In search of the Holy Grail: Outcomes metrics

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 - John Nance, MD
John "Jay" Nance, MD
Source: Johns Hopkins Medicine

It’s no secret that healthcare in the U.S. provides comparatively poor value. That’s not an opinion. It’s a fact, as costs are high relative to outcomes compared to other Western nations. What can the profession of radiology do to help reduce the former while simultaneously improving the latter?

John Nance, MD, Johns Hopkins Medicine, took up the question in a talk at the annual meeting of the Society of Imaging Informatics in Medicine in National Harbor, Md.

Defining value in healthcare as outcomes divided by the costs necessary to deliver them, Nance said that radiology has shown no problem acknowledging that it lacks meaningful outcomes measures. But recognizing a problem and solving it are two different things.

“We know that reimbursement is going to be tied to outcomes,” said Nance, who was a resident physician at Johns Hopkins at the time of the SIIM conference. “This means that, in the future, if we can’t measure it, not only can we not manage it, but it looks like we’re not going to get reimbursed for it, either. This has certainly put us in a precarious position as we move forward.”

Before spotlighting some of the different payment models that could support possible solutions, Nance reviewed—and briefly critiqued—the three major national systems applying metrics to outcomes:

  • The Healthcare Effectiveness Data and Information Set (HEDIS) started in the early ’90s and now used by more than 90% of America’s health plans to measure HMO performance and match patients with plans. “To put it bluntly, administrators are paid contingent to the HEDIS metrics,” Nance said. “They matter.” Out of 81 of these metrics, only three have anything to do with diagnostic imaging—screening for osteoporosis, screening for mammography and avoidance of advanced imaging for low back pain. “You’ll note that, of those three, none are related to outcomes,” Nance said, “and none of them are controlled by radiologists themselves.”
  • The Physician Quality Reporting System (PQRS), launched by the federal government in 2006 and now the largest pay-for-reporting initiative in the U.S., has 254 metrics. Excluding interventional radiology, only 13 of those 254 that have to do with diagnostic imaging, Nance said. “And again, out of those 13, none deals directly with patient outcomes. So in effect, none are measuring our value.”
  • The National Quality Forum (NQF), the multistate nonprofit that seeks to set and validate various quality metrics for healthcare, endorses 636 measures—just 15 of which deal specifically with diagnostic imaging. That’s 2.4%, despite the fact that imaging accounts for 14% of total healthcare costs, Nance pointed out. “Each NQF-endorsed metric has a steward. Usually it’s professional society or something similar. ACR is the steward of only one NQF-endorsed metric at this time and, again, none of the measures deals specifically with patient outcomes.”

So there you have your national quality value outcomes measures, said Nance. How is radiology responding?

Avoid red herrings

Radiology has traditionally measured its value, or at least its promise of quality, through credentialing. If you were board certified, that meant you were good enough to practice radiology, Nance stated. No longer will credentials be considered a true measure of value.

At the same time, most of the metrics proposed in the radiology literature—from number of safety or quality projects completed, to patient satisfaction surveys, to rates of peer-review agreement rates—look at processes rather than outcomes.

Nance noted that the American College of Radiology has advanced a number of more meaningful tools for, and approaches to, demonstrating quality, most notably Imaging 3.0, RadPeer and ACR Appropriateness Criteria. “But, importantly, there are no good suggestions on how we are going to tie these things to reimbursement,” he said. “Furthermore, the data on both RadPeer and ACR Appropriateness Criteria for actually improving outcomes is lacking at this point.”

Showing the shortcomings of other measures presently in place, Nance noted that structure measures, such as whether or not PACS is in place and how many nurses per patient are on staff in the ICU, sometimes do indeed correlate with outcomes. “However, particularly within the imaging department, these have not been shown to correlate as highly with outcomes.”

Another set of options—process measures focused on various aspects of clinical and business operations—are both ubiquitous and straightforward