Mapping a course to measure the impact of payment reform

October 25, 2017

While satellite images have revolutionized cartography, there is no eye-in-the-sky view available to see the impact that payment reform is having on the health care system. With the help of foundation funding, a multi-stakeholder advisory committee and researchers at Discern Health, CPR set out to create that view.

It wasn’t easy. The first round of brainstorming produced over seventy possible measures to assess payment reform’s impact, which is more territory than we could cover.  With careful navigation, we boiled those seventy measures down to twelve.  We focused on indicators already in wide use, available at the state-level, and that assessed clinical care in areas where there is both high spending and significant variation in quality. But the main criterion was that the indicators provide meaningful insights into payment reform’s potential impact on the health care system.  The twelve measures we selected are meant to tell us if the sweeping changes to payment occurring in the health care system today correlate with improved patient outcomes and more affordable care, though we will never be able to point to exact causation. Each of these measures is a kind of compass, helping us navigate toward our north star.

For example, one of these twelve measures is the rate of cesarean birth among low-risk pregnancies (NQF 0471). Cesarean sections are one of the most common surgeries in the United States and a big cost-driver for health care purchasers. What does this have to do with a scorecard about payment reform?

This measure may illustrate whether the health care system changes how it delivers care in response to the economic signals health plans send to providers. Economic signals could be bundled payments, blended payments, or other payment methods that hold providers accountable for providing evidence-based care. A medically unnecessary cesarean section represents low-value care – it is more expensive and puts the mother and baby at higher risk for adverse effects than full-term spontaneous vaginal birth. Payment reform in this context aims by paying providers based on value to reduce the rate at which they perform cesareans among women who don’t need them.

Of course, more than just payment reform affects the rate of cesarean deliveries. Awareness campaigns aimed at expectant mothers around avoiding unnecessary cesareans could also lower cesarean delivery rates, as could education for health care providers, among other strategies. The health care system is so complex that finding causation between payment reforms and changes in quality outcomes is not only beyond the scope of Scorecard 2.0, but also near impossible. Instead, our analysis will focus on whether changes in how much payment reform there is and what type are correlated with better quality and more affordable care.

In another example, CPR selected the Behavioral Risk Factor Surveillance System (BRFSS) “Unmet Care Due to Cost” measure to assess the affordability of health care.  Collected at both the state and national level, BRFSS is one of the largest continuously conducted health survey systems in the world. The Unmet Care Due to Cost measure identifies the percent of adults who reported that there was a time during the last year when they delayed or went without care due to worry about the cost. This nationally recognized metric provides the patient’s point of view, letting individuals speak for themselves as to what is affordable or too expensive from their perspective. In addition, the metric is publicly available and has been in use for many years, allowing for a trend analysis. This measure can serve as an additional compass: are we steering in the right direction?

With our 12 compasses in hand, we have drawn the map of Scorecard 2.0 and are ready to set sail.  CPR is excited to have three co-captains on this expedition. In addition our partners that we previously announced in New Jersey and Virginia, the Center for Improving Value in Health Care (CIVHC) will be the champion of the Scorecard in Colorado. We are thrilled to partner with CIVHC to chart the impact of payment reform in the Centennial State. We know with their input and guidance, we will leverage fair winds on the voyage.

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