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Driving Improvement in Value for Patients

The purpose of any product or service is to create value for people. In the health sector, value is created by enabling health or improving healthcare. Patients experience value when their medical conditions are resolved safely, effectively and efficiently, as well as when disease or disease progression is prevented. Improving value—the quality received per dollar spent—should be the clear goal of health sector competition. Unfortunately, today, that is often not the case.

In a normal functioning market, providers of services (or producers of goods) compete on results—their ability to provide the highest quality at the lowest prices. As a result, value increases, often with simultaneous improvement in quality and efficiency. But in healthcare, information about quality and cost  is poor. Most people have better information about their restaurants, cars and sellers on eBay than they do about treatment choices or care-givers. Most critically, information about medical outcomes is rarely available.

Without true results measurement, doctors, teams, hospitals and health systems have traditionally competed in unproductive ways—shifting costs, attempting to accumulate bargaining leverage, or restricting services. This decreases value both by eroding quality and driving up administrative costs. But dysfunctional competition in health care is not inevitable. Competition in health care can be redirected to drive dramatic improvements in value. The first step in that process is measuring results—risk adjusted outcomes, and prices, for patients.

The discussion of outcome measures often focuses only on information for consumers and thus misses a key point. Physicians need measures of results to know what needs to improve and to develop insight about improvement. Value for patients increases with these improvements in care and outcomes whether or not they “shop.” For example, critics often observe that patients do not use the publicly reported information about mortality rates for coronary artery bypass graft (CABG) surgery in New York state. But patients clearly have benefited. Mortality in CABG surgery declined 41 percent in the first four years of public outcome reporting, and the Society of Thoracic surgeons became motivated to increase dramatically the state of the art in measuring risk adjusted outcomes and in understanding the best practices that underlie superb outcomes.

Outcome measures focus everyone on improving value for patients. And when patient value is the compass setting the direction, interests become aligned: physicians, patients, employers, health plans, hospitals, and society benefit. Outcome measurement will be most effective in driving rapid improvement if it is combined with “evidence-based” information that is widely available, enabling any physician or nurse to be up to date on care for any condition or set of conditions.

Indeed, there is an enormous opportunity to enable and accelerate improvement in care processes, safety, and health results by calling for immediate development and use of risk-adjusted outcome measures. In some fields, such as cardiac surgery, organ transplants, and cystic fibrosis, efforts to measure risk adjusted outcomes are well-developed. In other areas, there is currently less definition. (What is “good” rheumatology?)  But improvement will be spurred by measurement of results in all medical conditions. These measures need to be risk adjusted, peer-reviewed, universally collected and publicly available. Efforts of physicians and teams to achieve great outcomes will drive evidence-based medicine in the best sense, and that will not happen quickly any other way.

The nation cannot legislate or require evidence-based medicine. Practice standards make sense to a point; appropriate practice will reduce medical errors and some kinds of inappropriate care. But requiring process compliance is not the same as pursuing high quality. Different providers using the same processes achieve very different results because guidelines can never cover everything. And results…full recovery, disability, pain, cognitive impairment, mortality, time before returning to work, etc…. are what really matter for patient value.

Many of the objections to outcome measures, and even to enabling coaching with evidence-based medicine, are based on assumptions about how the measures will be developed and rolled out. Assurances of on-going risk adjustment and peer review are critical because the first measures are certain to be imperfect. Perfect measures may never be achieved, but more damage is done by not starting.  The size and effect of the “imperfections” in the methodology and reporting can be reduced by using multi-dimensional measures, by using expert groups to develop the measures, by having peer review of the measures, by letting everyone work with the measures for a year before reporting begins, by having a window of time in which individuals and organizations can confirm the accuracy of the numbers to be reported, and by having an ongoing way for people to suggest additions and modifications to the measures in use. And nothing will speed the development of great measures faster than putting good ones to use. 

Meaningful outcome measurement will focus physicians and teams of care givers on improving results and processes. When risk-adjusted outcomes are universally collected and publicly reported, attention to process improvement will be animated.

The current enormous variance in processes and outcomes of American medical care is both unsafe and unacceptable. The nation can do far better than the current dynamics of well-intended but often uninformed care. Improving quality by improving the judgments and choices of physicians is critical. Sure, there will be arguments about outcome measurement– both thoughtful and defensive. Many of these arguments are based on deep experience in a world in which many judgments are not well informed. The dynamics of the system will change with development and availability of both outcome data and insight about how good outcomes are achieved. Once physicians and teams are required to report results, it will no longer be optional for them to pay attention to the processes and approaches that yield improvements in value for patients. Because outcome measures identify a clear focus on improving value for patients, health and health care will improve with unprecedented vigor. Value will be enhanced by improvements of efficiency as well as quality due to better treatment choices, fewer mistakes and repeats, faster recovery, better prevention and less disability.  Reducing costs by improving quality benefits everyone.