Risk Adjustment And Promoting Health Equity In Population-Based Payment: Concepts And Evidence

“[Introduction] [..] population-based payment models, as in the Medicare Shared Savings Program or Medicare Advantage (MA) program, can facilitate the resource reallocations necessary to address health care disparities. Risk adjustment is the mechanism by which payment is allocated in these models. Traditionally, risk adjustment has been conceived and executed purely as a predictive exercise. Regression is used to predict total annual per person spending as a function of demographic and clinical characteristics. A person’s predicted spending is converted to a risk score, which is applied to a base regional rate to determine the prospective payment or benchmark for that person. … Read More

Value-based payment has produced little value. It needs a time-out

“The concept of value-based payment became widespread among U.S. health policymakers and analysts during the 2000s. It collectively refers to interventions that offer doctors and hospitals financial incentives that, in theory, induce them to improve both components of health-care value — cost and quality — without generating the hostility provoked by managed care insurance companies during the HMO [health maintenance organization] backlash of the late 1990s. [The Center for Medicare and Medicaid Innovation reviewed 54 models of value-based payment. Only four were certified to be expanded:] The Home Health Value-based Purchasing Model demonstration cut Medicare spending by 1% with mixed … Read More

Public Reported Health Outcomes: A National Initiative to Improve Care

“recent research demonstrates that hospital mortality rates can vary by a factor of 3 to 1 and health plans by 4 to 1, and publicly available quality ratings of health care plans and services do not correlate well with outcomes. What is more, lack of transparency among health plans and provider organizations prevents purchasers from making informed choices based on relative quality of provider organizations and health plan networks. Currently available outcomes data are limited to Medicare fee-for-service. [..] For at least five decades, the public health care conversation has focused primarily on rising costs, while the US has lagged … Read More

Measuring Performance of the Diagnostic Process

“During the diagnostic process, it is not unusual, or incorrect, for working diagnostic labels to change as new information is acquired and as the patient’s condition evolves both naturally and in response to interventions. The language used to communicate risk of disease and uncertainty about diagnosis is not uniform and may be overly ambiguous (eg, “cannot rule out,” “consider the possibility”). Thus, attempts to standardize and measure diagnostic processes should avoid unrealistic expectations or overzealous judgments to be both accurate and fair in judgment (eg, driving performance not feasible under the conditions at the time, or expecting actions predicated on … Read More

More work on diabetes

David H Jiang et al. published an article in Health Affairs last month arguing for a set of diabetes quality measures that are actually linked to optimal diabetes health. Composite measures that include “all-or-nothing” components will incentivize providers to focus on patients who are most likely to achieve the measure rather than those who would benefit the most clinically. This would also adversely affect patients with socioeconomic barriers to optimal health, as those patients are more likely to have multiple unmet measures or not meet a measure that is more difficult to achieve (e.g., smoking cessation). A more equitable approach … Read More

Peers, Professionalism, and Improvement — Reframing the Quality Question

“As [health economist Jonathan] Kolstad explained, much of the insurance–industrial complex is built on the assumption that profit-seeking physicians will always consume excess resources unless barriers are put in their way. Formularies and prior authorizations, for example, create adversarial relationships between insurers and physicians, who may bristle at having nonphysicians dictate what’s best for their patients. Contributing to this tension is our dependence on randomized, controlled trials to tell us the “right” way to treat any one patient on the basis of average treatment effects in large study populations. The resultant technocratic approach to quality often fails to account for … Read More

Metric Myopia — Trading Away Our Clinical Judgment

Excerpt – The perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. But if value is defined as quality divided by cost, measuring value faces all the same problems as measuring quality — flawed risk adjustment, metric gaming, omission of the many aspects of quality that defy measurement. So why do we continue to embrace these flawed constructs, particularly when it’s not clear that the current regulatory approach serves patients or clinicians? [president of the Commonwealth Fund David] Blumenthal offers international context: “The French, the Brits, the Swedes — they don’t torture their … Read More

Reassessing Quality Assessment — The Flawed System for Fixing a Flawed System

“Berwick recognized that blaming workers for factors beyond their control quashes goodwill and encourages cheating. This insight accords with a foundational principle of the QI [quality-improvement] movement: most quality lapses reflect a faulty system rather than faulty people. To improve quality, we must fix the system. Some 30 years later, however, the fix is itself a massive system. As reimbursement models shift toward value-based payment, QI is no longer just about being better, but about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. Though I could find no authoritative estimate … Read More

Learning from Real-World Implementation of Daily Home-Based Symptom Monitoring in Patients with Cancer

“Routine use of home-based symptom monitoring and management using electronic patient-reported outcomes (ePRO) to improve care delivery is on the horizon. Randomized clinical trials demonstrate that use of patient-reported symptoms can have marked impact on patient outcomes, including minimizing symptom burden, enhancing quality of life, reducing hospitalizations, increasing time receiving cancer treatments, and, in some studies, improving survival. [..] few health systems have successfully, fully integrated ePRO. [..] In the study by Daly and colleagues, the authors begin to tackle an important question of frequency of assessment administration in ePRO. This study used daily symptom assessment in contrast to the … Read More

How New England caught the COVID deaths much of the country missed

“The USA TODAY Network in New England and the Documenting COVID-19 project partnered to investigate how New England became a positive data anomaly in terms of COVID death reporting accuracy. Across the region, excess deaths during the pandemic are almost completely accounted for by official COVID deaths, according to our analysis of Centers for Disease Control and Prevention mortality data and expected death models developed by demographers at Boston University. In other parts of the country, these COVID deaths were missed or certified incorrectly as other causes. [..] Hospitals are a dominant and central data source to capture the pandemic’s … Read More