Many of us have sat and wondered, if one could define something as high quality, what would that sound or look like? Many times, we would come up with multiple meanings and visions, depending on the circumstances we were involved in, or what we were looking for at a given moment. While many physician practices are signing on to value-based agreements, and being compensated for improving on quality measures designed by third parties, ensuring cost-effective management of acute and chronic conditions, working hard to improve overall scores on HEDIS and STARS, the question remains, what do patients think about this? Do they truly understand quality and appreciate the amount of work that goes into improving quality of care?

The term “quality” typically, involves providing a “value”,

• Quality is the customers’ perception of the value of the suppliers’ work output.
• Quality is seen as error-free, value-added care and service that meets and/or exceeds both the needs and legitimate expectations of those served
• The word “Quality” represents the properties of products and/or services that are valued by the consumer
• “Reducing the variation around the target”

Then there are the more humorous definitions of quality from the late Jackie Mason, who defined his “high quality” doctor, “I know I go to the biggest and best doctor in New York. He is so good and so big that I can never get an appointment to see him.”

A more logical approach to quality, which is “when the customer returns, but the product doesn’t.”

Of course, there is the definition that was a takeoff from a well-known movie, “Quality is never having to say you’re sorry”!

Quality in healthcare is an enigma for many. How does the typical layperson know if they are receiving high quality care? There are certainly a lot of commercials across various media outlets that talk about cancer centers, orthopedic centers, as well as commercials that highlight people with past medical problems treated at tertiary care centers who claim they would not be here if it wasn’t for the doctors at those centers. Does that define quality? Here is what I have seen those individuals not in the medical field depend on to define quality:

• Utilizing the “3 A’s” of healthcare: These include the following in the order written
  • Availability: I can see a doctor NOW because I am sick…he/she is great because they squeezed me into their schedul
  • Affability: What a nice person the physician is. He explained things and treated me well
    • I have also heard remarks from people about how good looking the doctor was, but not sure that qualifies as an “affability” statement
  • Ability: Here the best definition I have heard from lay individuals is “after going to the doctor, I felt better almost immediately.” Also, “I am so glad he gave me those antibiotics for my cold, I got better in about a week instead of the seven days that poor Jenny needed to lay around for.”
• Soliciting feedback on social media seems to be the most common way to find the next greatest physician, as does reviewing Yelp or Google reviews. More on this later.

So, how we have done selling objective measures of quality? Essentially, we have done a terrible job in helping lay individuals understand quality in healthcare. To start, let’s evaluate what professionals consider for reviewing quality in healthcare:

Joint Commission (JC)
The JC has done a great job in building itself as the premier organization for hospital accreditation. It focuses primarily on patient safety and quality of care. The JC does this by performing an in-person survey, on key elements for inpatient care.

Along with the actual review of documents, the survey involves “tracer methodology”, that allows a JC surveyor to follow a patient or process from the beginning (admission or through the Emergency Department), though their hospital stay and the discharge process. This is supposed to give surveyors a sense of how processes work in real time at a facility.

The Joint Commission is not without faults. While surveys are supposed to be a “surprise”, most facilities have a pretty good idea on when they are coming and usually have a 60-day window during which there is a period of frantic preparation. Advance preparations that take place include clearing of hallways, securing medical records, completion of discharge summaries and other housekeeping chores. Employees are prepped on what to say during an interview and how to respond to questions that might be asked by a surveyor inquiring about an issue.

In 2000 the JC introduced a 10-point pain scale. The purpose was to address the underassessment and undertreatment of pain during a hospital stay, a concept introduced in the 1990s. Physicians were charged with making sure patients remained relatively pain free, primarily by ordering pain medications during the hospital stay, and at the time of discharge. Later, it became clear that this practice significantly contributed to the over-prescribing of medications and the opioid epidemic we see today.

National Committee for Quality Assurance (NCQA)
NCQA was established in 1990 with the primary purpose of reviewing and certifying health plans, a growing entity in healthcare. Since that time, NCQA has expanded their role into the certification of medical groups for specialized care, including excellence in the care of patients suffering from diabetes and strokes and Patient-Centered Medical Home, for example. The standards developed and followed by NCQA includes areas of quality of care, process and workflows for services related to Population Health, patient and provider rights, including oversight of appeals and grievances processes as well as credentialing and recredentialing.

In 1999 NCQA offered up a program to measure quality performance for health plans on behalf of their membership. At that time if was referred to as the Health Plan Employer Data Information Set or HEDIS that consisted of over 56 measures across 8 domains of care: (1) effectiveness of care; (2) access and availability of care; (3) satisfaction with the experience of care; (4) health plan stability; (5) use of services; (6) cost of care; (7) informed health care choices; and (8) health plan descriptive information) applicable to the commercial, Medicaid, and Medicare populations. In 2007 NCQA changed the name to the Healthcare Effectiveness Data Information Set to be more consistent with the purpose of the program.

Since then, NCQA has developed additional programs that cover a wide range of areas regarding quality of healthcare delivery. The question remains, how have all of these programs improved layperson awareness of objective measures in quality care? To date, there is information available regarding choice In health plans based on HEDIS and STARS scores (that uses HEDIS measures to make up a large part of the content of STAR measurements), but little to offer patients any insight into quality care provided by physicians or other providers.

There are other programs and organizations that address various aspects of care and that rate hospitals and physicians from different perspectives. These include:

• Merit-based Incentive Payment System (MIPS): A program using standards of care to make Medicare programs more relevant to real-world practice and offer incentives for better care. Results are not generally shared with the public
• Leapfrog Survey: A self-described watch-dog organization that publicly reports on critical safety and quality information, that can help identify better care for healthcare consumers and purchasers. The organization uses management standards in several areas including pediatrics, maternity care, critical care, complex surgery, intensive care unit care, joint replacement, medication safety, outpatient care, preventing and responding to patient harm and patients’ rights and ethics
• Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): The first national, standardized, publicly reported survey of patients’ perspectives of hospital care. The survey is shaped by three broad goals that are relevant in any hospital facility. The three goals of the survey include: creating incentives to improve the quality of care, producing comparable data on patient’s perspectives, and increasing transparency within healthcare to make the public more accountable.
  The HCAHPS survey is more connected to the patient’s actual experience and asks about doctor and nurse communication, staff responsiveness, the hospital environment, pain management, medication communication, discharge information, care transitions, overall rating of the hospital, and likelihood to recommend the hospital. In addition, for hospitals participating in the Hospital Value-Based Purchasing Program, higher HCAHPS scores mean higher reimbursement rates from CMS.
• US News and World Report: A print media organization that reviews hospitals and their performance of various procedures and scores them based on their success rates. The issues around co-morbid conditions are typically not considered and hospitals are given ratings and not rankings. As noted by US News and World Report, it is a “good starting point” for identifying hospitals that perform certain procedures better.
• State Based Databases: Many states have implemented databases and registries for tracking the performance of key procedures and hospital quality. New York, for example, developed a database known Statewide Planning and Research Cooperative System or SPARCS, which is a comprehensive all-payer database initially developed in 1979. SPARCS currently collects patient-level detail on patient characteristics, diagnoses and treatments, services, and charges for each hospital inpatient stay and outpatient (ambulatory surgery, emergency department, and outpatient services) visit; and each ambulatory surgery and outpatient services visit to a hospital extension clinic and diagnostic and treatment center licensed to provide ambulatory surgery services and is one of the most comprehensive databases of its type in the country.
• Health Insurance Ratings: Around 2008, many health insurance companies began utilizing their databases to rank physicians based on quality and cost efficiency, for the purpose of directing patients to those physicians with the best performance in those areas. Programs were developed to assess quality based on measures and adherence to guidelines that were, in most cases, third-party sourced to nationally recognized entities who published their guidelines. Data was extracted from claims for quality, and cost efficiency was determined based on the use of episodes of care (software that looks at the total cost of treating a condition, either acute or chronic) that are both risk and severity adjusted.
  The health insurance ratings generated some concern from physicians who felt they were “black boxes” and not well understood and lacked oversight. States across the country soon joined together and NCQA was chosen to develop a standard process and certification for programs, including allowing physicians to challenge the results and have a reconsideration process in place.

While many insurance companies have discontinued their programs, others have refined their programs somewhat and continue to offer information on highest ranking practices and physicians within several specialties.

What Do We Need to Do Next for Quality
Healthcare has certainly come a long way since the days when quality was purely subjective. Now that data is more readily available, more objective measures in quality should help shape the future of patients’ determination in where they get their care. The information provided to healthcare providers and to the general public is plentiful…sometimes too plentiful. What data is needed and the veracity of data remains in question as well as the sources of this data. So how do patients and even providers decide what is important, and what is relevant? How do quality measures for value-based care figure into a patient’s decision-making?

Right now, the public use of data is in question. It appears that the deluge of advertising across various media sources and social media “recommendations” continues to create confusion and sometimes competes with objective information. Media sources have taken up the direct-to-consumer advertising mode, typically based on patient anecdotes on how they survived catastrophic medical problems by seeking care at this health care system. What the relevance to someone who does not have that rare or advanced diagnosis remains in question. At best, the information, while tugging at the heart strings, does little to provide objective data into success rates of treating patients with the same or similar conditions.

Social media has become a repository for “recommendations” for physicians. Not a day goes by that my social media feed doesn’t have at least three unique threads of conversation looking for a physician who can treat their condition, and meets their own requirements of location, office hours, gender preference, hospital privileges or specifics around the ability to treat certain conditions. I have seen requests looking for an orthopedist who can do shoulder replacements, gastroenterologists to perform screening colonoscopies, ENTs for clearing cerumen and cardiologists typically categorized by sex, hospital affiliation, procedures performed in their office or convenience to certain towns or neighborhoods. These requests are going out to individuals of all kinds of backgrounds and experiences…but few who actually have experience in healthcare or would be qualitied in assisting in directing the poster to the “best” options available. I know that when I have suggested that the individual go back to their referring physician to get names of physicians who provide the necessary services, or consult publicly available databases for doctors rankings, I usually get pummeled by “keyboard warriors” who appear to have a much better grasp of what a good doctor is who would fit the needs of that person than I would after over 15 years in analytics.

Clearly, we need to do a better job at helping people identify better providers of care. Physician groups and organizations work hard at improving their quality scores and overall health outcomes of their patients. Yet, most of that goes unrecognized because communications on the quality performance and what it means remain limited. Helping individuals navigate information on quality will help push people into getting better care. Higher revenues from better quality scores can be compounded for an office that demonstrates real improvement in treatment and prevention of disease and keeps patients healthy by attracting more patients looking for better care.

If you would like assistance in understanding how you are performing or how to improve your own healthcare delivery and improve the quality of care you provide as well as value-based compensation, contact us at info@copehealthsolutions.com.