Quality/Outcomes

The Better Healthcare Program (BHP) is based on three fundamental improvements over the traditional fragmented, fee-for-service healthcare system in the United States, which costs more and delivers less quality than in any other developed (OECD) nation:

  1. Replacing fee-for-service provider reimbursement with risk-adjusted capitation and other value-based methods.
  2. Organizing providers into integrated Better Care Teams that are motivated and organized to treat the whole patient.
  3. Measuring the quality of care in meaningful ways that enable (a) Better Care Teams to continuously improve and (b) consumers and other purchasers to select health plans and providers on the basis of quality as well as cost.

Currently, in order to make informed decisions, purchasers of healthcare must know enough to seek out and combine information from multiple sources.  Even then there are numerous barriers to purchasing the best care they can afford, including:

  • Hospital ratings that do not adequately reflect outcomes
  • Hospital rating services that provide either too much or too little information to the consumer.
  • Insufficient information on non-hospital providers’ quality of care in most states.
  • Lack of consensus among healthcare professionals on the best methodologies for measuring quality
  • Lag times of 1 to 3 years between the occurrence and public availability of outcomes.
  • Lack of an all-payer outcomes database at the federal level and in most states.

Why Measure Outcomes?

The US ranks far below other developed countries when it comes to life expectancy and various other measures of mortality and morbidity.  The rationale for the proposed system stems from the following deficiencies in the current system:

  1. mortality rates can vary by a factor of 3 to 1[i] or more. 
  2. Research also shows that existing publicly available quality ratings of health care plans and services do not correlate well with outcomes.

It seems axiomatic, therefore, that an effective method of reporting comparative health outcomes to purchasers of healthcare would motivate health plans and providers to improve their performance.  In short, publicly reported outcomes for health plans and providers would enhance  competition based on quality.

“I still can’t tell you whether Geisinger is the highest performing health system in the United States.” Richard Kronick, PhD – former Director of AHRQ (12/7/2020)

Why Public Reporting?

Changing the National Conversation

For at least 5 decades the public healthcare conversation has focused primarily on rising costs while the U.S. has lagged behind other OECD countries in numerous measures of mortality and morbidity. Exceptions to the cost focus has been several reports of the National Academy of Sciences on improving the quality of care.1-3  These have underscored that there is an as yet unrealized opportunity to substantially improve the quality and safety of care in the U.S. while reducing unnecessary care.  Yet while the U.S. reports jobs and GDP growth, inflation and unemployment on a regular (monthly or quarterly) basis, no effective reporting system holds health plans and providers accountable to the public for health outcomes.  But if the U.S. published a few key risk-adjusted measures of mortality and morbidity, purchasers, government officials, consumers and voters would ask why we lag behind so many other countries. 

External Motivation

“The introduction of PR programs at different levels of the healthcare sector is a challenging but rewarding public health strategy. Existing research covering different clinical outcomes supports the idea that PR could, in fact, stimulate providers to improve healthcare quality.”[i]

In the words of Peter Drucker, “If you can’t measure it, you can’t improve it.” Consider, for example, how focused management of most publicly traded companies are on quarterly earnings per share (EPS).  A system that regularly reports mortality and morbidity to the public could bring the same kind of focus to healthcare organizations and purchasers.  A study in Wisconsin found “that large group practices will engage in quality improvement efforts in response to public reporting, especially when comparative performance is displayed….”[ii]

Changing the Purchase Paradigm

Today individual and corporate purchasers of healthcare are flying virtually blind when it comes to quality.  No rating system for health plans and provider groups provides outcomes information, as opposed to HEDIS process measures, in a usable way.  If purchasers, consumers and government officials had timely data on mortality and morbidity of procedures, hospital acquired infections and medication errors they would have the tools to choose best performers.  This would also drive poor performers to improve, thereby improving the overall quality of care in the U.S.  What consumer or employer would choose a health plan, hospital or provider organization knowing that its actual mortality rate is several times that of another available plan?  A robust outcomes reporting system, as described herein, is needed to change the purchase paradigm. 

Power of Competition

One of the founding principles of the U.S economy and the current U.S. health insurance system is competition.  Enabling health plans and provider organizations to compete on the basis of outcomes would align well with a national goal of improving upon the measurable outcomes of other nations.  Giving purchasers of healthcare the ability to select plans with low mortality and morbidity rates could create a sea-change in the way they make their health coverage decisions.

Network Enhancement

“Patients receiving care with poor teamwork are almost five times as likely to experience complications or death”[iii]

A recent study found a fourfold difference in mortality rates among health plans within the same county[iv]. With the substantial variations in outcomes among health plans and hospitals, comparing mortality rates could enhance the popularity of high performing plans and counter the excessive emphasis on choice in employer-sponsored health insurance plans, in which HMOs’ market share is less than  20% . 

A National Initiative?

In addition to benefitting purchasers of healthcare, public reporting of outcomes could be a powerful tool to improve the overall quality of health care in the United States.  It would aid government payers, regulators, economists and planners in allocating resources.  By measuring and aggregating a few outcomes measures, the country could establish goals for quality of care at the federal, the state and county level and identify problem areas that need attention. 

“We should produce an annual report card on health system performance, with information on risk‐adjusted total cost of care, on performance on quality and outcome measures, and on disparities in care and outcomes for disadvantaged groups.”[v]
Richard Kronick, PhD – former Director of the AHRQ (12/7/2020)

[i] The impact of Public Reporting on clinical outcomes: a systematic review and meta-analysis (BMC Health services Research 7/22/2016)

[ii] Publicly Reported Quality-Of-Care Measures Influenced Wisconsin Physician Groups to Improve Performance (HealthAffairs 3/2013)

[iii] Surgical team behaviors and patient outcomes. American Journal of Surgery, 197, 678–685. Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, Thomas EJ (2009). 10.1016/j.amjsurg.2008.03.002

[iv] Choosing the Wrong Health Insurance Could Kill You Jason Abaluck (Yale Insights 9/2/2020)

[v] The promise and peril of health systems (Health services Research 12/7/2020)

[i] Go to the Wrong Hospital and You’re 3 Times More Likely to Die (NYTimes 12/14/2016)