Rethinking Metrics & ROI in Health Care

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Editor’s Note: Cambia Grove is proud to partner with the innovation community to amplify their perspectives on topics applicable to the larger health care ecosystem. This Q+A conversation took place at Cambia Grove’s June 3 event, “Paying for Health: A Domestic Perspective.” Speakers’ comments have been edited for length. The views expressed in this article are solely those of the author and do not necessarily reflect the opinions or positions of Cambia, Cambia Grove, or any other entity or organization. 

 

You might not think a provider and payer would agree on much these days. But Vin Gupta, a pulmonologist and ICU physician at UW, and Peter Long, Senior VP of Healthcare and Community Health Transformation at Blue Shield of California, both heartily agree: Health care needs fundamental change, and a good place to start is in rethinking our metrics and payment strategies.

Dr. Gupta works on the front lines of the COVID-19 crisis in Seattle and is a medical contributor to MSNBC. Peter Long is the force behind his health plan’s rethinking of the bridge between medical and social services and addressing the issue of health disparities. They shared their insights into the innovations and opportunities that could lead to lasting health care transformation. Hayley Hovious, President of the Nashville Healthcare Council, moderated with Maura Little, Executive Director at Cambia Grove asking audience Q&A. 

1. What factors are key to individual health vs. population health in the US?

Vin Gupta, MD 

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I used to think patients had agency over their health. But three factors – zip code, gender, and especially race – have removed some degree of agency.

People don’t have the ability to marshal resources to access health care if they’ve been in a cycle of poverty. 

COVID-19 has really emphasized that. On the inpatient side, I’m caring primarily for individuals who get life-flighted from Yakima. They’re migrant laborers, they’re generally brown and black, and they have one common theme: They presented too late to health care, and they’re very sick when they hit the doors of the ED. This is the story you’re seeing in Louisiana, in New York City, across the country. What you’re seeing is a progressive loss of agency for certain individuals in America.

2. What’s the payer’s role in keeping both individuals and communities healthy?

Peter Long

At its best, a health plan’s role is to create the conditions under which health can happen. In the absence of a macro system of health in our country, it falls upon health plans to create microsystems that work in different communities and promote health. 

Our first role is supporting providers through our payment policies, data collection, and overall partnership with them. Our second role is to bridge the divide between health and social services, so that we impact the whole person and meet their needs. The third and hardest role: How do you move from individual care to systemic factors that influence health more broadly? We have a robust foundation, we support community agencies, and we actively take on public policy roles to take on structural issues that prevent people from being healthy. 

3. What’s the relationship between cost and outcomes?

Peter Long

Our first step would be to associate our outcomes with costs. 

Health care is one of the few industries where we don’t have a clear return on our investment.

We’ve had the Triple Aim since 2008 as a way to relate cost, quality, and outcomes. But still, in our policy discussions, we tend to think about each individually. The secret is: Yes, it’s about cost, but it’s about cost in the context of the outcomes it produces. That’s the conversation we’ve been unwilling or unable to have in the US for quite a while. We’re blindly putting our money in the wrong places.

4. What makes for a “good” outcome?

Vin Gupta, MD
The conversations we need to have as a country are politically difficult. We allow a lot of things to happen in an ICU, for example, that I don’t think we should. Advance care planning happens way too late in this country. 

A study done at the VA a few years ago showed that 30% of Medicare dollars are spent in the last three weeks of life. What’s the root cause? One is our attitudes around death and dying. We don’t have an infrastructure to wrestle with palliative care at scale – or get wide acceptance that this can be a “good” outcome. On average, of those who get palliative care in a VA setting, they receive services about five weeks before death. That’s not adequate servicing of a critical health care capability. 

5. What metrics should we use to tie together cost and outcomes?

Peter Long

The outcome measures we use in health care don’t relate to people’s lives. A starting place would be taking patient-reported outcomes we’re measuring today, such as from HEDIS or CAHPS, and cross-walking them with real issues in a person’s life, such as dignity in dying, economic opportunity, well-being, and agency. 

Three things a health care plan can do. First: build transparency, because so much of this is opaque, and we’re not sure how to calculate outcome measures. Second: build standardization across plans to reduce the burden on providers. Third: build trust. Our measurement system reflects a fundamental lack of trust among patients, providers, and plans. 

Often, we create measures in lieu of building trust, so that’s our ultimate antidote to getting the right measures that are durable and drive to the outcomes we all seek.

6. How would you measure outcomes as a physician?

Vin Gupta, MD

We don’t do enough with patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs). If we’re going to move to a value-based-care reimbursement model, we need metrics in line with that. So far, this is a “Wild West” variable. But if it’s not standardized at the individual provider-to-patient level, how can we possibly aggregate the data and make sense of it, to move the needle on an intervention? Digital health data is becoming more commonplace, so let’s make use of that to provide metrics to improve patient outcomes. 

7. What can we learn from our current experiences? 

Peter Long

It’s either going to get much better or much worse. There’s not a path going back to normal. We’re going faster in certain pockets of skill to produce better health through data, but what’s the overarching vision? COVID-19 and the current cries for racial justice have exposed the lack of a model to hold this all together – and more importantly, a governance process to help us achieve that. 

I heard someone reflect that we’ve become a health care system that chases capability. We do things because we can, and we do things because they’re reimbursed. 

We’ve lost our way as a system that meets the actual, felt needs of people.

It’s imperative to experiment. There’s nothing stopping state Medicaid agencies or health plans from creating micro-solutions to show how it could work differently and produce different results. That would create breadcrumbs as we move forward, and when the next policy window comes, we’ll have more information about what will work. 

Vin Gupta, MD

There’s going to be a greater drive toward consuming health care at home. We’ll see a federal emphasis on making permanent what are currently temporary telehealth reimbursement rules. Centers for Medicare & Medicaid (CMS) passed 90 guidelines in the last 10 weeks; in the prior 10 years they passed about 90. Making sure that equity is built into technological innovation and that the legislative landscape follows in parallel are both key.

8. What metrics should we use to rebuild the system and evaluate success?

Peter Long

I would start with a national conversation: What are the incentives and what does success look like? We did this in South Africa to define rights and responsibilities in the health system. It was a deep, national conversation about people’s values and priorities.

What we’ve not thought about in healthcare is a “nested” measurement system, where we think about providers at the point of delivery. We capture patient-reported outcomes. Then we build up to process measures. Our foundation funded work through our Core Metrics project, which gave us 15 domains at a macro level to assess real-world health outcomes. We need to build out all these layers with more rationale. If Blue Shield uses the HEDIS #16, and someone else uses CAHPS #12, there’s no reasoning behind it. 

Interoperability around data is incredibly important – but from a platform approach. We have so many point solutions coming from amazing start-ups. We need to think about aggregating them onto a few platforms, so that what gets paid for and what we’re competing on is: How do you put together these point solutions with a human connection to drive change? 

Vin Gupta, MD

I wonder if HEDIS measures ask the right questions. Where’s the HEDIS measure asking if a patient was followed-up within 48 hours of starting an antibiotic? Antibiotic failure rates are a cost sink. I wonder if we’re not asking the right questions because we know our health care system could never do these touchpoints at scale. We don’t have that capability, so we’re not measuring for it.  

Fundamentally, we have the wrong health care work force. We don’t have enough MDs and ARNPs practicing at the top of their license. We need metrics around provider happiness. We have too many highly specialized individuals and not enough mid-level providers who can do day-to-day care coordination. We’re taking for granted that we’ll have providers work for us, on the ready and agile, in the next crisis. 

But the more we burnout providers, the more we furlough them, the more we’ll have poor outcomes.

About Rebecca Buffum Taylor

Rebecca Buffum Taylor is the Founder of Prose Arts LLC, specializing in health and medical communications. She researched and ghostwrote The Healthcare Crisis: The Urgent Need for Physician Leadership, a look behind the scenes of our spiraling health care costs and failed attempts at reform. Congressman Adam Smith wrote of the book: “It offers a unique understanding of the factors driving costs in our health care system . . . It is the most objective analysis I have seen on this critical public policy challenge.” Rebecca has held senior editorial leadership roles in publishing, including Editorial Director for the nation’s largest patient education publisher and VP/Executive Editor for an international photojournalism book packager. She was Executive Editor of The Face of Mercy: A Photographic History of Medicine at War, a $1.3 million international photojournalism book project published by Random House. Her clients include the American Academy of Ophthalmology, EvergreenHealth, WebMD, Kaiser-Permanente, Amazon, GeneSage.com, HealthTalk.com, Glamour magazine, Warner Books, Chronicle Books, and Jossey-Bass Publishers. Her work can be seen at ProseArts.com.