We spend a lot of time in the Acumen blog discussing the Health IT related programs nephrologists encounter during their busy lives. Recently we’ve discussed the ongoing transformation in how we are paid to render health care related services. Unless you’ve been living in a cave of late, you recognize the U.S. healthcare system is slowly but surely moving away from a system that financially rewards volume to one that rewards value. As we’ve described before, value is about the efficient delivery of quality and it’s sometimes represented as a simple equation:
Value = Quality / Cost
Of course it’s one thing to represent this transformation as a simple fraction. It is quite another thing to measure the numerator and denominator in this fraction. In today’s post, let’s set the denominator aside and tackle what many believe is the much more difficult piece of this puzzle to measure, quality.
What is quality?
A simple question, perhaps, but it has a complicated answer. Is quality measured by the number of late-stage CKD patients with a flu vaccine? Is it the percentage of hemodialysis patients with an AV fistula? How about my personal favorite, the number of ESRD patients with a calcium greater than 10.2? These measures are easily recognized as clinical quality measures, but a funny thing happened during the journey to value-based purchasing, the definition of quality evolved.
Books have been written and scientific papers published in an effort to answer this question. Suffice it to say, I am not going to solve this riddle in an 800-word blog post. Instead, I would like to remind you of a framework which is increasingly being used by the entities that are measuring the quality of the care we deliver; a framework that few of us have heard of.
The Triple Aim
The National Quality Strategy was birthed by the Affordable Care Act (ACA). Among the many things the ACA created was a requirement that Health and Human Services “establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.” In early 2011, the Agency for Healthcare Research and Quality (AHRQ) delivered the National Quality Strategy to Congress. That strategy included three aims and six priorities whose intent was to focus our collective attention on quality and the measurement of quality within health care. The three aims should be very familiar to everyone (except the cave dwellers referenced above), as they are the “Triple Aim” fashioned by Don Berwick and colleagues:
- Better care
- Healthy people and healthy communities
- Affordable care
To advance the three aims, AHRQ established six priorities in its original publication in 2011. Those six included:
- Making care safer by reducing harm caused in the delivery of care.
- Ensuring that each person and family are engaged as partners in their care.
- Promoting effective communication and coordination of care.
- Promoting the most effective treatment and prevention practices for the leading causes of mortality starting with cardiovascular disease.
- Working with communities to promote best practices to enable healthy living.
- Making quality care more affordable for families, individuals, employees, and government by developing and spreading new health care delivery models.
National Quality Strategy Domains
Fast forward to today and those 6 priorities have morphed into what we now call the six National Quality Strategy (NQS) domains.
- Patient Safety
- Patient and Family Engagement
- Care Coordination
- Clinical Processes/Effectiveness
- Population and Public Health
- Efficient Use of Healthcare Resources
Do you see number four on this hit parade? That’s the bucket where the three clinical measures I mentioned at the beginning of this post live. They are measures of quality, but in many cases they represent 1/6 of the stick by which we are measured, and today we are being measured at every turn. I spend more time than I care to admit reading about and thinking about CMS quality programs that impact nephrologists. The six NQS domains are ubiquitous in their presence across the breadth of the CMS drive towards value-based healthcare.
Every individual PQRS measure lives in one of the six domains. Successfully reporting individual PQRS measures requires “9 in 3”—shorthand for reporting nine individual measures—but not just any nine will do. Those nine must include at least one measure from three of the six NQS domains. What about our new friend the physician value-based payment modifier? Yep, quality is measured there by equally weighting five of the six NQS domains (number six on the hit parade is effectively measured on the cost side of the VM house). Finally, consider the arrival of the ESRD Seamless Care Organization, thankfully shortened to ESCO. What framework is used to measure quality within an ESCO? Surprise! Once again it is the quality domains established within the National Quality Strategy.
Strategy and Culture
There’s a saying in the business world that goes something like this: “Culture eats strategy for breakfast.” We’ve grown up in a health care culture that recognizes quality solely along clinical lines. Value-based purchasing is rapidly changing the world around us. Our patients are filling out CAHPS surveys for CMS which are designed to measure the beneficiary’s experience of care in the hospital, in the dialysis facility, and in our offices. Measures of patient safety and population health are now equally weighted with our old friends that attempt to measure pure clinical quality. Changing the culture required to execute the National Quality Strategy will be a heavy lift for many, but those who succeed will likely be among those who thrive in the world of value-based health care. As we have recently discussed, the transition to value-based healthcare is well underway. What are your thoughts about the National Quality Strategy? Drop us a comment and join the conversation.
Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.