Core measures are attempt to define ‘value’ of care

Issue: March 2016

ByAnthony A. Romeo, MD

The movement toward a value-based health care system is undeniable. Through CMS, the U.S. government has made a clear effort to shift payment away from a fee-for-service model to alternative payment models that reward value and coordination of patient care.

While the fee-for-service model can be easily implemented in practice, it inherently incentivizes physicians to focus on the quantity of care they can provide without assessing its value to the health care system. Fee-for-service can encourage barriers to integrated care because health care providers are individually rewarded for separate procedures for each component of an episode of care, even if there is duplicity. The method of billing and collecting fee-for-service reimbursement is far less complex than an integrated, value-based payment model.

Value-based reimbursement

A value-based reimbursement system is the cornerstone of a value-based health care delivery system, one of the many goals of the Affordable Care Act (ACA). Politically, the ACA was heralded as a solution to providing health care insurance to uninsured Americans and to create incentives to reduce health care costs. The reduction in costs would be realized by moving to a model that encourages integrated care for the best overall value.

Anthony A. Romeo

For physicians, physician groups and health care institutions, a value-based system requires a paradigm shift in the way care is provided so all services offered for an episode of care are coordinated. The services need to be documented and evaluated in ways not typical for fee-for-service models. This requires sophisticated health information systems to capture, analyze and report data required for value assessment and value-based reimbursement.

Definition of ‘value’

If the government and third-party payers are going to reward value, then we need to have a method to define “value.” Value in health care has been framed as the outcome of care divided by the cost of providing the care. Cost of care is more easily determined as the dollars spent and can be carefully tracked. However, defining and collecting the most useful measures for outcomes has been more challenging. Outcomes of care cannot be captured by a single measurement or question. The data set to define important outcomes is different depending on the intended purpose of the after-care analysis.

Outcome measures based on patient-specific factors may be helpful to assess patient satisfaction with care and the overall sense of improved well-being and function. However, this information may have little value to orthopedic surgeons who are interested in the objective and technical measures of outcome. Both areas of measurement, as well as others, may inform the surgeons about the care provided, but priority has been on the surgeon-specific perspective, such as range of motion, strength and measurements of function. To truly define value to the patient and health care system, the emphasis has shifted to patient-based outcomes, including a formal assessment of the patients’ experiences with health care providers.

Since 1995, Consumer Assessment of Healthcare Providers and Systems (CAHPS) has been used by the Agency for Healthcare Research & Quality to rate health care experiences in the United States. Among the areas of measurement are communication with physicians, education about care, timeliness of care and the level of courtesy provided by the physician and staff. As surgeons, while we may believe objective and reproducible measures should be the key to value assessments, subjective patient-based assessments define outcomes of care and the value to patients and the health care system. The value of care as determined by these parameters will affect reimbursement for the care we provide.

Core Quality Measures Collaborative

Last month, CMS proposed the Core Quality Measures Collaborative to determine the quality of health care. The goal is to reduce the number of measurements required to define important patient-based outcomes so all parties involved in health care delivery have common ground to evaluate and reward better valued health care. The core measures will be in accountable care organizations, patient-centered medical homes and primary care, cardiology, gastroenterology, HIV and hepatitis C, medical oncology, obstetrics and gynecology, and orthopedics. The orthopedic measures include sections on hospital-level risk-standardized complication rates after elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA); hospital-level 30-day all-cause risk-standardized readmission rate after elective primary THA and TKA; and patient experiences with surgical care based on the Consumer Assessment of CAHPS Surgical Care Survey.

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CMS is already using measures from the core sets and will continue to introduce additional core measures, as 2016 is considered to be a year of transition. By having a common language to evaluate patient perceptions, core measures may reduce variability, independent measurement selection, collection burden and overall cost. However, the core measures may not provide meaningful information that can impact positive change. For many conditions, the correlation between subjective patient-based outcome measures and objective surgeon-based outcome measures is unknown.

Part of the process

The development of core measure sets is all part of the process to move our health care system into an integrated, value-based, patient-focused model. The alignment and acceptance of the core measures by public and private payers, as well as physicians, will lead to a clearer definition of outcomes. These outcomes will not replace the surgeon-based outcomes needed for our own self-assessments and improvements in the surgical and nonoperative management of musculoskeletal conditions.

These core measures are an attempt to define the value of the provided care in a method that rewards efforts that result in higher levels of patient satisfaction and positive health care experiences. This is critical to the understanding and management of population health care. Understanding the ideal purpose and goals of the quality metrics is useful when accepting the inevitable that we will need to participate in the new paradigm of a value-based health care system.

For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.

Disclosures: Romeo reports he receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.