Reprinted: Forbes, 6-27-2023
We rate Uber drivers, restaurants, Amazon delivery, and much more, but when it comes to our own health experience, we often have little to no data. That’s especially scary because the business model of the health care provider (e.g., Doctor) is to get money from the insurance company. The patient is actually not the customer. Knowing quality is, therefore, of utmost importance for each of us.
At the risk of oversimplification, let’s define three broad measurement areas in today’s healthcare: (1) Metrics about quality of care. Those metrics are related to treatment effectiveness and patient satisfaction. (2) Metrics about need and utilization of care. These metrics gauge the health requirements of a population and how often one uses what type of service. (3) Metrics about value-based healthcare. They are different from the two others as they try to measure disease prevention rather than disease treatment. They measure actions taken to prevent illnesses before they happen or to reverse them.
Quality of care metrics are indicators used to evaluate how health services increase the likelihood of desired health outcomes. They provide a way to measure and control the effectiveness, safety, and efficiency of care provided. As I started my journey in Healthcare as a product manager with Google, I was stunned by the amount of different quality indicators healthcare has created. I learned from one of the best, Michael Howell, MD. He was previously the Chief Quality Officer at the University of Chicago and is now the Chief Clinical Officer at Google. He educated me about various organizations that establish metrics in today’s healthcare system, such as the National Quality Forum (NQF), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare and Medicaid Services (CMS), and others. Each of these organizations follows its own unique set of metrics. For example:
- Hospital Readmission Rates: This metric gauges whether a patient, once discharged, stays out of the hospital. High readmission rates suggest poor quality of care or deficient discharge planning.
- Mortality Rates: This metric ensures patient survival.
- Patient Experience: This assesses patient satisfaction levels with their healthcare experience.
- Patient Safety Indicators (PSIs): These track in-hospital complications and preventable adverse events, among others.
Those are just a few crucial ones. You’ll find a far more detailed metrics review in Michael’s excellent book about healthcare, which I always keep within easy reach on my desk. But as Michael often reminded me, “We have many metrics, but the real challenges are in finding the metrics that matter and preventing unintended consequences with any given metric.”
Yes, metrics are hard work, and even if there is much evidence that a given metric correlates with outcomes, it does not mean that this metric leads to good actions. Take, for example, a simple metric on mortality for surgery. It seems right; patients should not die if they undergo surgery. But what if the situation of the patient was complex to start with? See here a story where a patient did not receive care and died because giving him the appropriate care could have resulted in a worse quality score for the doctor.
NEED & UTILIZATION METRICS
Those metrics are often associated with population health costs of care. Thus no surprise that the biggest payer in the US, the Centers for Medicare and Medicaid Services (CMS), influenced many of these. There are two main areas: need and utilization metrics. The need metrics look at population health measures such as the prevalence of diseases, morbidity, and health risk factors. Utilization metrics, on the other hand, look more at whether or not someone should have gotten a given intervention. I had the privilege of meeting with Marty Makary, MD, a recognized authority in his field. His revolutionary book, “The Price We Pay,” outlines the inherent flaws of the current fee-for-service system in U.S. healthcare, arguing that it often promotes improper incentives. As Makary told me, ” It is not sufficient to just measure the quality of medical procedures, but we also need to evaluate the appropriateness of these interventions.” One of the examples he showed that stuck with me the most is Marty’s research on Mohs micrographic surgery (MMS). He showed there that the current fee-for-service payment structure might encourage some doctors to perform multiple surgeries rather than one, as they are paid per procedure. He highlighted the power of transparency in correcting misalignments and built a web portal (gameasures.com) where one can look up appropriateness scores for any doctor.
VALUE-BASED CARE METRICS
We have had measures for prevention for a long time. But only the onset of shared savings and other risk agreements in healthcare has boosted this area. Quick reminder, what is value-based care? I started this article with the point that the patient is not the customer in our healthcare system. The patient is the reason for a business transaction between the insurance and the healthcare provider. Value-based care aims to put the patient in the center. Essentially, a doctor or healthcare provider will only get paid when they improve your health. With this alignment of incentives between doctor and patient, we don’t need to worry about appropriateness or quality of care measures. It sounds simple, but measuring health improvement is difficult. Is it cost? Is it life expectancy? Is it quality life years? Is it a mix? You get the issue overall. We at Marpai Connect believe in Value-Based Care and set up a wide range of value-based care agreements to reverse, manage and avoid diseases such as diabetes, asthma, COPD, heart failure, and many more. Thus my team and I are at the forefront of this topic. While we are working with many value-based care point solutions to create an ecosystem of providers for our self-insured employer clients, we came across the following types of metrics:
- Bio Markers that are clinically proven. For example, in our agreements with our vendors to reduce or reverse diabetes type 2, we look at measurements of HBA1C. This measurement is clearly linked to cost, health outcomes, and longevity. The critical part here is that we look for clinical proof. We work with clinicians and medical researchers to ensure we are set up correctly.
- Other Measured Outcomes: Sometimes, biomarkers are hard to come by. We are then using other outcomes that, however, are still linked to scientifically proven health improvements. For example, in our work to reduce the burden of Musculoskeletal (MSK) disorders, we are using a mix of Pain Reduction (VAS) scores, functional health improvement (PROMIS-10) scores, and GAD/PHQ scores.
- Cost: Cost of care is easy for a third-party administrator to measure as we see all the claims. However, cost alone is not sufficient. Too easily can cost be changed by using different drugs, different care suppliers, or even preventing care without actually improving the health of our members.
In short, we are using a mix of those three areas. What are we de-emphasizing? Engagement metrics. Why? Because they often lack the evidence that they work. Let’s give you a simple example. We early on launched a program to close care gaps. It’s important for each of us to get the right screenings at the right time; however, if we only measure the engagement with our Emails or sms, we would not paint the right picture. What counts is whether or not the member has closed their care gap and whether worse-case situations like colon cancer reduce.
Our approach is working. Many Value-Based Care providers have entered the market not to offer transactional fees for service businesses but to create value by better managing risk than traditional health providers. Take Vori Health, they are the leading digital health value-based care provider addressing Musculoskeletal (MSK) disorders. We recently announced them as one of our partners for our Ecosystem. As we first met CEO and founder Ryan Grant, who is on a mission to re-humanize medicine, he directly understood the setup. “This kind of risk sharing that encompasses both cost and quality, is highly progressive,” he said directly after our first meeting.
As written before, healthcare data is changing our industry for the better. Using the right metrics healthcare can deliver “improved outcomes and save costs” as Lorenzo Consoli from NuvoAir explained. They are the leading digital health value-based care provider for respiratory conditions. The time is right and 40% of the commercial market wants to get access to value-based care. Let’s help to make it accessible to everyone. The future is now.