ACP: Benefits, harms, and quality in high value, cost conscious care

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

Last month, my column introduced a concept paper published in the Annals of Internal Medicine by Owens and colleagues titled High-Value, Cost-Conscious Health Care: Concepts for Clinicians to Evaluate the Benefits, Harms, and Costs of Medical Interventions. This month, I’ll take a closer look at value, the determination of which interventions are likely to be beneficial, and measuring the quality and costs of interventions.

There will soon be a real-world test of the benefits, harms, and costs of medical interventions in order to achieve the dual aim of providing high quality care while controlling health care expenditures. The 2010 Affordable Care Act (ACA) provides that, starting on January 1, 2012, Accountable Care Organizations (ACOs) agreeing to quality thresholds may share in the cost savings they achieve for the Medicare program.

A qualifying ACO must be a clinically-integrated organization of health care providers that is accountable for the quality, cost, and overall care of the Medicare beneficiaries covered by the ACO. Qualified ACOs must meet patient-centered criteria established by the Secretary, have defined processes to promote evidenced-based medicine and patient engagement, and report the data required to evaluate quality and cost. CMS is expected to shortly release a proposed rule on ACOs, followed by a 60 day comment period, which will provide draft regulations on the formation of an ACO.

Value in health care delivery is an important concept when thinking about high-value, cost-conscious care. Value is the relationship between the quality of care provided (numerator) and the costs of delivering the care (denominator). Owens, et al, in their concept paper determined value by “an assessment of the benefit of an intervention relative to expenditures.”

In a December 2010 article from the Harvard Business School, Michael Porter relates quality and cost with a simple and useful definition of value: “…the health outcomes achieved per dollar spent,” and that “outcomes, the numerator of the value equation, are inherently condition-specific.”

If outcomes are condition-specific, ACOs will have to become learning organizations with the expertise to evaluate the evidence for the diagnosis and treatment of a given condition in order to determine whether an intervention for that condition is the right intervention (or not) to meet the patient’s value goals — quality and cost — and the value goals of the ACO and Medicare, which must be met in order to share in the savings. As learning organizations, ACOs will need to incorporate comparative effectiveness research (CER) and cost effectiveness analysis into the routine work flow of the ACO — a sea change in the manner that we now reach decisions in patient care.

Accountability in accountable care will require ACOs and their components, such as medical homes, to routinely assess and report, through performance measures, the quality and costs of the care provided. The National Quality Forum (NQF) sponsored a recent report by Schneider and colleagues at the Rand Corporation titled Payment Reform: Analysis of Models and Performance Measurement Implications. This is a very useful resource to help understand the current state of measurement related to quality and payment, building on the extensive work on measuring quality and resource use underway at the NQF.

High-value, cost-conscious care is a team sport. All the members of the accountable organization responsible for the delivery of care — patients, physicians, hospitals, employers, insurers, and others — must share the common objective of high quality and affordable care and share in the rewards of delivering such care if health care reform is to be successful.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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