Can We Get to the Next Level When It Comes to Quality Measures for the Care of Patients with Complex Needs?

June 27, 2018
A blog posted online on Tuesday on the Health Affairs website makes important points about the landscape around the measurement of quality in the context of care for patients with complex needs

A blog posted online on Tuesday on the Health Affairs website makes extremely important points about the landscape around care delivery and care management for patients with complex needs.  Even its title says a lot: “Measuring What Matters Most to People with Complex Needs,” authored by Julie P.W. Bynum, M.D., M.P.H., an adjunct professor at The Dartmouth Geisel School of Medicine in Hanover, New Hampshire.

Dr. Bynum begins by noting that “Recent efforts to increase accountability for health outcomes and costs has put a spotlight on the immense challenge of providing high-quality and efficient care to people with complex needs, many of whom require inputs from both the medical and social care systems to remain at their highest functional capacity. People with complex needs often have functional limitations, such as the inability to effectively communicate, move about, or take care of themselves without additional help, and they may have behavioral health needs that typically incur high health care costs. Traditionally, these individuals have been a source of revenue for health systems due to the sheer number of covered services they receive. Yet, under new payment and delivery models, such as accountable care organizations and bundled payments, these people could be viewed as a serious financial risk because of their outlier expenditures and potential for poor health outcomes. Herein lies an opportunity to improve the management of care for this population.”

As Bynum continues, “The National Academy of Medicine’s (NAM’s) special publication, ‘Effective Care for High-Need Patients: Opportunities for Improving Outcomes, Value, and Health,’ serves as a primer for how health care stakeholders can use evidence-based approaches to effectively manage care for this population. How to measure quality and outcomes as models of care and policies are implemented, while also managing costs of care, should be further discussed. Accountability measures for this population are necessary to assess the effectiveness of health financing reform efforts.”

Bynum points out something that those caring for patients with complex needs already know: “People with high needs often have multiple chronic conditions and seek care in many different settings for which quality measures already exist. Yet, simply applying the myriad condition- and setting-specific measures separately to this population will not sufficiently inform whether care was high quality. That approach ignores the complex interplay of factors, such as degree of care coordination, quality of life, independence, and overall mental and physical status that drive outcomes and care experience for this population.”

Further, Bynum notes, “A conceptual framework of performance measurement for people with high needs must take the whole person into account. Referring to the high-need population as “patients” reflects our tendency to overlook needs that extend beyond the walls of the disease-based medical care system. If the social care needs of a person—such as food and housing insecurity, transportation needs, supports for daily activities such as mobility and personal care in the home environment or addressing behavioral issues—are not adequately met, they may in fact end up as “patients” in hospitals or clinics that are ill-suited to address the root causes of their decline. Without accountability metrics that incorporate gaps between medical and social care domains, it will be challenging to assess whether health financing reforms are effective or if they result in adverse consequences, such as delays and denials in care, for high-need individuals. Measures of unmet need for social care or caregiver burden are examples that capture core elements of any effective management team and may provide balancing measures for potential cost shifting from medical to social care providers.”

Dr. Bynum captures some of the core issues here with great insight and articulation. What’s more, we’re talking about quite a large number of people here. “As of 2014,” a 2017 RAND Corporation report authored by Christine Buttroff, Teague Ruder, and Melissa Bauman, notes, “60 percent of American adults had at least one chronic condition, and 42 percent had more than one chronic condition. NOTE: Percentages may not total 100 because of rounding. The prevalence of multiple chronic conditions is higher among older adults.” Those researchers note that “[C]hronic disease is a burden not only for these patients but also for the health care system overall. Those with multiple chronic conditions have poorer health, use more health services, and spend more on health care—trends that have been stable since 2008.”

So, given that 42 percent of American adults are living with two or more chronic conditions, the lack of meaningful systems to accurately measure the quality of their care and care management can only be seen as alarming. What’s more, we are heading into a phase in the overall evolution of the U.S. healthcare system in which it will become more vital than ever for policymakers, purchasers, payers, consumers, and providers themselves to obtain more accurate insights into the quality of care and care management that patients with multiple chronic illnesses are receiving. And yes, one could draw an analogy to the idea of refueling planes while in flight, as we need to reimagine quality measures at the same time that more and more providers enter into accountable care organization (ACO), population health, bundled-payment, and other value-based contracts with the purchasers and payers of healthcare.

And it goes without saying that healthcare IT leaders will necessarily play a very important, even crucial, role in all of this. Senior healthcare IT executives, both clinical and non-clinical will inevitably be a part of the broad (and specific) discussions that will be evolving forward in this arena. I’m especially thinking, of course, of CMIOs, CNIOs, and other senior clinical informaticists in patient care organizations. Without them, any measurement regimens that are developed will only be seen as externally imposed—and therefore unwelcome to the practicing physicians, nurses, and other clinicians on the front lines of care and care management.

So these are challenges that were inevitably going to wash up against our healthcare delivery system, and, in fact, are already doing so. But there are opportunities inevitably embedded in these challenges, too; and the biggest is the opportunity for CMIOs, CNIOs, and other clinical informaticists to take part in the grand enterprise of developing meaningful measures that will accurately measure the levels of quality of care delivery and care management taking place right now in the healthcare system, and will encourage improvement in all areas.

As Dr. Bynum notes, “The biggest challenge for measuring quality of care for high-need people may be a technical one—identifying the population to be measured. The starter taxonomy is a tool to help health systems and payers segment individuals based on the care they need and how often they might need it, and is set out in the NAM report. It is informed by research that uses costs from administrative data to define who should be considered high need. These data do not include use of social care services, the unifying factor linking the disparate groups comprising the high-need population, which precludes identification of people with high needs before their medical costs skyrocket. We lack tools in electronic medical records (EMR) that capture social care received through community organizations, long-term care providers, or informal caregivers. Inclusion of these tools in EMRs would allow identification of people who require community-based supports earlier and will ultimately augment our ability to improve their experience and possibly affect downstream costs of use.” What better opportunity for clinical informaticists to help lead the industry forward?

And Dr. Bynum concludes her blog on an optimistic note. “It’s a promising time for people with high needs, whose struggle with complex care is increasingly being addressed using evidence-based models that have incentives in place for their wide-scale dissemination,” she writes. “Strategies for assessing quality that incorporate social care services and providers, attend to goal-aligned care plans, and consider innovative approaches to measure coordination, or the lack thereof, will be important for marking the path toward better care.” I sincerely hope that the intelligent, thoughtful leaders in our industry take up this challenge with the same vigor and dedication with which they’ve taken up every challenge so far, because this is a very important—and consequential one indeed.

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