Quality in Healthcare : The New Formula

| July 25, 2018

The new definition of quality in healthcare should expand to include patient experience as well as appropriate care metrics.

Redefining Quality In Healthcare 

Ever since “Crossing the Quality Chasm” was published by the IOM in 2001, groups have iterated on the need to better define quality and value in healthcare. Driven by changing, occasionally competing, payment models that began to focus on population health management, physicians struggled to clearly articulate “quality” in healthcare. Michael Porter’s groundbreaking article in 2010 entitled, “What is Value in Healthcare?” drew a connection between quality and costs of care through measuring health outcomes.


Technology breakthroughs and the age of healthcare consumerism are spurring experts to revisit our notion that traditional value in healthcare is equal to the quality of care delivered relative to the amount the care costs. The new definition of quality in healthcare should expand to include patient experience as well as appropriate care metrics. One way to tackle the upward trend in utilization is to assure the “next best action” taken by clinical teams is necessary and appropriate given the latest guidelines, patient-specific risks, and shared decision-making between the patient and the doctor.


Patient Perspectives

Medicine today has become “on demand.” The age of doctor paternalism in medicine has sunset. Patients, who are now tech-enabled consumers like every other industry, often arrive for a physician visit armed with internet research. Imagine a patient with lower back pain visiting a specialist who recommends physical therapy and not a procedure.

The patient, however, believes a spine procedure is in order based on his research. Consistent and standardized shared decision-making is required to educate and inform the patient of the correct course based on the latest guidelines and his personalized risk profile.

Even so, today’s consumer-oriented, web-based review environment allows patients to self-report their experience with a physician through online forums. These online reviews are seldom based on actual quality data or cost data, but rather are based on a patient’s perception of the experience with the physician.

Rating tools like Healthgrades™ are increasingly playing a role in who healthcare consumers select for care. The industry has a unique opportunity to integrate the consumer experience as a part of the overall quality of care. However, relying on consumer self-reported data alone is an insufficient quality measurement.


Data-driven Opportunities

The emergence of “big data” in healthcare brings with it consumer-driven demands for greater transparency. Because information is more ubiquitous for providers and patients, it can be used to crowdsource patient reviews, learn about hospital ratings and even learn about cost transparency. Many of these measures are crude at best, but actively used by the general public.

Many healthcare companies, large and small, are beginning to offer an array of patient-specific data to providers so they can make better medical decisions.

Perhaps more impactful on the future of medicine is enabling consumers to make treatment decisions on their own through the use of data and technology. Dr. Eric Topol, founder of the Scripps Research Institute, provides many examples of how consumers can use smartphones to diagnose medical conditions like atrial fibrillation.

Ten years ago, this serious condition required a cardiologist specialist to diagnose and treat. Transparency is also taking hold within the Centers for Medicare & Medicaid Services (CMS), which posts Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data. Despite the progress, many consumers don’t realize this data is available.

Those who are aware continue to struggle with distilling it to a simple, understandable and usable picture of provider performance. Health plans have traditionally attempted to fill this void, but with limited success. Newer insurance companies are beginning to change this paradigm.


Healthy Relationships

As it relates to improving outcomes while controlling costs, the most frequently asked question is, “How do we ensure patients get all the care they need and none they don’t?” In partnership with high-performing providers, health plans are in a unique position to manage patients more effectively and efficiently. For example, a health plan that includes embedded care coordination can proactively identify those members in need of better managed care.

Health plans are beginning to collaborate with providers to generate smaller sets of more meaningful measures to monitor physician performance, such as measuring the total cost of care. Health plans and providers together will need to craft personalized patient engagement strategies and comprehensive care coordination that includes pharmacy. Performance-based incentives are a key element in shifting provider behavior from fee-for-service toward value-based care.

In theory, the provider that works to maintain high marks within all six quality pillars set forth by the IOM should also be able to create a better patient experience. In order to be successful, providers will need near real-time data from health plan partners. Creating incentives that continuously reinforce a strong PCP-patient relationship offers an opportunity to improve a member’s overall quality of care while reducing the total costs of care.


Creagh_Milford_DO_MPH_FACOI_Chief Medical Officer of Healthcare HighwaysCreagh Milford, DO, MPH FACOI | Chief Medical Officer, Healthcare Highways Chief Medical Officer of Healthcare Highways, Inc., and a National Academies of Medicine Fellow, Creagh Milford DO, MPH, FACOI has held senior executive positions with FullWell, Mercy Health, Massachusetts General Physician Organization, Massachusetts General Hospital, and Partners Healthcare. He holds a Doctor of Osteopathy from the Chicago College of Osteopathic Medicine, and a master’s degree in Health Management and Policy from the Harvard School of Public Health, where he continues to guest lecture. He also held positions with the Centers for Medicare and Medicaid Services and the Department of Health and Human Services. Follow him on LinkedIn and Twitter and enjoy more of his industry insights, here.