WASHINGTON -- Physicians and other health policy experts explored the challenges of getting value-based payment right at a briefing hosted by Health Affairs on Thursday.
The event was sponsored by the American College of Surgeons, American Medical Association, Blue Cross Blue Shield Association, Booz Allen Hamilton, Federation of American Hospitals, Johnson & Johnson, and Premier.
David Baker, MD, MPH, executive vice president of the division for Health Care Quality Improvement for the Joint Commission, spoke about reforms to current value-based payment strategies that could drive improvement in hospitals.
"It's time to retire the readmission reduction program," Baker said. He believes doctors should focus on reducing admissions across the board, not only readmissions. He noted that as a primary care physician, he could have one patient readmitted five times in a year for issues considered preventable and never be penalized.
Baker also remarked that 30-day readmission rates have dropped from 21.5% to 17.8% from 2007 to 2015, with very little decline after 2012. "In other words, the juice has been squeezed," he said.
Studies have found that only 10-25% of readmissions are preventable, said Baker, a statistic he translated to say that 90-75% of differences between hospitals are "spurious and do not reflect true differences in quality."
"Everything that we know scientifically for improving care, or the main things that we know, we've already done," he said. Citing chronic obstructive pulmonary disorder, as an example, he added, "If you look at the literature, there are almost no interventions that improve mortality."
Baker also stressed that outcome measures must be more carefully considered. Many outcome measures have questionable validity, inadequate risk adjustment, and are "unlikely to improve quality of care."
Poorly conceived outcome measures may also have unintended consequences, he noted.
"There's nothing that improves 30-day mortality for stroke except taking patients who probably should be allowed to die peacefully ... and keeping them alive for 30 days," he said, when "what they really want and what their family wants is to be able to die at home."
Jonathan Perlin, MD, PHD, echoed Bakers' concerns regarding unintended consequences of certain hospital measures.
He highlighted the Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) survey, which asks patients to rate how well their pain has been controlled. In light of a nationwide opioid epidemic, such questionnaires put clinicians in an impossible position.
"I know that physicians that are measured by those are very sensitive to wanting to have superior evaluations, particularly if their institutions, in the interest of transparency, publish those," he said.
In this new reality, Perlin said, providers should have measures to hold them accountable for managing pain rather than achieving 100% freedom from pain.
Perlin also spoke of the need for measures that capture continuous improvement, and in particular the need for more timely feedback. Certain mortality measures include a lookback period of 4 to 12 quarters, he said.
"This is like driving down Pennsylvania Avenue steering in your rear-view mirror, based on what you saw four blocks ago. It's really dangerous to be here at 15th Street kind of attending to what happened on 19th, but that's what we're being asked to do with some of these very lagging measures."
One last challenge when providers think about quality measurement is the resources required to make improvements actually happen.
In other words, this kind of healthcare transformation patient care happens at a cost.
Cheryl Damberg, PhD, MPH, a researcher and professor at the Pardee RAND Graduate School, said, that providers may need to hire new staff and invest in new equipment to achieve these aims.
"I do think we need to signal the behavior we want and then we need to provide some resources to support providers doing that work," she said.
She emphasized that quality programs should focus on paying for improvement instead of reaching flat targets.
"Many providers ... may be very far from that target, and yet we're still asking them to make considerable investments to get there. "
Baker added that for safety net hospitals, in particular, incentive payments could come too late.
"They need more up-front payments in order to be able to improve their infrastructure and to have the payment or the promise of potential payments, when they don't know whether they are going to improve or how long it will take," he said.