Newtown, CT – April 27, 2012
What happens when you use a product for a purpose other than the one it was designed for? If you're lucky, it might work. But most often you get bad results. There are two current examples that offer important lessons in that respect. First are DRGs. They were designed and introduced for a very specific purpose – to cap the facility costs for hospital stays. And the designers had an option either to create a cap for every possible stay, or to group like stays together and create a single payment for all those like stays. They chose the latter, which makes a lot of sense and hence came the diagnosis-related groups. In August 2011, CMMI launched the Bundled Payment pilot, focusing the first phase on episodes that start with a hospital stay. The Bundle, however, includes professional services in addition to the stay, and can include post acute care costs in addition to costs associated to the admission. There are, however, significant differences in the mix of patients that are admitted for a particular stay and there are important reasons why they shouldn't be lumped together. For example, a patient admitted for the placement of a stent can have simple coronary artery disease or could have had a prior heart attack and perhaps early stages of heart failure. And while the facility costs might be similar and not vary much based on the underlying diagnoses of the patients, the same is not true relative to professional services needed to manage the patient during and after the stay. As such, extending the logic of the DRG, the product if you will, to something for which it was not designed, is a bad idea. Second are physician office system surveys, most currently known as the PCMH survey. In 2003 Bridges To Excellence commissioned the NCQA to work on the first version of that survey, which was called the Physician Practice Connections survey. It was designed to be used in conjunction with other measurement tools, and in particular tools focused on measuring the clinical markers of chronic conditions. The design was meant to link systems with patient management. Today, the PCMH tool is used autonomously, almost as a sole way of measuring quality in a practice, and that use is problematic, at best. Next week we will release a study that shows to what extent what you measure really matters.
What this means to you – we're always looking for shortcuts because it makes life easier, but the easy life is what has gotten us into the bog. After all, is there anything easier than FFS payment? But that doesn't mean it's right, quite the contrary. Products designed for one purpose, especially in our complex health care world, are most often not appropriate to use for another purpose, however simple that might seem. PCMH surveys were designed to measure the systems and processes in physician practices, not to measure the quality of care they deliver. It's not an appropriate shortcut to infer that a PCMH-recognized practice has high quality care. It has good systems and processes, but we don't know whether those systems are being used to generate good outcomes. Similarly, DRGs were used to group certain stays for the purposes of paying hospitals for similar stays. They should not be solely used as a basis to group patients for the purposes of bundled payments that include professional services and post acute care. Avoid the bogs because it's a lot harder, and take longer to get out of them, than taking the slightly longer road.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.