PDF A reader responded to my recent post about accountable care organizations with the question, “How do you measure quality in an accountable care organization?”
Good question!
In other words, if a health care organization is accountable, what do you measure and how do we know that this organization is actually responsible for what is measured?
Vitality as performance
These are the two top challenges with the accountable care organization initiative. How does one define and measure the desired outcomes, and how does one define the group of practitioners that are responsible for those outcomes.
In my post I wrote the following:
The study first grouped physicians and patients around their primary hospitals. What it revealed is that when the hospital performed well, the physicians and physician practices affiliated with that hospital or hospitals also performed well.
Mortality – the ultimate performance measure
The reader appears to be asking: How do you know that a hospital is performing well and how do we know that the physicians are performing well?
The study I referenced examined patient outcomes for patients with heart attacks, colon cancer, and hip fractures.
High-performing hospitals were defined as those in the lowest quartile on both risk-adjusted one-year mortality and risk-adjusted one-year costs (using standardized prices); low-performing hospitals were those in the bottom quartile on both measures, while the other three groups had intermediate levels of performance.
Mortality is clear. It is a minimal expectation for a health care system that patients survive. There are some who think it is not fair to judge any part of the health care system because people die.
Performance – can we do better than mortality?
Yet the United States is not in the top twenty countries for life expectancy, for infant mortality, for maternal deaths, for avoidable deaths. There may be more sophisticated measures, but sophisticated sometimes just muddies the waters.
This study also used process indicators to measure performance for physicians and physician practices. Did they do certain things that are normally associated with good medical practice and desirable outcomes? This study referenced the incidence of mammograms, diabetic screenings, and colorectal cancer screenings as its performance measures for ambulatory care.
The authors of this initial study make it clear that they are exploring a concept. Is it possible to define a larger group of practitioners and attribute to that group certain performance measures?
They use available and admittedly crude claims data to make their case. They concede that even with risk adjustment outcomes there may be inadequate adjustments for population health status and that more sophisticated multi-dimensional measuring tools need to be developed.
In a more recent article, Mark McClellan et al propose a list of more sophisticated performance measures. They stage them as beginning, intermediate and advanced and group them into care coordination, care effectiveness/population health, safety, patient engagement, and efficiency.
It is all about mortality
Most of these more sophisticated “performance” measures are process measures that may help medical managers understand the connections between process and outcomes. But how much do they contribute to understanding the health status of the patient population?
What really counts is whether people are living longer, healthier and more productive lives. I see far too many people who are forced to retire early because the extra weight they carry has caused their knees to give out. Or they have not managed their diabetes and have become insulin dependent, which disqualifies them for a commercial drivers license.
To achieve these outcomes requires a much more holistic approach to health care than our current fragmented and piecework approach.
Accountable organizations are a significant step in the right direction. Are they enough?
The debate around performance measures and who is responsible for them is a huge step forward.
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