HCI3 Update From The Field: Focus on Survey of Systemness Has Little To No Impact On Cost or Quality

Submitted by francois.debrantes@hci3.org on Friday, February 28, 2014 - 01:34

Newtown, CT – February 28, 2014

You only know if processes and systems are doing their jobs by monitoring outcomes. It's a lesson the NCQA refused to listen to and now the results are in – In 2002, shortly after the release of the IOM's "To Err is Human" report, we launched an effort to encourage physicians to redesign their systems of care and deliver better patient outcomes, especially for those with chronic conditions. As part of that effort, we hired the NCQA to work with us to develop a survey that could assess "systemness" in physician practices. Its purpose was to help guide physicians on the types of processes that could lead to more systematic improvements in the management of patients. That survey, which we called the Physicians Practice Connections tool, was one of a two-part Bridges To Excellence reward program: systems + outcomes. The second part was a focus on intermediate outcome measures for patients with diabetes or cardiac disease. Soon thereafter the NCQA decided to develop the second version of that survey, and then a third. This coincided with broad cries from the industry about the shortage of primary care physicians and the widening gap in pay between PCPs and specialists due to the distortions in the RBRVS by the AMA's RUC. And so was born the PCMH program. From the start, we expressed significant concern about the lack of focus on measuring outcomes of care, but they were brushed aside because "it would be too hard for practices and no one would qualify for Recognition." And so here we are…

What this means to you – Earlier this week, a paper published in JAMA highlighted what we had predicted, and what our own studies have shown for years, namely that the sole focus on a survey of a practice's systemness has little to no impact on cost or quality of care. What does have a significant impact is the focus on the outcomes of better patient management, especially those who are most at risk for avoidable hospitalizations. What's really frustrating is that studies dating back to the 1990s about ambulatory care sensitive conditions clearly showed that better management of patients led to fewer hospitalizations. The Camden Coalition found the same in their work with super-utilizers. And a recent study of medical homes in MN found that practices with better processes had better outcomes in a state where a focus on outcomes is maniacal. In other words, it's the outcome that matters, and the processes support those outcomes. For several years, practices in MN have had to report the nation's most stringent measures on patients with diabetes and cardiac conditions. The results are public, and it should come as no surprise that practices that have adopted better internal systems are getting better results, because their line of sight is on those results, not simply on filling out a survey about the processes used. So here's the bottom line: the NCQA PCMH SURVEY SHOULD NEVER BE USED BY ITSELF TO ASSESS A TRUE PATIENT-CENTERED MEDICAL HOME, AND SHOULD NEVER BE THE BASIS FOR REWARDING PRACTICES. In fact, its usefulness has run its course. In an age of wide adoption of EMRs and registries, the focus of incentives has to shift entirely to the results of the care provided. We've already lost enough time on this. No need to lose any more.