by Wyn Staheli, Director of Research
November 3rd, 2017
One important component of health care reporting is the utilization of quality measures which are typically classified into one of three broad categories: structure, process, or outcome.
- Structural measures define the healthcare provider’s capacity, systems, and processes (e.g., EHR use, ratio of providers to patients)
- Process measures indicate what providers do to maintain or improve health (e.g., preventive services like mammograms, blood sugar testing for diabetics)
- Outcome measures are intended to indicate the impact of provided healthcare service(s) on the overall health status of the patient
All three measure types are essential to assessing improvements in providing care and have also begun to play a critical role in payment systems such as Medicare’s Quality Payment Program (QPP). It should be noted that sometimes one type of measure affects another. For example, if blood sugar testing is not done (process measure), diabetic patients have adverse consequences (poor control outcome measure). A statement by the Center for Medicare and Medicaid Services (CMS) demonstrates this inter-connectedness. One of the stated goals of QPP is to “Emphasize outcomes, including patient-reported outcome measures (PROMs) and measures of functional status; and global outcome and population-based measures, balanced with process measures that are proximal to and strongly tied to outcomes.”
Although it may seem like yet another administrative burden to providers since most measures are not billable services, these quality measures serve an important purpose. The data gathered from these measures allows researchers and payers to evaluate the effectiveness of treatment protocols with the ultimate aim of disseminating the best patient outcomes through proven, evidence-based practices. Both providers and patients need this information to be able to make the best-informed treatment decisions.
There are many organizations which are working together to establish quality measures. Professional organizations are encouraged to participate in the National Quality Forum (NQF), which works with the Measure Application Partnership (MAP) to establish the quality measures used by CMS. Other organizations working on quality measures are the National Committee for Quality Assurance, The Joint Commission (TJC), and the National Association for Healthcare Quality (NAHQ).
This remainder of this article focuses on outcome measures which have a primary goal of:
- Improving individual patient care
- Improving overall population health
- Reducing per capita healthcare costs
All those involved in health care, from payers to providers, agree that these are worthy goals. The Institute for Healthcare Improvement (IHI) calls this the “Triple Aim” and describes outcome measurement as “a critical part of testing and implementing changes. Measures tell a team whether the changes they are making actually lead to improvement.” According to the HealthCatalyst website, the following are some reasons why healthcare organizations measure outcomes:
- Reveal areas in which interventions could improve care
- Identify variations of care
- Provide evidence about interventions that work best for certain types of patients under certain circumstances
- Compare the effectiveness of various treatments and procedures
It should be noted that CMS has different, yet somewhat overlapping, outcome measures for providers than for facilities. Provider-reported outcomes are heavily focused on clinical care and the patient/caregiver experience whereas hospital outcomes (in order of importance) are: mortality, safety of care, readmissions, patient experience, effectiveness and timeliness of care, and efficient use of medical imaging. CLICK HERE to read more about CMS’s Hospital Inpatient Quality Reporting Program.
For providers, two very important outcome measure categories which were considered top priorities in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are clinical care and the patient/caregiver experience.
As the title implies, clinical care measures are those directly related to care provided and include the following:
- health outcomes (e.g., pain management)
- clinical processes (e.g., controlling high blood pressure)
- patient safety (e.g., use of high-risk medications in the elderly)
- efficient use of health care resources (e.g., use of imaging studies for low back pain)
- care coordination (e.g., diabetes management)
- patient engagements (e.g., initiation and engagement of alcohol/drug dependence treatment)
- population and public health (e.g., preventive care and screenings)
- adherence to clinical guidelines (e.g., CMS’s “Statin Therapy for the Prevention and Treatment of Cardiovascular Disease” protocols)
These measures can include patient reported outcome measures (PROMs) and functional status measurements which are closely tied to outcomes, performance measures, and other topics important to everyone involved in health care. Some are based on evidence and clinical practice guidelines from professional clinical societies.
Patient and Caregiver Experience
These measures focus on patient-centered care and family and caregiver experiences such as organizational structures or processes that foster the inclusion of persons and family members as active members of the health care team and collaborative partners with clinicians and provider organizations. According to CMS, “This domain also includes PROMs that assess patient-reported experiences and outcomes that reflect involvement of persons and families in the care process and demonstrate knowledge, skill, and confidence to self-manage health care.”
Patient compliance is closely tied to other clinical outcomes. For this reason, payers and healthcare providers, as well as organizations, track this measure. For example, the Medicare Advantage program uses the Health Outcomes Survey to evaluate their “ability to maintain or improve the physical and mental health functioning of its Medicare beneficiaries.”
Patient Reported Outcome Measures (PROMs)
As has been noted, PROMs play an important role in several types of quality measures since they help to identify many types of patient problems including pain, fatigue, depression, and social or physical functioning. This is why they are also an integral component of integrated care models. Many organizations are using them to find associated conditions (e.g., depression) or obstacles (e.g., mobility issues) which are contributing factors to overall patient health. For example, when a questionnaire identifies depression or pain control issues, treating these comorbid condition(s) can lead to better outcomes.. PROMs can also help to identify patients that need a change in a treatment plan, as well as establish medical necessity for payers (e.g., Oswestry Disability Index).
While the patient’s perceived quality of care may not tell the full story, there is value in tracking this information. For example, the UK’s tracking of patient outcomes for joint replacements through PROMs identified a problem which resulted in a manufacturer’s recall. According to an article by Harvard Business Review, “[Recent] strong evidence suggests that improved patient satisfaction is in fact correlated with better health outcomes and quality: Increased satisfaction is associated with decreased length of hospital stay, lower readmission rates, reduced mortality, and fewer minor complications.”
There are thousands of PROMs which could be used by providers. They can be administered via paper or electronically. Some are even included as a requirement for certain types of services (e.g., annual wellness visit, health and behavior assessment) so be aware of those requirements.
PROMs also play a role in payment. As stated earlier, they can establish medical necessity. Additionally, they can be tied to reimbursement rates through the Quality Payment Program (QPP). For example, the following are some of the PROMs listed in the 2017 Quality Measure listing for the QPP:
- 222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
- 219: Functional Status Change for Patients with Foot or Ankle Impairments
- 223: Functional Status Change for Patients with General Orthopaedic Impairments
- 218: Functional Status Change for Patients with Hip Impairments
- 217: Functional Status Change for Patients with Knee Impairments
- 220: Functional Status Change for Patients with Lumbar Impairments
- 221: Functional Status Change for Patients with Shoulder Impairments
- 342: Pain Brought Under Control Within 48 Hours
- 435: Quality of Life Assessment For Patients With Primary Headache Disorders