Do. Or do not. There is no try. Yoda’s advice may be a little black and white, but it gets to the heart of why value-based reimbursement puts such a focus on health care outcome measures.
As payers increasingly negotiate value-based care contracts with providers, these measures help ensure that providers deliver high-quality care to your employees in efficient, cost-effective ways. And providers have every reason to hit their marks — not just because patient health is tantamount, but because a portion of their potential payment is tied to their performance. Here’s how it all goes down.
Measuring Value-Based Care
Providers are assessed on various quality measures, but the two most important ones are process and outcomes. Process measures can record how many times a service was performed for a targeted population, such as the number of people with diabetes who have their blood pressure tested, how many women over 45 receive breast cancer screenings or even how often — and how well — clinicians wash their hands.
Outcome metrics, on the other hand, gauge results, such as what a doctor’s surgery-induced mortality rate looks like or whether a patient picked up an infection in the hospital. Providers generally report these health care outcome measures to payers, including Medicare and commercial insurers. Payers use these metrics to provide bonuses to or impose penalties on providers.
Process measures are an important first step, but it’s outcomes that make the difference in improving care and controlling costs. There are hundreds of health care outcome metrics, but that’s a lot to keep track of. These three categories are among those most worth your attention.
1. Patient Safety
Safety-of-care outcome measures cover avoidable medical errors. A landmark 2016 BMJ study concluded that medical errors are the third leading cause of death in the U.S.
Dozens of metrics fall under the safety rubric, including the rate of surgical complications and skin breakdowns. For example, a skin breakdown — a bedsore, for instance — occurs when pressure decreases blood flow to the skin. It’s almost totally preventable, and it often happens when a patient isn’t moved enough. Providers can use skin assessment tools to evaluate safety measures and ultimately reduce the risk.
Another aspect of patient safety is medication safety. The Annals of Pharmacotherapy estimated the cost of prescription drug-related morbidity and mortality at $528.4 billion each year and noted that the problem isn’t due to patients skipping their medicine. Instead, it found a larger problem of “nonoptimized” medication therapy.
2. Avoidable Readmissions
Each year, between $25 and $45 billion goes toward avoidable complications and unnecessary hospital readmissions. That said, this trend is on the decline, in large part because of metrics associated with Medicare’s Hospital Readmissions Reduction Program. Under the program, hospitals face penalties of up to 3 percent of Medicare’s reimbursement if they have higher-than-expected unplanned 30-day readmission rates. In 2018, hospitals lost more than $500 million in potential revenue.
Before the program began, hospitals received the same amount of money regardless of how their patients fared after discharge. If you’re cynical, you might point out that a readmission — even a totally avoidable one — was financially advantageous: Hospitals would be paid again for the second hospital stay. Now, it’s a financial drain.
National data from as recent as 2015 indicates that readmission rates have decreased for both Medicare patients and those with Medicaid or private insurance. This suggests that hospitals and health systems are making significant changes, not only to avoid the penalties but also to improve overall quality of care. The first conditions covered by the penalties were heart failure, heart attacks and pneumonia. That’s since expanded to include several others, including hip and knee replacements and chronic obstructive pulmonary disease.
The specifics are still being refined, but readmission penalties in some form are here to stay. Private insurers often take a cue from Medicare, and there’s no exception here, with some rewarding hospitals that reduce readmissions.
3. Patient Experience
Don’t confuse this with patient satisfaction. Patient experience surveys ask about elements like patient-clinician communication, patients’ understanding of medication instructions and the efficiency of the discharge process. Research suggests that good patient experience often correlates with better care.
This information comes directly from the patient, family or caregiver — it’s not filtered through the provider. The most common patient-experience surveys are in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of surveys. Some CAHPS surveys are specific to a condition or provider type, but they all have the same general purpose: to assess patient-provider communication, the hospital’s environment and the discharge process.
The Right Tool Is Not Enough
It may be helpful to think of outcome metrics as an evaluation of how providers use the tools they have. Process measures are important because they assess whether providers are using the right tools, but that can’t be the final measure. The right tool is useless if it’s not used properly. What really matters, ultimately, is that outcomes improve, and that only happens when these tools are used to create positive change and show the benefits of value-based care.
This brings us back to Yoda. You know, initially, that trying is important. That’s why process measures are a good place to start. But ultimately, it comes to the result: Do or do not. And that’s something that can only be measured by outcomes — your employees’ health.