Quality Improvement Efforts Should Focus on Providers, Not Geography

ORLANDO — Three times I raised my hand with the intent of interrupting a talk by health care economist Michael Chernew, and three times I lowered it quickly before he saw me.

My intent was to ask the Leonard D. Schaeffer Professor of Health Care Policy at Harvard Medical School about the news that the Supreme Court had ruled in favor of the federal government in King v. Burwell, thus allowing millions of Americans to continue receiving a subsidy for buying health coverage on the federally run insurance exchange. But he was a featured speaker at the HFMA Annual National Institute and I didn't want to be a jerk by interrupting.

The moment Chernew brought up Medicaid, though, I couldn't hold back and my hand shot up and stayed up.

Chernew handled the news like the pro that he is, even if for a second the admittedly talkative professor was taken aback. "I need to have a deep breath," said Chernew, who is a current member of the Institute of Medicine at the National Academy of Sciences and a former vice chairman of MedPAC. Attendees clapped, though not vigorously.

Chernew, meanwhile, was quickly back on track with some analysis. "We're more likely to stay on the same trajectory that we're on," he said, "so everything I just said is more important than it was."

And about that, his talk took aim at what he considers misguided attention to geographic variation. How so?

Quality measures used in health care today are not good, with a lack of correlation found among different measures in a region, he said. That means, "regions don't have a footprint that says, 'I have really good quality or I have really bad quality,' " he said.

So if you wanted to tackle that as a goal, doing so would take a lot of finesse in picking which quality measures to use, or perhaps better measures.

Chernew says the focus needs to be on providers themselves. "We've gotten to the point where I tell you the obvious: There's just an enormous amount of care that's not providing a benefit," Chernew said.

While many point to studies being done in geographic variation as seminal work, it has led researchers to focus too much on areas, Chernew argued.

"It turns out areas don't deliver care, providers deliver care," he said. "You can't call up Boston and tell Boston, 'You have to be more efficient.’ The solutions are not going to focus on areas, the solutions are going to focus on providers.”