement. "Do we really need more than a thousand measures?"

"The collection of data needs to be as streamlined as possible," agreed the panel's top Republican, Sen. Orrin G. Hatch of Utah.

Former Centers for Medicare and Medicaid Services (CMS) Administrator Mark McClellan called for action this year by his old agency to shift the focus of quality measurement to such outcomes as whether a patient actually loses weight or quits smoking rather than more "process" oriented measures, such as whether a physician tracks the body mass index of a patient or provides counseling on smoking cessation.

Part of the process needs to involve changing payment, McClellan said. Adding outcomes measures on to the current fee-for-service system won't be effective, he said. Such measures need to increasingly be incorporated into models of team-based care, such as accountable care organizations and patient centered medical homes, he said.

McClellan said even a short-term doctor payment fix could be a vehicle to begin setting such changes in motion.

David Lansky, CEO of the Pacific Business Group on Health, spoke on behalf of such purchasers as Boeing, Target, Disney, Wal-Mart, Intel, GE, Wells Fargo and the California Public Employees Retirement System.

"When I asked our members last week how they would describe the value of our national quality measurement efforts to their own companies, they responded with one word: 'abysmal,' " he said.

"Our large employer members believe that providers should be required to measure and report the outcomes that American families and employers care the most about—improvements in quality of life, functioning and longevity," Lansky said.

"After a patient has a knee replaced, is her pain reduced, can she walk normally? Can she return to work? When a child has asthma can he play school sports, can he sleep through the night? Unfortunately, the measurements we use today leaves us unable to make many of these vital judgments about the quality of doctors, hospitals or health care organizations.

"Congress should direct CMS to identify and adopt useful standardized measures that address consumer and purchaser concerns far more quickly," Lansky added.

Minnesota a Model

Lansky cited Minnesota as an model for CMS to follow. Its statewide quality reporting and measurement system requires all orthopedic surgeons in the state to measure patient outcomes one year after surgery and to ask patients standardized questions about pain and functioning, he said.

Lansky said process measures can help providers improve quality but mean little to consumers. They "lock in the care processes of today that may not be the most useful tomorrow."

Process measures "should be developed and implemented by providers and professional societies in whatever ways they deem helpful toward improving the publicly reported outcomes," he said. "That way, patients have the information they most need to guide their choice of providers and treatments, and providers can identify priority areas and drive rapid improvement."

Christine K. Cassel, who heads the group that develops consensus among providers, government, consumers and others about which quality measures should be applied to providers in Medicare and elsewhere, said "the nation has not come as fast or as far as expected."

One reason is that electronic health records, although they are spreading through the health system, aren't well designed to capture performance data to assess quality of care, said Cassel, the new CEO of the National Quality Forum.

Data exists to begin developing outcomes measures, she added, but stakeholders have to agree on what to adopt. "If everyone agrees on the same basic measures, then we're all rowing in the same direction," Cassel said.

Cassel along with another witness, Elizabeth McGlynn, agreed that measures now aren't very useful to consumers. Wider use of a star system, such as the ratings of quality in the Medicare Advantage program that assess some plans as five-star plans would be more useful, they said.

McGlynn directs the Kaiser Permanente Center for Effectiveness and Safety Research. She said that the Kaiser health plan pays a lot of attention to getting high ratings on the star system. McClellan added that it would be nice if the Medicare Advantage program incorporated more outcomes measures into the star rating system.

McGlynn also said that quality has improved under process measures. She said that "within Kaiser Permanente, we were able to use our electronic health records to assess the delivery of preventive care interventions such as mammography screening" to detect breast cancer. "As a result, our rates are among the highest in the nation and our patients benefit."

She seconded McClellan's notion that payment must change if quality is to improve.

"Making progress on quality is hard work," she said. It "requires a team approach to problem-solving; it requires robust and timely information, effective leadership, and it might be easier to achieve if the way we paid for health care rewarded higher quality, not greater quantity."

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