Health as a Metric. The Prerequisite for Reform

All of the debates on whether real health care reform can be achieved have me puzzled.  I come back to a simple question.  What do we mean?

Are we talking quality, affordability, or access to care?  I guess that is why the reform movement (if there is one single movement) seems disorganized.  While one reformer may optimize around one of these issues (universal coverage), others may focus on other issues (affordability).

If you were to ask a child why health care is important, and I have, the answer would be simple—to make us better.  If making us better is the goal, then we should have a metric for this.  But we don’t.  It is easy to measure coverage and cost, but “health” is an elusive concept when it comes to measurement.  For example, if a person presents to a hospital with a heart attack, even if they survive and eventually go home, we would be hard pressed to define their optimal level of “health.”  Perhaps in this person’s case, some would argue that it would be prevention of a second heart attack.

Let us go back to the child and ask her how do we know we are healthy.  This child would answer, “Because we feel good.”  Again, clarity and brilliance.  Translate this to the absence of disability or pain and the presence of fitness. 

As this gets into the realm of “touchy-feely,” the participants in the health care debates steer clear of it.   But in the end, this is what patients want out of the healthcare system.   This is what I want.  Don’t you?

So why should this matter for the health care reform debate?  Because Americans have proven they want good health care at any cost.  They have demonstrated this by spending more than any other country in the world on health care.   They are ambivalent about how it is done (socialized vs. private, etc…), as long as they have access to health (note I said “health” rather than “health care.”)

We need to find a way to apply a set of metrics to health.  It needs to be relatively easy to administer, comprehensive, and consistent with people feeling as if they are in good health.  When there are metrics, we can point at legislatures, physicians, and industry and say, “we don’t care how you do it, just get this done.”   I believe they would.  And I believe that the problems we discuss today—affordability, access, cost—would be much easier to solve.   

Comments

[Scott Hodson]

My Firm's point of view is that to truly "move the needle" on cost and quality, an organization must begin by clearly defining and measuring it, and then making the results available to trustees, employees, physicians and the general public. Transparancy is essential to achieving significant lasting improvement in quality and patient safety.

While there is no standard healthcare industry definition of what constitutes "quality," we have found that top healthcare performers adopt a composite of measures that consider:

Clinical Outcomes: Ultimately it is the outcome that matters most. Risk adjusted healthcare quality measures such as inpatient mortality rate, readmission rate, complication rate are commonly accepted indicators of quality outcome success.

Clinical Process: Effective clinical processes are essential to achieving superior healthcare quality outcomes. At a minimum, current publicly reported "core measures" should be considered. Evidence based physician order sets and clinical care plans provide a rich assortment of additional quality process measures.

Patient Experience: Effective communication with caregivers, environment, and customer service are an important part of an effective treatment program. The medicare Hospital Consumer Assessment of Healthcare Providers and Systems is one good source of useful performance data.

Resource Utilization: "Too little" or "too much" care can adversely affect outcomes. Measures such as risk adjusted average length of stay, ICU ALOS, and cost per case are examples of effective resource utilization indicators.

Top performing organizations not only define and measure healthcare quality, they ask the question: "How are we doing? We believe that the best way to answer that question is to compare your results to those of "Top Performers." There are a number of organizations that provide excellent health care industry clinical quality and financial benchmark information. Through benchmarking, organizations are able to identify their strengths and weaknesses, and develop strategies to address and overcome healthcare quality gaps.

Benchmarked performance ratings on individual measures can then be weighted and rolled up to measure overall quality performance for individual conditions (e.g. pneumonia vs. AMI, individual hospitals within a health delivery system, or a system - wide composite score.

Finally, true improvement occurs when "stretch" goals are established by Board of Directors, and hospital management incentives are tuned to the achievement of those goals. We have seen breakthrough improvements in quality and patient safety when this approach is used to identify and address problem areas.