Contributor: The Illusion of Quality in Value-Based Care

Over the last 10 years, value-based care (VBC) programs have expanded rapidly. Although select programs have improved quality or reduced costs, we haven’t seen any that have managed to scale and deliver benefits across payers, providers, and patients. In the first article of this series, we identified 4 main challenges that health care organizations need to tackle in order to deliver effective value-based care at scale: (i) the missing patient, (ii) the quality illusion, (iii) the capacity shortage, and (iv) the complexity concern. In this article, we’ll take a deeper look at the quality illusion.

Patient experiences and outcomes must be the heartbeat of health care delivery. However, current VBC programs tend to use adherence to a process—such as completed screenings, questionnaires administered, and others—to measure quality. And clinical outcomes, as well as other elements such as access, equity, and experience, are secondary. As a result, the “quality” of VBC programs is just an illusion.

Asher Perzigian | Image Credit: Accenture

A prime example of this is a 2022 study that compared Medicare’s Merit-based Incentive Payment System Score (MIPS)—one of Medicare’s key quality programs—with physicians’ composite clinical outcome scores, which averaged observed-to-expected outcomes across 6 measures. The researchers found that 19% of physicians with low MIPS scores had composite clinical outcome scores in the top quintile (superior outcomes), whereas 21% of physicians with high MIPS scores had composite clinical outcome scores in the bottom quintile (poor outcomes).

This raises the question: are we really incentivizing the right measures? By realigning quality to clinical outcomes, we can avoid creating an illusion of improved quality when all that has really been measured is adherence to a process. At Accenture, we believe there are 4 core elements of true quality:

1. Clinical Outcomes: Measures of a patient’s health status and improvement of disease states. These should be used as the cornerstone of assessments of care quality.
2. Experience: Patient satisfaction with care delivery. These measures assess providers’ ability to deliver care that is understandable and actionable for the patient.
3. Access & Availability: The ease with which patients can access care with a provider. These measures can be used to understand a provider’s impact on the availability of care for a given population.
4. Equity: The quality of care provided across socioeconomic groups and the mitigation of barriers to care. These measures can be used to understand which providers are able to impact underserved groups.

Organizations aiming to leverage patient outcomes as indicators of care quality face 2 primary challenges: capturing these outcomes and connecting them to physician responsibility. For instance, the benefits of preventative interventions might take over a year to become apparent, extending beyond the typical payer-provider agreement, or they might be marked by the absence of subsequent health incidents, which can be difficult to measure. Therefore, the responsibility for outcomes cannot rest solely on the primary care provider; the entire care team, including the patient, must be engaged and incentivized to improve outcomes.

Ajay Mody | Image credit: Accenture

To advance, consider these 4 key opportunities:

1. Shadow Metric Experimentation: Integrate and track 'test' measures in contract negotiations to discover new metrics better linked to outcomes. For example, what if health care providers could trial new metrics with payer partners ahead of committing to their adoption in future contracts? This may increase willingness to experiment with how outcomes could be measured by lowering the stakes of the initial trial period.

2. Right Provider, Right Incentive, Right Outcome: Extend patient management responsibility beyond the primary care provider by including metrics aligned with the roles of specialty providers in driving patient outcomes. For instance, a health care network could track cardiologists' performance in reducing readmission rates for heart failure patients.

3. Open-source Outcomes: Make provider performance on quality of care and cost radically transparent, prioritizing ease of interpretation to empower patients. This could involve creating a publicly accessible dashboard displaying key quality metrics such as surgical complication rates, patient satisfaction scores, and cost per episode of care.

4. Quality-based Provider Compensation Models: Shift compensation models from volume incentives to quality incentives and cost efficiency, aligning quality metrics with providers' scope of impact. For example, a primary care clinic could reward providers based on the percentage of their patients achieving target blood pressure levels, rather than the number of patient visits.

Measuring the "quality" of value-based care programs solely by process compliance does not identify areas for improvement or actually enhance people's health. Therefore, it is crucial to move beyond the "quality illusion" and pave the way for health care that measurably improves people's quality of life.

Accenture’s Florence Murabito and Lydia Trogdon also contributed to this article.