Value-Driven Health Care

Over the last three years, I have been visiting different communities where groups have formed to pursue the measurement of quality. Generally, it has been a few curious doctors, convinced if they had a way to measure quality they could improve the outcomes. Other times, it would be a group of large payers looking for metrics that would allow them to negotiate lower prices. The best of these organizations however, are the places where all the stakeholders are working together.

The collective result of all these groups working independently was a large number of measures but not much standardization. Our progress was highly fragmented.

Great effort has been made recently among medical organizations, insurers, government, employers and unions to develop what I will collectively refer to as the “quality enterprise.” I’m referring to organizations like the National Quality Forum, the AMA Physician Consortium, the Ambulatory Quality Alliance and Hospital Quality Alliance and others.

I am a big advocate of this kind of collaborative stakeholder process. I think it is the best way to arrive at national standards. I often restate the commitment of HHS to adopt endorsed measures when they are available and to adapt our activities as they are adopted.

While progress is being made, gaining agreement on a modest number of uniform measures has taken a fair amount of time. Frankly, the process remains complicated and slow. Hopefully, it will gain speed as experience is gained.

However, we need standardized methods for quality measurement and very soon.

As health care’s largest payer, I believe HHS has a duty to push the envelope and I want to tell you about a project we have initiated.

HHS is in the process of doing an inventory of all the quality measures we are currently using someplace in HHS. We intend to harmonize the measures we are using, and then we plan to publish our set so everyone can see our current and planned measurement thinking.

I hope this will have the effect of accelerating the velocity of the quality standards process.

With standardized quality measures laid beside standardized price measures like I wrote about earlier this week, consumers will be in a position to make value the most rewarded virtue in health care.

Learn more about Value Driven Health Care.

Comments

While I agree that metrics are required to measure quality and therefore cost/benefit (value) in everything we purchase, healthcare included, I am only motivated to concern myself with value when I have to pay for what I purchase. Value-driven healthcare will become just another fad until healthcare, like all of the other purchases we make, becomes a competitor among alternative things on which I could spend my money. Only then will the healthcare consumer consider value as a concern when making healthcare purchases. Otherwise, it’s the payer’s concern that it is getting value for what it pays – not the consumer who is causing the expenditure.

This is the fundamental flaw is government-sponsored and employer-sponsored health “insurance.” It isn’t insurance. Insurance should indemnify us from being wiped out financially from a catastrophic medical event. All other healthcare costs should be paid by the consumer. Nanny state bureaucrats think this would be a tragedy, which is why Medicare and Medicaid are the financial disasters they have become. They are not only financially defective, they are structurally defective.

Two decades ago, one MB of mainframe memory priced out at about $1 million dollars. Today I carry 4GB of memory in my pocket iPod for which I paid $150. During those two decades, healthcare technology and treatments have made mind-boggling strides, yet unlike every other “new thing,” I don’t get more for less in healthcare, I get more for a lot more. This should tell us that something is wrong with our healthcare system, and we don’t have to look far to find the problem – it’s the way it’s paid.

Healthcare will become value-driven when it becomes consumer-driven.

William H. Franklin, Ph.D.
Vice Chairman
Jackson Healthcare Solutions

Posted by: William H. Franklin | May 13, 2008 at 12:12 PM

Does HHS currently require any sort of Quality minimums. If I remember correctly, hospitals currently have to report on something like 26 areas, which might go up soon. Are there certain minimums in these areas that must be met? Comparing to SarBox, it would be interesting if the HHS would be able to require compliance (above a certain minimum) in these quality areas, though I'm not sure a penalty structure would really work here.

Posted by: Blake Fasching | May 13, 2008 at 07:01 PM

Value Driven Communications

Again, sincere thanks to allow me to express a comment in your site SM. the Secretary

Kast week in Canad a train was quarantine, one death and few persons presenting flu-like symptoms.

The Canadian Government act swiftly in its Containment Protocols but the Communications where not clear.

I have two questions for you M. Secretary Leavitt;

In bird flu forums that are sometimes news source for journalist we have realise that to avoid more problems that it is preferable to not have some health authority to tell the public that there are no reason to panic and we have things under control.

Of course we do want the situations under control but for how it is being communicate shouldn't we
have pretty straight forward speech and not that difficult and in the best interest of public health.

Dont we want people in authority to tell us what tests are being done and what the results are.

Like, we have done this specific test and it is negative, we know H5N1 is a long shot but we ruled it out with this test.

We are now sequencing this virus that seemed particularly virulent compare it with other recent viruses.

In addtition to antigen tests from a good nasopharyngeal specimen we took serum for antibody tests and we are going to repeat this in seveal weeks to see if there has been a rise in antibody titer.

Don't we want to hear person in authority saying that they did a viral culture to see if more than one virus may have been involved.

This would give us the credibility and confidence that competent authorities are adequately dealing with the situation and would be better accepted by a more well-informed public

The above is the work of Flu Trackers Team.

So my questions are;

Do you agree with such a protocolic Communications ?

And since you are going to China will you promote such Communications ??

Thank you again for all the work and good that you have done.

Snowy Owl

Posted by: Snowy Owl | May 13, 2008 at 10:03 PM

As both a hospital CEO and a citizen/consumer, I support the principles you support regarding consumers having information and making choices. Mr. Franklin (above) is right on concerning costs/insurance.

I also feel the efforts to bring consumers quality information are positive steps. The HCAHPS information and core measures, although not perfect, are decent initial efforts to give the public better information. The release of the patient mortality information, however, has been like the Wright brothers claiming that they are ready for commercial airline service.

For example, did you know that the Heart Attack (AMI) mortality rates are not adjusted for the length of time a patient waits to seek treatment for their heart attack (one of the biggest factors affecting mortality)? We have seen them wait up to three days before presenting to our ER. It is not factored in because you can't get this important information from the billing data CMS uses.

This year, hospitals have watched CMS quietly make adjustments to HF (heart failure) mortality rates for terminal patients after last year listening to press conferences explaining how experts from Havard and Yale had leveled the playing field. What they actually did is smooth off a spot on the side of a mountain!

I hope you and your successors are successful in improving healthcare consumer quality information. I'm sure you would agree that limited amounts of good information trumps lots of bad information anytime. If you lose credibility, you lose the game. Unfortunately, the mortality information currently fits in the latter category and CMS and your national health committees are not listening. Let Orville and Wilber keep flying the plane, but let's not keep trying to sell plane tickets -- yet -- people may get hurt.

Posted by: Brian Turney | May 16, 2008 at 07:12 PM

Many positive posts, yet none of the authors are physicians, who are the ones that will be most affected by your drive towards "value driven healthcare". If you go to the physician-only site, www.sermo.com, there are numerous active discussion threads concerning anxiety about bankruptcy, about how to disenroll from Medicare, and about the poor state of affairs for general medicine and family practice, and of course about you and others in power or trying to manipulate physicians through poorly thought-out legislation. There is now even a letter over at www.sermo.com is to be sent to Congress that has so far been signed by 2700 physicians.

Quality... standardization... negotiate lower prices... all are euphemisms for processes meant to force physicians to work for the minimalist wage as possible, all the while failing to control high malpractice premiums with tort reform, failing to control the burden of the ever expanding uninsured costs, and failing to control the abuses of HMOs hell bent on trying to force doctors to work for little to nothing. Physicians on the other hand cannot unionize or walk out in the jobs like other workers can so as to negotiate a living wage.

Mr. Secretary, healthcare is not like buying a car. You are buying a complicated service that is delivered by human beings that have spent their lives trying to improve the lives of their patients. Medicine is an art that is very tough to quantify, qualify, and at times to control.

Cutting provider earnings together with forcing them into expensive pay-for-performance and e-prescribing schemes costing tens of thousands of dollars in computers, EMRs, and in more secretarial overhead will essentially destroy medicine and Medicare.

NO studies have yet to demonstrate that EMRs improve quality or cut costs. On the contrary numerous studies have shown just the opposite, including 3 major studies in the past six months alone, from the Centers for Disease Control, the Medical Records Institute, and Congressional Budget Office.

Yet you continue to push your agenda of a "value driven healthcare system". Maybe one day you can actually visit a physician office to see what these practices have to go through simply to keep their doors open.

Sincerely,
Al Borges M.D.

Posted by: Al Borges, MD | May 30, 2008 at 11:07 PM

Quality standards and reporting are appropriate for larger organizations that can afford to dedicate resources in this effort. I didn't notice a distinction between large hospitals/organizations and the solo practitioner and this is a very important distinction to draw. If solo practices are to face more federal reporting requirements without compensation, this will drive many out of business due to increased costs and time spent on activities without reimbursement. Solo Primary Care doctors are a key ingredient in any value driven healthcare initiative but their unique situations are not mentioned or apparently considered in the policy making decisions.

Posted by: Eric Beeman | June 01, 2008 at 11:20 PM

Dear Mr. Leavitt:

Read your recent statement about incentives to doctors office using Certified EMRs. We have been using a Non certified EMRs for more than 4 years, running paperless office successfully, getting appreciation from patients,colleagues, pharmacies, hospital. We have received Governors award 2 years in a row using non certified EMRs. Certified EMRs are not superior to non certified ones, they cost more, slowing down doctors in Presdient's Bush of encouraging doctors to use EMRs.

I am of the opinion that one should not perpetuate brainwashing of doctors offices to use Certified EMRs. You may be sold on using Certified EMRs. But you should really speak and spend time with Doctors offices using Non certified EMRs and see why and how successful they are using Non certified EMRs.

Instead of disincentivising offices for not using Certified EMRs you should run a study, who is providing better care for the population with certified and Non certified EMRs.There is no study which has been shown of date that Certified EMRs are better. You may have heard that from Certifying body, but that is false claim.

Hopefully you will revisit this issue of pushing Certified EMRS and make a better judgement.

http://www.amazingcharts.com/ub/ubbthreads.php?ubb=showflat&Number=8559&page=1#Post8559

Posted by: Joseph, MD | June 06, 2008 at 05:15 PM

Sec. Leavitt:

Thank you for the opportunity to express our views on healthcare quality measurement.

As a family physician in a small practice, committed to high quality care for my patients, I have great concerns about what appears to be a trend toward holding physicians accountable for "quality" through P4P reimbursement measurement, with no apparent concern that physicians themselves are being asked to bear the cost of these new standards WITHOUT any additional remuneration.

For example, it appears that practices like mine may eventually be required to pony up our own money to purchase an expensive "certified" EMR bloated with features we don't really need and which don't accrue any meaningful benefit to patients. Non-certified EMR's are not necessarily cheap knock-offs and must be evaluated on what the GOALS of an EMR really are - allowing doctors to provide better care, hopefully faster and cheaper. One way some of the better, les expensive EMR solutions help us is to allow us to take advantage of the crucial benefits of an EMR without spending $30,000 or more, partly because the EMR company does not need to pay the exhorbitant fees necessary to become and remain certified, charged of course by those doing the certification! The criteria needed to become certified are arbitrary and are not supported by evidence that certified EMR's are in fact superior. This is a small example of an unfortunate trend in American healthcare: spending more money on administration and on the business of practicing medicine, and getting an awful return on our healthcare dollar. I'm sure you know the statistics on where we rank in the world with respect to healthcare quality. This one tiny issue of (potentially) requiring certified EMR's is yet another example of why - we constantly waste money on things that don't really accrue benefit to the people we are trying to serve.

Please don't make our difficult situation worse by caving in to the "Certified" vendors' claims that their products are superior. They just aren't; they're just more expensive. Please look carefully and objectively at this very important issue.

Respectfully,

Jim Theis, M.D.
New Orleans, LA

Posted by: James Theis, M.D. | June 17, 2008 at 05:28 PM

Since publication of the IOM’s groundbreaking reports outlining the prevalence of preventable medical errors and the actions that can be taken to significantly reduce them, U.S. healthcare industry leaders have made significant investments in clinical process, technology and organizational infrastructure to improve quality and patient safety. And significant additional investment is anticipated to be required in the foreseeable future. However, in our increasingly challenging reimbursement and economic environment, it is becoming increasingly important to be able to demonstrate adequate ROI to sustain the pace of investment required to truly impact care.

Have you noticed how much everyone wants to find “some way” to measure Quality of Care? And the benefits of Evidence Based Care? And the financial impact of improved Quality? And, have you noticed that the best that people are able to do is bring anecdotal evidence…a few examples…some case studies…some hypotheses about the relationship between clinical process and clinical outcomes? Almost every presenter at the most recent Zynx Health Conference in San Diego brought illustrations of benefits – clinical, operational and financial – yet the resemblance they bore to each other was coincidental, at best.

We believe the reason for this is that the science of Hospital Quality Management is relatively immature. Hospital Financial Management, by contrast, is very mature, as evidenced by things like standard financial statements, consistent charts of accounts, universally accepted metrics and measurements, easy benchmarking, etc. Comparable capabilities are not possible in the current world of Hospital Quality Management – not for lack of demand or desire, but for lack of commonly agreed-upon definitions, metrics, and reporting mechanisms.

Posted by: Scott Hodson | July 22, 2008 at 03:53 PM

Health care workers have every right to NOT have to perform duties that are in opposition to their deeply held religious convictions. Christian convictions are precious... they come from our Lord to begin with, and are carried into life by our own commitment to them. These people are nearly always your most compassionate workers, and most effective.

Posted by: Gordno Rose | September 06, 2008 at 11:33 AM

THANK YOU for moving on the conscience rights of health care providers. I am very encouraged by your work on this and I hope it is in place before the end of President Bush's term. We know this will not happen if not under President Bush. Great job!

Posted by: Charlotte Schmitz | November 20, 2008 at 10:57 AM