The Concept of Quality Measures in Healthcare: The Good, the Bad, and the Ugly!

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Quality has to be defined in specific terms or metrics- it cannot be something abstract. Quality metrics enable physicians to translate patient needs into measurable goals. It is necessary to define a set of quality metrics while planning to know what exactly needs to be done. Quality metrics are utilized by both products and processes to establish acceptable performance measures and are crucial for quality management and measurements.

The healthcare scenario in the USA and other countries underwent massive policy and business model transformation in recent years. Healthcare companies have started to explore new quality metrics or KPIs (key performance indicators) to satisfy the new standards.

Examples of KPIs can be staff to patient ratio, insurance claim denial rate, and so on. KPIs are objective tools used by organizations to measure their performance and help healthcare professionals deliver better care. More straightforward quality measurement will make it easier for all stakeholders to see progress and work on the areas on which they know they have to focus. Objectivity does bring in more benefits.

Is KPI Ideal for Healthcare Industry?

We have to establish accurate KPIs for the healthcare industry. KPIs should be well defined, thoroughly communicated, and quantifiable, and aligned with your goals. Quality metrics should be specific and personalized for the physician’s independent practice. It can lead to many benefits such as colossal scale measurement of company data, determination of positive and negative aspects of an organization, supply chain management transparency, increased sales and revenue, brand identity development, customer and employee satisfaction, increased employee productivity, scalability, cost-effective operation and so on.

But there are downsides too- the chance of personal bias as quality is measured by human intervention, employee resistance, and others. We also have to keep in mind that the quality metrics should be relevant to the medical field; they should consider specifics such as human life expectations and other variables. The quality of healthcare is reflected in the doctor-patient relationship and the patient outcome, and relying 100% on KPIs may not be the best thing. It can create resistance, physician burnout, and mistrust among stakeholders.

We cannot rely on the quality measures developed by non-medical entities like corporates and insurance companies that use cookie-cutter protocols. Quality is measured against something similar, and the concept of similarity in individual independent practice is relative to the patient’s expectation and physician’s transparent expertise. There are too many variables to consider, and the quality measures must be implemented at the individual practice level and unique to the independent physician practice.

It will be unfair and counterproductive to both physicians and patients if quality measures developed by non-medical entities are enforced upon them. The formula of one size fits all does not apply to healthcare and only suitable for insurance companies and big data.

The Implications of MIPS and MACRA

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and Merit-based Incentive Payment System (MIPS) have transformed the payment policy of care providers and doctors under Medicare. Under MACRA, the Centers for Medicare and Medicaid Services (CMS) devises payment models for Medicare patients through the Quality Payment Program (QPP) that depends on the outcome.

But according to a survey by the University of Pennsylvania, only 8% of doctors are very familiar with the program. 60% were not at all or slightly aware. On top of that, MIPS requires physicians to file quality and other reports, including Electronic health records (EHR), and increases the workload and frustration. They also have to file feedback to negate the payment determined by the program.

The researchers also found that more than half the doctors were willing to change their behavior to benefit from the system. That could lead to undesired results as the researchers expressed caution that the physicians can ‘game the system’ to rep the incentives. Also, the policies can have unintended consequences, and the researchers warned policymakers to monitor the program intently to prevent such happenings. They also advised them to align the program guidelines with physician’s perspectives for better results.

Suitable Quality Measurement for Healthcare Industry

KPIs, MIPS, MARCA- they are all cookie-cutter methods that ultimately lead to increased mandates, resistance, unfair penalties, loss of revenue, physician burnout, and patient frustration. We need to generate trust from the other end in exchange for transparency. Any reimbursement should be based on personalized medicine and patient outcome and tailored to individual practice, physician, and patient expectations taking into account available socioeconomic resources.

If we utilize the production model and consider doctors and patients as “production line concepts,” we will fail. Such quality measures would be substandard, unethical, and prone to malpractice. Clinical judgment is getting clouded heavily by the greed of corporate entities and government mandates encouraged by the lobbying of the corporates.

Physicians should look into their inherent qualities and open their minds. They already have the support of their patients under the privilege of the doctor-patient relationship, which is the strongest indicator of quality in medicine- we cannot let corporate medicine destroy this crucial bond. We also have technologies that can lead to endless possibilities, but they will always mix the good, the bad, and the ugly! On the other hand, corporate KPIs will always be counterproductive and hinge on bad and ugly only.

Corporate entities will adopt the ‘one size fits all approach where they must consider every aspect of independent physician practice. Physicians and patients must take control of strategy customization, technology validation, and data ownership. They should specifically concentrate on crypto mining and data mining activities relating to specific clinic and professional endeavors.

Let us join hands in a bid to promote healthcare beyond geographic and socioeconomic borders!