Before You Claim Global Payments Are Improving Care…

Everyone’s fretting about the cost of medical care, and whether changes in health care delivery and payment systems will save money. But what about the more intimate aspects of medicine? What about the actual care?

WBUR’s Martha Bebinger offers her thoughts:

A Health Affairs report out last week concludes that a relatively new global budget contract in use by Blue Cross Blue Shield of Massachusetts has “improved care.” Hold on. If this is the threshold for success, then the move to global budgets is going to disappoint a lot of regular, non-medical people, like me.

Take a closer look at the evidence of “improved care” in the report. There are two charts (and summaries, both are below). The first includes scores for 21 ways to measure whether patients received recommended preventive or maintenance care. The second looks at whether patients with diabetes, hypertension and cardiovascular disease are more likely to have their ailments under control with care through a global budget than through fee for service. Yes, there is some evidence that patients are receiving better preventive care.

But to me, “improved care” should mean more: Are patients in a global budget healthier, happier and more productive than those who receive are through traditional fee for service? I understand that measuring “health” is really hard. One quality guru told me that the U.S. has not expanded ways to measure health care quality since we started using HEDIS in, was it the early ’90s? OK, but if you can’t tell me I will be healthier under a global payment, then don’t make the claim.

Here are some examples of things I want to know when comparing patients in and outside a global budget:

1) Do your kids with asthma miss fewer days of school?

2) Do adults diagnosed with depression miss less work?

3) Are patients readmitted to the hospital for the same or a similar ailment less frequently?

4) Do patients develop fewer hospital acquired infections?

5) Do moms suffer fewer complications after a normal vaginal delivery?

I don’t want to minimize the importance of helping diabetics keep their blood sugar under control. This is important. But I need more clear, understandable proof of “improved care.” Is it out there?

Here’s the chart on the 21 preventive and maintenance measures:

On the chart that looks at chronic disease management control, here’s what the report says:

Formal evaluation of outcome quality measures could not be conducted because of the lack of pre-intervention enrollee-level outcome data. However, an unadjusted analysis of weighted averages for five outcome metrics across provider organizations suggests that intervention groups achieved better or comparable outcomes in 2009–10 relative to recent Blue Cross Blue Shield of Massachusetts network averages.

And here’s the chart:

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  • Jackbrahms

    Chronic care benchmarks should result in affirmative answers to your first 2 questions, no? If asthma and diabetes are managed by the best practice guidelines, then those patients will be less impaired in school, work and other dimensions.

  • Michael Chernew

    Martha is correct that the science of quality measurement is
    still young. There are many important aspects of quality for which there are
    not yet accepted measures and others than cannot be measured well enough on a
    large scale.  We agree with her and in fact note in our article: “Our
    process quality measures did not capture all aspects of health care
    quality”.    However, as Martha notes, the measures are the
    state of the art for what is available today.    In fact, the
    AQC measure set is similar to (or more comprehensive than) that used in most
    pay-for-performance programs nationally.  Moreover, the landmark study of
    quality by McGynn et al (2003), which called attention to the significant gaps
    in care nationwide for basic preventive and chronic care services, used many of
    these same measures.   That the AQC is ensuring that patients receive
    these evidence-based services seen as fundamental to good prevention and
    chronic disease management is, indeed, an important achievement.  
    And even more, AQC groups’ success at achieving extremely high levels of
    control for patients with three of the most highly prevalent chronic conditions
    – diabetes, cardiovascular disease, hypertension – represents extremely
    important progress toward improved population health.  Keeping these 3
    conditions under good control is known to avoid devastating complications,
    suffering and cost in the near- and long-term. Certainly continued monitoring
    of the AQC is needed and many unknowns, including the long run sustainability
    of the model remain.  But at a time when we are struggling to find systems
    that encourage hospitals and physicians to spend less money without diminishing
    quality, the AQC provides encouraging evidence.  While it is indeed true
    that the field of performance measurement must continue to advance, this should
    not diminish our collective appreciation over the significant progress that AQC
    groups made in two short years on a very broad set of quality and outcome
    measures.  We would all like to have better, more comprehensive measures.  But we cannot delay reforming our health care
    system while we wait for better measures to be implantable on a wide scale. 
    Your readers should not lose sight of the big news from the study – quality, as
    best as we can measure it, is going up and costs are going down.

    Cite: Elizabeth A. McGlynn, Steven M. Asch, John Adams, Joan Keesey, Jennifer
    Hicks, Alison DeCristofaro, and Eve A. Kerr. The Quality of Health Care
    Delivered to Adults in the United States N Engl J Med 2003; 348:2635-2645. June
    26, 2003

  • Shannon Brownlee

    On the other hand, if care and outcomes are no WORSE under global budgets, and we spend less on health care, on balance it’s a success. 

    • guest

      Anyone who’s interested in these topics should read your excellent book, Overtreated.

      • Nancyc Orourke

        Is that the name of the book..Overtreated? 

    • Martha Bebinger

      Hi Shannon – yes – I would agree with your conclusion, “on balance.”  But as you can see from the HA article and others, the claim is “improved care.”  Before that claim becomes “fact” in the conversation about global budgets, we need to acknowledge that it is based on a limited definition of “care.”