Are some quality measures, while well-intentioned, actually dragging doctors away from more pressing needs of their patients?
That's a question that Martin Serota, M.D., and a handful of other safety net providers are pondering. The chief medical officer of AltaMed Health Services in Los Angeles worries that doctors are sometimes forced to dedicate money, staff and resources to meeting arbitrary quality metrics that aren't always critical in their markets. Meanwhile, those providers must spend less time on community issues that are having a much larger impact on health, such as tuberculosis, HIV, food, shelter or domestic violence.
"Health care is local and we all have local challenges," Serota says. "And it's really distracting to have national guidelines that are meant to be generalizable applied to specific populations. Every population has its own issues."
Serota cites mammography screenings as an example of one quality measure that some have argued isn't necessarily evidence-based, and may not be the most important target for a safety net provider to pursue when its patients are facing more pressing social and economic concerns. While Serota's views are focused on the outpatient clinic side, he believes the same concerns apply to the hospital inpatient side, where the Joint Commission and the Centers for Medicare & Medicaid Services set quality metrics.
In an article in the June issue of the Journal of the American Medical Association, Serota and two other doctors argued that quality measures should head in a different direction, one that's more outcomes-based, simple and easily adapted to local markets. Hospitals could be judged on three overarching categories — risk-adjusted emergency department and hospital use, measures of enabling services, and patient satisfaction measured by the Hospital Consumer Assessment of Healthcare Providers and Systems survey.
Helen Burstin, senior vice president of performance measurement for the National Quality Forum, agrees. Doctors have experienced frustration for many years trying to sort through a cacophony of different measures coming from various sources, and focusing on outcomes rather than processes might be the best way to clear things up.
"Outcomes measures are pretty much at that very high level and, regardless of the community you're in or the kind of patients you care for, those are still going to be the most important," she says. "How you focus in on some of the other processes you think you can use to drive improvement toward those outcomes is where customization and prioritization at the local level is really critical."
Nancy Foster, vice president of quality and patient safety policy at the American Hospital Association, says the association has commented often to CMS that current measures have a bias that disadvantages safety net providers and may not be the most important set of guidelines for any given hospital. Measuring readmissions is the right thing to do, she says, but often a wealth of factors outside the hospital's four walls contribute to those cases.
"It's great that they've raised this question about whether the measurements are right, but let's not forget that even if the measures are right, there still may need to be an adjustment to reflect differences in the patient population to create a fair comparison of what the provider was able to accomplish," Foster says.