I'm reading through the Massachusetts AG's report on Examination of Health Care Cost Trends.
The report points out many things that are obvious:
- Payment changes absent substantive changes in care delivery will ultimately fail
- The logical route to improved (and lower cost) care is through care coordination, which is defined in the report as: "care that is managed across care settings, continuous over time, and patient-centered."
- This is a near perfect match with the essential features of primary care: access, person focused relationship over time, comprehensive services, and coordination of care.
- Current measures of quality do not appear to address the failings of the current system
From page 19 of the report:
"We also reviewed CMS, HEDIS, Mass-DAC, and ACES measures to understand how well providers in Massachusetts deliver care as compared to each other and, where national data is available, how they perform as compared to health care providers nationally. Our review shows that providers in Massachusetts deliver excellent care with little material variation in the quality of care delivered.18 For example, substantially all Massachusetts physician groups performed above the national average on HEDIS process measures. Other measures that we examined, such as CMS hospital process measures, show the same trend: little variation in the measured quality performance of providers, and high quality care from all providers. Based on our review of these measures, there are some differences in provider quality performance and room for improvement in certain areas of performance, but our review does not suggest that any provider performs consistently better or worse than any other."
I paraphrase: "In spite of the facts that our current market fails to achieve meaningful goals and recognizing that considerable variation exists, our current approach to quality measurement fails to recognize meaningful variation and fails to provide any indication that our system is struggling."
If the current approach to measurement cannot identify variation when variation is known to exist, and if the current approach to quality measurement cannot identify system failure when the system is obviously failing, then the current approach to quality measurement is of very questionable value indeed.
High performing health care is founded on primary care.
Primary care has four cardinal features:
Access
Person-focused relationship over time
Comprehensive care
Care coordination
High performing health care results in better population health outcomes and reduced cost of care by avoiding potentially preventable events
Safran, Wasson and others have demonstrated that people can accurately report their experience with these cardinal features of primary care and both show us great variability between practices and strong indication of system failure: Wasson tells us that only 35% of a national sample report that they experience the bulk of these positive attributes.
In addition to our national conversation and efforts to change payment, we must talk about the immense momentum behind a failed approach to quality measurement. Patient experience with the core attributes of primary care appears to be a much more logical starting point.
