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Amid the fractious healthcare reform debate, there is one clear point of consensus: We need to be paying for quality, not quantity, of care. But what does that mean?
The ultimate measure of quality is a positive health outcome: longer life expectancy, a second heart attack that never occurs, a cancer that never returns. Those are measurable, but they take a long time to observe and ultimately have no impact on reimbursement. Lawmakers often get confused on this when discussing preventive medicine, which they grandly pronounce will keep people healthy and somehow save money immediately. But the payoff in preventing more expensive care later may be decades away, and it is difficult to count something that does not occur.Experts estimate that nearly one-third of medical spending is unnecessary and therefore wasteful. But no healthcare industry player will admit to providing wasteful goods or services. For those footing the bill, it calls to mind the famous quote by department store magnate John Wanamaker: "I know half of my advertising is wasted. I just don’t know which half." We certainly aspire to a system that fairly pays for optimum evidence-based care with measurable results and a minimum of administrative overhead. Easy to say, hard to do.Establishing accountability for the cost of medical decisions is difficult because our tradition is to consider clinical imperatives before their economic consequences. Probably the most common tool for attempting to address both is incentive-based pay-for-performance (P4P) reimbursement, which pays a bonus for either quality care or improved quality.Medicare, Medicaid and private-sector initiatives also attempt to reward healthcare organizations for efforts to adopt electronic medical records and electronic prescribing, and creating "medical homes" to coordinate individual patient care. Hospitals and larger multispecialty groups are forming accountable care organizations, designed to handle a range of services for each patient and share one payment that encourages cost efficiency, preventive care and quality.Typically, there are four types of quality measures: (1) clinical outcomes, which are the best but hard to measure; (2) process measures, such as screening and drug dispensing; (3) structural measures, such as adoption of technology, and (4) patient satisfaction, which is problematic because it may be unrelated to quality of care. Current programs are not designed to reap cost savings because many measures target underuse of the system. For example, BlueCross BlueShield of New Hampshire pays bonuses to physicians who screen patients for breast, cervical and prostate cancer and high cholesterol, help patients manage diabetes and provide other recommended preventive care. In these cases, this almost always means rewarding physicians and hospitals for delivering more services for which they can also bill. But there is evidence that other programs are being recalibrated to focus on cost efficiency of care.
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