Ensuring excellent quality and outcomes is the essential goal of medical care. To achieve it, a multitude of quality metrics have been added to clinicians’ work. They include things such as controlling blood sugar for people with diabetes, ensuring that eligible adults are screened for colon and breast cancer, and guaranteeing that children are up to date on their vaccines and are receiving topical fluoride treatments.
Quality metrics were designed to help improve both patients’ outcomes and providers’ performance. But the number of quality metrics has ballooned. In a safety net hospital like ours, providers must account for 60 different quality metrics during each patient visit, many of which are “standalone,” or required by just one payer.
While most quality metrics have a strong foundation in public health data, they do not necessarily improve the quality of a patient’s life or their health-specific outcomes. And as the number of quality metrics required by different payers accumulates, the task of completing them can quickly overshadow the patient-provider interaction. This is particularly true in primary care, a specialty that carries the burden of ensuring the completion of numerous quality metrics for each patient, even if they do not necessarily align with the patient’s agenda for the visit.
Researchers recently calculated that it would take a full-time primary care physician 14.1 hours a day to complete all the recommended routine health measures for their patients. But clinical visits generally last just 20 minutes and have not gotten longer as quality metric requirements have expanded.
While well-intended, the current state of quality metrics is helping fuel the exodus of primary care physicians and overall clinician burnout.
How did we get here?
The dawn of quality metrics can arguably be traced back to Florence Nightingale, “The Lady of the Lamp,” who, in the mid-1800s, astutely studied gaps in patient care and formulated specific measures to improve health outcomes. Her visionary work was advanced in the 1960s, with the development of the Donebedian model, a structure that measured the processes responsible for delivering better patient outcomes. It was not until the 1990s, however, that the United States began to see a groundswell of quality metrics in health care.
In the early 1990s, the National Committee on Quality Assurance (NCQA) worked to standardize the evaluation of quality metrics and report on them within individual health plans across the United States. In the late 1990s, President Bill Clinton established the Advisory Commission on Consumer Protection and Quality in the Health Care Industry. One of its tasks was to recommend and standardize metrics that would measure health care quality and value. The commission laid the groundwork for the birth of groups such as the National Quality Strategy, which further aimed to use these standardized health metrics to improve the quality of care, improve the health of a population, and reduce the cost of care.
To many people working in health care policy and delivery, the guidelines that emerged from groups such as NCQA were seen as a welcome change from the wild west days of fee-for-service, when medical care was largely being paid for based on what health care providers did for their patients, such as procedures and tests, rather than how the care they provided improved their patients’ health. But the expansion and layering of quality metrics from different payers has had unintended consequences, including less personalization in patient care.
In the collective 30-plus years the two of us have been practicing medicine, we have felt this dramatic shift in our clinical visits with patients. Electronic medical systems now include multiple alerts reminding us and our colleagues to complete multiple quality metrics during routine or even urgent visits. We often struggle with balancing quality requirements that are the highest priority for a specific patient versus those metrics that may be good public health measures but are not the highest priority for that patient’s specific circumstances.
Our experiences and expertise have taught us that rather than a long list of quality metrics with a one-size-fits all approach, providers and patients should be afforded the opportunity to personalize a custom list of high-value quality measures based on each patient’s particular circumstances. We are not alone in thinking this.
The leaders of several centers associated with the Centers for Medicare and Medicaid Services, which administers health care coverage for more than 150 million individuals through Medicare, Medicaid, the Children’s Health Insurance Program, and Health care.gov, published a statement last year in the New England Journal of Medicine recognizing the overwhelming burden of quality metrics. In their NEJM Perspective essay, they called for a universal set of quality metrics. If enacted, it would mean safety net hospital systems, for example, would shift from 60 quality metrics to 23. This would be a huge step in the right direction and one that we and many other clinicians would support.
Action, however, is delayed. Several big questions need to be answered before moving on: What will it take to get insurers and other payers aligned to streamline the untenable number of quality metrics? What would it take to advance to metrics created for different patient types including, at baseline, metrics for children versus adults and differentiation for geriatric patients?
CMS must collect perspectives from disparate voices and experts in the field and quickly put a stake in the ground to advance the universal metrics that it has proposed.
While streamlined metrics alone won’t solve the primary care crisis, they are a step in the right direction. Indeed, there is no set of quality metrics that can account for the trust built between primary care providers and their patients. Trust is why patients come back for care, and it is trust that most profoundly affects the health of patients, communities, and populations.
The special sauce of primary care will not be saved until the overwhelming number of metrics that sit heavily on primary care providers’ shoulders is winnowed down. Universal and personalized metrics can help open the doors to true transformation in patient care and outcomes, and in turn help reduce provider burnout.
In the encouraging words of Florence Nightingale, we must “never lose an opportunity of urging a practical beginning, however small.”
Katherine Gergen Barnett, M.D., is a primary care physician, vice chair of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center, an associate professor of family medicine at the Boston University Chobanian & Avedisian School of Medicine, an associate at Harvard Medical School’s Center for Primary Care, and a health innovator fellow at the Aspen Institute. Lara F. Terry, M.D., is chief of value-based care at Boston Medical Center Health System and a geriatrician in the Geriatrics Division at Boston Medical Center.