Meaningful Metrics for Health Outcomes Management


Healthcare outcomes have become one of the most spoken of and written about topics in healthcare media since the Patient Protection and Affordable Care Act (PPACA) was signed into law. Discussions ranging from which metrics best reflect the true quality of care delivery, how to measure these metrics, and how the CMS will tie metrics to an ever-changing reimbursement structure are just a few areas that have garnered much interest.

Measuring healthcare outcomes and linking the remuneration of healthcare providers to a widely-accepted quality benchmark is by no means new. However, the establishment of the Patient-Centered Outcomes Research Institute, an organization whose aim is to link the relative health outcomes, clinical effectiveness, and appropriateness of healthcare to the CMS reimbursement structure is an encouraging sign that a new kind of healthcare assessment methodology is possible.

Healthcare providers are reacting to the changing benchmarking environment through structural realignment (e.g., the formation of ACOs) to reduce gaps in care, and by partnering with best-in-class HEDIS and STAR coding and reporting solutions. However, questions remain whether today’s widely-accepted quality measures, such as HEDIS and STAR, are truly representative of high-quality healthcare.

Proponents of HEDIS have shown the ability to quantify both quality and cost reduction in more than 90% of episodes, but how well do these fiscal incentives align with our definition of quality healthcare when considering the following?

  • Overall care quality administered to those with comorbid conditions
  • Relative priority of mutually exclusive care outcomes
  • Individualized care protocols

How can quality measures and patient concerns be better aligned?

One area of quality measurement that has been gaining a great deal of traction is Goal-Oriented Patient Care, a new paradigm that promotes assessing each episode of care on a more individualized basis. In contrast to HEDIS measures, which barely touch on the qualitative aspects of healthcare, a goal-oriented approach measures the success of a given treatment or care regimen based on an expanded definition of quality, such as:

  • Remediation of specified symptoms
  • Gaining a desired physical functional status
  • Achieving desired social and role functions

Although achieving certain goals as it pertains to these criteria may lower a physician or health system’s scoring according to current standards (e.g., if an indigent person declines an expensive, but recommended, procedure, or if a wheelchair-bound individual elects to forego the physical therapy necessary to once again become ambulatory), a more holistic quality measurement framework would take into account the achievement of mutually agreed-upon care goals and likely rate such an accomplishment as a success. It is easy to see how other beneficial, yet unintended side-effects of highly-individualized care plans could ultimately lower the cost of care delivery for the system as a whole, without impacting the well-being of patients. When assessing the feasibility of goal-oriented outcomes measurement frameworks, it is important to consider how they fit within a healthcare system reacting to the needs the more informed, retail-like consumption exhibited by today’s healthcare consumer.

Recently, progress towards a more patient-centric quality assessment framework has been made at the federal level by the National Institutes of Health (NIH).  The NIH’s Patient Reported Outcomes Measurement Information System (PROMIS)  framework has been developed to provide healthcare providers with a system of highly reliable, precise measures of patient–reported health status for physical, mental, and social well–being.  Results of such research initiatives will ideally provide clinicians and researchers with patient–reported data currently unavailable within traditional outcomes reporting frameworks – and subjective data about how patients view and will react to various treatments and how they align with their expectations will be a powerful catalyst, improving the design of treatment plans and management of chronic conditions.

It remains to be seen how or when patient-centric, goal-oriented methodologies will be integrated within national programs such as the CMS Value-Based Purchasing Program, but we will continue to watch and report on this area as part of our ongoing advisory work in the sector.

Let us know what you think.

Anthony Nanne
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