For a number of years, CMS, which operates the Medicare, and the federal component of the Medicaid, programs, has been embarked on an intensive effort to improve quality, first by requiring on incenting the collection and public reporting on various measures it believed reflected quality and now by embedding those measures into “value-based” payment systems, so that performance actually affects what providers get paid. Significant issues have been raised about the design and impact of CMS’ efforts, not just by providers but by policy groups like the Medicare Payment Advisory Commission. The primary concerns have been that the number of measures overwhelms providers and may make it hard for payers and consumers to focus on what is most important, that by singling out certain measures less attention may be paid to other equally significant quality efforts, and that the measures often are shown to be unrelated to either health outcomes from care or to overall improvement in a patient’s health, which always should be the most important goal of any health system. CMS has released a report on the impact of its quality efforts, which not surprisingly finds them to be very positive. (CMS Release)
The report examined performance over the 2006 to 2012 period on 119 measures in seven quality programs. Some of the highlights that CMS called out include that performance improved over the period on 95% of these measures and the 35% were categorized as high performing, meaning that scores were over 90% on them. There was less race and ethnic disparity in scores by 2012 than was present in 2006. And CMS claims that 7,000 to 10,000 lives were saved because of improvement in performance on heart failure treatment measures and that 4,000 to 7,000 infections were avoided due to gains in performance on hospital surgery process measures. Both of those claims are a bit of a stretch, as causality is very hard to show, especially in an environment where there is general awareness of the need to strive for the best outcomes for patients. While CMS is happy, or says it is, providers may be more disgruntled, with a number expressing the view that these programs are expensive to comply with. And researchers have generally failed to find strong evidence that these efforts actually improve health, which doesn’t necessarily mean they are a bad idea, but should lead us to be cautious to ensure that the costs are worth the benefits.