Among the 11 recommendations in the ground-breaking Blueprint for Complex Care, released in late 2018, was to develop standard quality measures for complex care programs beyond cost and utilization. A new report from the Institute for Healthcare Improvement (IHI) and the National Center for Complex Health and Social Needs assesses the current state of complex care measurement and recommends a path forward.
During a July 30 webinar put on by the National Center, participants described the current landscape of quality measurement in complex care and the challenges associated with developing measures that go beyond ones currently deployed in insurers’ value-based care contracts focused on cost savings.
Heidi Bossley, M.S.N., M.B.A., an independent consultant to IHI, explained that the National Center has established a Field Coordinating Committee to oversee projects to implement the Blueprint. The committee plans to convene an expert working group to create a set of target measures, standards and data stratification within five recommended measure domains. Among the goals would be to:
• Expand the consideration about value beyond cost and utilization;
• Demonstrate impact;
• Identify promising and best practices; and
• Accelerate learning and quality improvement.
One of the webinar speakers was Rebecca Ramsay, M.P.H., B.S.N., CEO of Housecall Providers, a Portland-area nonprofit organization and one of the largest providers of home-based medical care in the Western United States. She reflected on her experience working with stakeholders to define their population and identify quality measures to assess their impact on outcomes for individuals with complex needs.
Her thoughts also reflected her experience working at a Medicaid health plan, so she comes at it with a payer perspective as well as a clinical one, she said.
Housecall Providers serves a population comprised of the frail elders, non-elderly disabled, major complex chronic and advancing illness. Ramsay noted that each has distinguishing characteristics with multiple overlapping characteristics, and that if they were considered homogeneous with respect to quality improvement, the risks would be minimal and the benefits would be moderate to high; however, if they were considered homogeneous with respect to accountability (evaluation, payment) the risks could be very high and the benefits low.
“Heterogeneity is important to acknowledge to standardize a definition for payment. We wouldn’t want our outcomes evaluated alongside those of stable older adults. The markers of success are going to look different. We have experience in this in working through contracts with payers,” she said. “If the insurance company doesn’t understand how complex a patient is, the payment model will look the same as for a primary care clinic, and we would never be able to cover the cost.”
But she added that if providers could agree to a few standard (and measurable) distinguishing characteristics at the subgroup level, it would be feasible and very valuable for accountability purposes.
Ramsay asked, rhetorically, what do payers value in care for their complex populations? Answers:
• Cost mitigation;
• Quality outcomes — especially those that bring them more revenue from CMS/Medicaid because that translates into more services for those complex members;
• Member/patient satisfaction, which enables health plan loyalty and market share growth.
But she pointed out that insurers’ quality measures are often not appropriate or clinically meaningful:
“With our frail elders and palliative care patients, quality measures like a mammography rate or even a colorectal cancer screening rate, very common quality measures, are often not at all consistent with the patient’s goals of care,” Ramsay said. “Yet they are very common metrics that health plans use in their incentive plans. What is more important to our patients is quality of life and symptom burden metrics, and what is more important to their providers and families are the presence of an advance directive or strategies for fall prevention. We need to prioritize those measures that are important to patients and specific to the subpopulations of complex patients we are serving.”
She noted several other common pitfalls in value-based contracts when complex populations are involved, including when utilization and cost benchmarks are set without a comparison group methodology: “When using cost and utilization measures for population and program targeting, there is a high likelihood you are going to see regression to the mean after you enroll the patients in the intervention, making it hard to determine the effect of the intervention and making it even more important to have an appropriate comparison group,” Ramsay said.
“I can’t tell you how many times I have had to push back against value-based contracts that want to incentivize our practice to reach a relatively arbitrary and static ER visit rate for our patients without any comparison population,: she added, "and I will just say that I would never agree to this, and I don’t.”
She said there is a need to acknowledge that patients who have advancing illness and might be in the last 18 to 24 months of life are going to have increasing costs and to some extent higher utilization as time progresses. "We can’t measure success in mitigating costs if we are only looking at that population over time. We have to use a well-matched comparison population to measure those outcomes against.”
Other pitfalls include a lack of use of patient-reported outcomes, caregiver-reported outcomes, or social determinant of health metrics.
A standard set of program metrics, Ramsay added, could lead to the development of meaningful value-based contracts with payers, as well as tools for program evaluation and program improvement efforts and a way to do benchmarking and learning from similar programs.
Ramsay recommends agreeing to a taxonomy of subgroups and then focusing on agreement of a core set of measurable characteristics within each subgroup. She said there are some population definition characteristics that won’t need development, just alignment (age, functional limitation, utilization), while others will benefit from a defined pathway toward development (advancing illness, SDOH risks)
“I might suggest a collective impact approach where we organize groups of collaborating subpopulation experts to collect data on their identification methods to help us learn and make alignment decisions.”
“The field needs consensus and alignment on meaningful metrics for accountability – for me this is the No. 1 priority for metrics development. Without this, we are beholden to traditional health outcome and utilization/cost metrics that do not capture the nature or extent of the impact our programs are making. Programs will fail without payment models that capture and reward this impact.”