The Apixio Blog

Ending the Quality Wars

Quality has been a fraught concept in healthcare for many years. What does “high-quality” healthcare mean? Is it a lower mortality rate? Is it patients being able to get a next-day appointment with a specialist? Is it ensuring patients are satisfied with their hospital stays?

A Hospital’s Perspective on Quality

For many hospitals, high quality health care means strong clinical outcomes. It means lower deaths due to sepsis or medical error, and a higher success rate for surgeries and procedures. Think of the billboards you see promoting hospitals; they’ll often cite a US News & World report ranking, or a specialty they do particularly well. Quality is also  slowly becoming more synonymous with patient satisfaction-  happy patients (the rising prominence of patient satisfaction scores such as CG-CAHPS and Press Ganey is evidence of this).

A Patient’s Perspective on Quality

For patients, high quality means strong clinical outcomes, along with convenience and customer service. Like hospitals, patients desire strong outcomes, but it can be difficult for consumers to find and understand data on this subject. Therefore, they treat convenient and customer service as “quality” factors. In some cases, convenience even trumps what outcomes, as a 2014 survey from a consulting firm that works with hospitals noted, “consumers prioritize convenience over continuity and credentials” when choosing a primary care practitioner.

An Insurance Company’s Perspective on Quality

For insurance companies, high quality means the best clinical outcomes at the most efficient cost. It means allocating care to the individuals whom it would help the most, setting reasonable standards for care coverage, and helping patients to not get sick in the first place (with preventative care). As consumers begin to become more active insurance shoppers, through the healthcare exchanges, it may also mean elevating the customer experience..

What definition of quality is the right one? Well, maybe they all are. Maybe quality is inherently a nuanced concept that incorporates many angles, from clinical outcomes to convenience to affordability.

The Government Steps in to Mediate with MACRA and HEDIS

In fact, the government has stepped up in the past couple years and done a great job of building out quality metrics that reflect such a consensus. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) has a strict definition of quality that will be applied to all physician payments. The bundled payment model has a definition of quality that applies to all hospitals. The Healthcare Effectiveness Data and Information Set (HEDIS) is a definition of quality that applies to health plans. MACRA also initiated a physician registry through which patients should be able to search for physician quality.

Quality is becoming more and more important factor in the healthcare system, as it moves from fee-for-service to value-based care. Hospitals, insurers, and patients should embrace the nuanced definitions that HHS and CMS have put forward, as they take into account quality’s many angles. Sure, people want different things out of our healthcare system. But it’s time to end the quality wars and embrace the metrics we have today, which reflect a very reasonable approach.