Dr. Venkatesh notes that we currently have too many measures, including primary care focus, effectiveness and safety domains, individual focus, and feasible measures. What he feels we need is to fix the quality gaps, including specialty measure focus, equity, cost and care coordination domains, team focus, and focusing on measures that matter. The ACA and MACRA support a transition towards Qualified Clinical Data Registries (QCDRs), which will allow clinical flexibility, ownership, direct clinician engagement, real-time quality reporting, and the use electronic health record data. However, the risks of using QCDRs are variable standards, unknown data-linkage quality, “outside” unintended consequences, and potential fear leading to a wasted opportunity to advance measurement.
According to Dr. Venkatesh, there are four cross-cutting measures of the future, including (i) team-based quality measurement, (ii) population ownership, (iii) patient reported outcomes, and (iv) cost and resource use. Measuring team-based care across settings will have implications for the patient, clinician, and the system, leading to a shared accountability metric. For example, community-level catheter associated UTI rates provide an opportunity to align institutional (hospital, skilled nursing facilities, etc) measurement with providers and supporting the development of “healthy communities.” There are several unanswered questions regarding team-based measurement, such as (i) Are clinicians ready to agree on good outcomes? (ii) Are clinicians ready to share accountability? (iii) Will clinicians engage colleague in quality goals? and (iv) Is this possible within the current payment model?
Patient reported outcome measurements provide an opportunity to capture broader patient populations, pair with shared decision-making measures, and shift the focus to patient-defined improvement. As Dr. Venkatesh cautions, this will require substantial reduction in clinical paternalism. There are several cost measurement challenges we face moving forward, including (i) common conflating of cost and resource use, (ii) retrospective patient assignment (iii) poor decision-cost linkage in existing data, and (iv) poor clarity with regards to how we use this initiative alongside the alternative payment model.
Dr. Venkatesh concluded is talk with highlighting a few points with regards to the possible “next rabbit hole”: proportional attribution. Namely, we risk a false or oversimplified representation of care, promote silos, noting that attribution is not necessary for alternative payment model success (balancing quality measures IS necessary), which is ultimately rarely meaningful to patients.
Speaker(s): Arjun Venkatesh, Yale University, New Haven, CT, USA
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, Twitter: @zklaassen_md, at the AUA Quality Improvement Summit - October 21, 2017- Linthicum, Maryland