Do quality metrics actually improve care?
With Medicare and commercial insurers increasingly tying physicians’ reimbursement to their ability to report on—and meet—outcome measurements, the question logically arises, is it working? Is the growing emphasis on quality and value having an impact on patient health, and/or healthcare spending?
The short answer is, it’s too soon to tell. Still, intriguing—if scattered—evidence is beginning to emerge that it might be. For example:
Medicare spending for 2014 was projected to be about $1,200 less per beneficiary than had been forecast in 2010, the year the Affordable Care Act was passed, according to a Kaiser Family Foundation study. The slowdown in spending is partially attributable to “reductions in provider payment updates and Medicare Advantage payments” as well as cuts resulting from the 2013 budget sequester, the authors say, while adding that “providers may be tightening their belts and looking to deliver care more efficiently in response to financial incentives included in the ACA, and it is possible that these changes are having a bigger effect than expected.”
The National Council of Quality Assurance, in its study “The State of Health Care Quality 2014,” found improvements in 46% of the 139 Healthcare Effectiveness Data and Information Set performance measures it tracked over the previous three to five years, performance declines in 8%, and mixed results or no trend in 46%.
Medicare’s evaluation of the first year of its Comprehensive Primary Care (CPC) initiative, a collaboration between public and private payers designed to improve primary care delivery in seven regions, concluded that “CPC appears to have reduce total monthly Medicare Part A and B expenditures per beneficiary …. by $14, or 2 percent. The reductions appear to be due to the favorable…impacts on hospitalizations and emergency department visits (total and outpatient.)” The evaluation also found a four percent reduction in unplanned 30-day hospital readmissions, a decline it calls “sizable but not quite statistically significant.”
The national 30-day, all-cause hospital readmission rate average for Medicare fee-for-service beneficiaries fell from 19% in the 2007-2011 period to 18.4% in 2012, according to a 2013 study in Medicare & Medicaid Research Review. The readmission rate fell below 18% for the first part of 2013, Medicare subsequently reported.
“I’m a contract negotiator, and from my perspective I can tell you payers wouldn’t be investing (in quality initiatives) if they hadn’t already seen the outcome and the return on investment,” says Doral Jacobsen, MBA, FACMPE, senior manager with DHG Healthcare. “So pieces of this are working, though it varies by market and by practice.”
Nitin Damle, MD, FACP, a member of the American College of Physicians Board of Regents, is more cautious. “We feel that a more value-based approach to practicing medicine is important, so moving away from pure fee-for-service to a more value-based reimbursement system is the direction we want to move in. But we’re not sure yet if we are moving the needle in terms of whether patients overall are getting a higher quality of care.”