A New Vision for Quality and Equity
Authors: Helen Burstin
Journal: Annals of Internal Medicine (2020)

Supplement: Vision for U.S. Health Care21 January 2020A New Vision for Quality and EquityFREEHelen Burstin, MD, MPHHelen Burstin, MD, MPHCouncil of Medical Specialty Societies, Washington, DC (H.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3896 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Despite discontent with the current U.S. health care system, consensus on how it should evolve has been lacking. In this Annals supplement, the American College of Physicians (ACP) provides a bold and comprehensive vision for a health care system that puts patients at the center and provides access to affordable, high-quality care for all (1). The ACP believes that a new payment and delivery system should have quality as its cornerstone (2). To achieve this vision, we must carefully consider how to measure, incentivize, and improve health care quality and equity.Outcome measures that are meaningful to both physicians and patients must underlie a new paradigm for quality and equity. Current quality measurement efforts are frequently tethered to claims-based process measures that are often distant from outcomes. It is time to acknowledge the high burden and opportunity costs associated with quality measurement that does not result in improved outcomes. We must ask ourselves whether “the juice is worth the squeeze.” As ACP wisely notes, we need to avoid “flawed and misaligned metrics” that will not support improved delivery and payment models (2).To reduce the burden on physicians and other clinicians, we must implement timely, valid measures that result from seamless integration of clinical workflow with electronic health records, clinical registries, and cloud-based platforms. The ACP and other specialty societies should serve as the content experts in their respective fields and ensure that the electronic data we need to measure and improve care are valid, reliable, and current.A newly envisioned health care system must also consider equity. Even with equitable access to care, it is imperative that we routinely assess and address differences in care for subpopulations. As data systems improve, we must weave attention to disparities into the fabric of quality measurement, improvement, and incentives (3). The ACP's vision emphasizes the need to routinely assess and use data on a broad range of social determinants of health to improve care for all (4).Further, we must recognize that performance measurement can have unintended consequences for both patients and clinicians. It is essential that we consider whether a measure is evidence-based, valid, and feasible and how it will be used. As ACP notes, “quality is complicated by the measurement approach” (2). Complicating factors include who is measuring, who is paying, and the measure's intended use. We cannot examine measures without considering whether they are fit for their intended use. According to Goodhart's law, when a measure becomes a target, it ceases to be a good measure (5). Measures are misused if clinicians and health systems seek to optimize performance regardless of unintended consequences. Thus, the ACP recognizes the critical need to assess the potential unintended consequences of quality measures and programs before they are implemented. This assessment should include the adequacy of risk adjustment where appropriate for selected outcome and cost measures. Inadequate risk adjustment or stratification for clinical and social risk factors can penalize providers who care for the most vulnerable patients. Frakt recently noted the lack of rigorous evaluation of health policy (6). Our newly imagined health care system should embed field assessment and evaluation into new incentive and payment models to ensure that they are working as intended for all patients.If the United States fails to pivot toward more meaningful quality measurement, we risk overemphasis on cost and available claims-based quality measures by payers for provider selection and payment. As ACP notes, cost measurement is complex, but we need consistent measures and fair attribution methods. We should also consider how best to link cost and quality information (7). For example, we should not consider health care costs until a certain threshold for quality has been achieved. Regardless of the new model that emerges, we must take an evidence-based approach to understanding the effect of any new models on both quality and costs.The ACP offers a vision for a system that reflects the care of patients in multidisciplinary teams (2). Different disciplines and specialties bring unique skills and knowledge to the team, and meaningful quality measures should reflect team competencies, including quality and costs across patient-focused episodes, shared decision making, and patient reports of the care experience and outcomes. Quality is a team sport, and the patient should be a highly valued member of the team. There is limited evidence that transparency alone improves decision making by patients and caregivers, so a new health system should ensure not only that information is provided but also that it is understandable and actionable.The ACP's vision emphasizes the central role of primary care and internal medicine subspecialists, but it is critical that high-value care reflect coordination and collaboration across a broad range of care. This new delivery model should encourage and incentivize collaboration across specialties, including virtual care and consultations to improve patient outcomes. A study by Johnston and colleagues found that patients in rural communities had lower mortality and fewer preventable hospitalizations when they had access to appropriate specialty care (8). A new and improved health care system should incentivize care across the house of medicine to do what is best for patients.The ACP deserves applause for putting forward a bold new vision for a value-driven health care system that works to achieve what is best for patients. To make this a reality, we should drive toward measurement and incentives to ensure the highest levels of quality and equity for all.References1. Doherty R, Cooney TG, Mire RD, et al; Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3-S6. doi:10.7326/M19-2411 LinkGoogle Scholar2. Erickson SM, Outland B, Joy S, et al; Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: health care delivery and payment system reforms. Ann Intern Med. 2020;172:S33-S49. doi:10.7326/M19-2407 LinkGoogle Scholar3. Anderson AC, O'Rourke E, Chin MH, et al. Promoting health equity and eliminating disparities through performance measurement and payment. Health Aff (Millwood). 2018;37:371-7. [PMID: 29505363] doi:10.1377/hlthaff.2017.1301 CrossrefMedlineGoogle Scholar4. Butkus R, Rapp K, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: reducing barriers to care and addressing social determinants of health. Ann Intern Med. 2020;172:S50-S59. doi:10.7326/M19-2410 LinkGoogle Scholar5. Koehrsen W. Unintended Consequences and Goodhart's Law. Towards Data Science. 24 February 2018. Accessed at https://towardsdatascience.com/unintended-consequences-and-goodharts-law-68d60a94705c on 14 December 2019. Google Scholar6. Frakt A. Which Health Policies Actually Work? We Rarely Find Out. The New York Times. 9 September 2019. Accessed at www.nytimes.com/2019/09/09/upshot/which-health-policies-actually-work-we-rarely-find-out.html on 14 December 2019. Google Scholar7. Crowley R, Daniel H, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7-S32. doi:10.7326/M19-2415 LinkGoogle Scholar8. Johnston KJ, Wen H, Joynt Maddox KE. Lack of access to specialists associated with mortality and preventable hospitalizations of rural medicare beneficiaries. Health Aff (Millwood). 2019;38:1993-2002. [PMID: 31794307] doi:10.1377/hlthaff.2019.00838 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Council of Medical Specialty Societies, Washington, DC (H.B.)Disclosures: The author has disclosed no conflicts of interest. Her form can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3896.Corresponding Author: Helen Burstin, MD, MPH, Council of Medical Specialty Societies, 20 F Street, NW, Suite 1000, Washington, DC 20001; e-mail, [email protected]org.This article is part of the Annals supplement “Better Is Possible: The American College of Physicians' Vision for the U.S. Health Care System.” The American College of Physicians was the sole funder for this supplement. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 21 January 2020Volume 172, Issue 2_SupplementPage: S64-S65KeywordsDecision makingHealth careHealth information technologyMedical risk factorsMotivationPatientsSportsSub-specialty careVision ePublished: 21 January 2020 Issue Published: 21 January 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...