How Quality Fits into Value-Based Care, Organizational Improvement

Value-based care reimbursement strategies represent a shift in focus from the quantity of health services delivered to the quality of those services. Highlighting the importance of quality is ingrained in the framework of these models, but quality can be defined in different ways by the various players in value-based care models.

There are six domains of healthcare quality, according to the Agency for Healthcare Research and Quality (AHRQ) – safe, effective, timely, efficient, equitable, and patient-centered. Any of these domains can be leveraged in value-based care deals, though some are used more frequently than others. Payers and providers can agree to combine several measures for an overall quality score, and reimbursement rates can be adjusted based on these scores. Many value-based care contracts will include a requirement that quality measures have to be met prior to any shared savings payout.

Missing from this conversation oftentimes are the very individuals the deal aims to help: patients. For successful value-based care models, patients must remain at the heart of every population health strategy. Regardless of the domains selected for quality scoring, delivering high-quality, patient-centered care will assure high quality scores. 

SAFE

Patient safety is critical to quality care; as a result, many patient safety measures are either directly incorporated in value-based care models. Models, including measures such as preventable infections and preventable hospitalizations, directly highlight patient safety as a key quality measure.

Unintended infections and hospitalizations, among other things, are costly to a health system, so preventing unnecessary hospitalizations is a cost-saving strategy. Typically, these unwarranted infections and hospitalizations are avoidable with a greater emphasis on patient safety. For example, a physician or other clinician improperly bandaging a surgical site could lead to a hospital-acquired infection, which is preventable when providers take all the proper steps to ensuring patient safety.

EFFECTIVE

Readmission rates are the most common quality measure that emphasizes effective care. Payers articulate that if patients received proper care in the hospital and were counseled correctly on care-coordination after discharge, readmission rates should be low.

Providers often push back, arguing that they can deliver effective care to the patient, yet readmission rates can still be high due to factors outside of their control. As such, they believe this does not fully capture effective care delivery.

Many value-based care deals, therefore, choose to focus on process measures. These metrics outline if a provider is taking the proper steps to deliver the standard of care to a patient, more accurately demonstrating effective care delivery on the provider side.

EFFICIENT

Outcome measures in value-based care models articulate whether appropriate care was done and if it was effective. These measures most closely relate to traditional fee-for-service measures as they reimburse a provider if he completed a specific task necessary for good clinical care.

The goal of these measures is to understand if a provider’s care helped a patient: was the provider able to regulate a patient with diabetes’ blood sugar? Did the colonoscopy identify small polyps instead of large tumors?

TIMELY

While it is difficult to capture timely delivery for each patient, proxy measures can capture this. Patient-reported measures indicating whether a patient feels he was seen promptly or had to wait for an appointment can be used to understand timely care.  

Surveys, such as the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey, ask patients these questions and are already captured in Medicare Star Rating reports, making them easy to report for value-based care reimbursement models as well.

EQUITABLE

Equity of care is another difficult quality metric to capture. However, population health reporting strategies can help understand if a plan and provider are delivering equitable care.

Many value-based care deals emphasize preventive screening and reward providers if a certain percentage of their population undergoes a preventive screening. Delivering equitable care means that these screening rates are similar across various demographic groups. If they are not, stakeholders in value-based care deals want to ensure their reimbursement measures focus on closing the gap.

PATIENT-CENTERED

Patient experience is routinely collected by many providers through CAHPS surveys to measure a patient’s perceptions of the care they are receiving from their provider and their health plan. The survey asks if patients feel their doctor or health plan listened to their concerns and cared about their values, a proxy for delivering patient-centered care.

The value-based care model itself might also emphasize a focus on patient-centered quality metrics, seen in the patient-centered medical home model. This model highlights care coordination through a primary care physician and reimbursements are allocated based on the level of care coordination.

No single value-based care model incorporates all aspects on quality, but no quality measure lives in a silo. Many measures impact each other; for a value-based care deal, different quality metrics should be leveraged depending on the target population and stakeholders needs.

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