New health care law may spell opportunity for quality managers

Impact on outcomes seen as positive, but time frame concerns some

The recently passed health care reform legislation may have generated controversy in political circles, but there appears to be a consensus among health care quality observers that it will strengthen the position of hospital quality managers and give their roles even greater importance. Observers also applaud many of the components of the bill that address quality, although there is some concern that many will not take effect for several years.

"The day has really arrived for quality," says Janet Corrigan, PhD, president and CEO of the National Quality Forum.

"Over the past few years, those who do quality improvement in hospitals have taken much more of the limelight; this will do a lot to even further our importance in our health care delivery system," says Evan Benjamin, MD, FACP, senior vice president of health care quality for Baystate Health in Springfield, MA, and an associate professor of medicine at Tufts University.

"I see projects that will be very expansive around changing the payment of health care — things like hospital care organizations," he says. "And quality managers will be part of those discussions." Beginning in 2012, he notes, there will be accountable care organizations for outcomes, quality, and safety, as well as efficiency. "Those with experience in health care quality management will be very important," Benjamin asserts.

"I think it will certainly enhance and make the role [of the quality manager] even more critical than it is already," adds Corrigan. "Quality is an integral part of various payment programs; the legislation includes payment incentives tied to reducing avoidable readmissions, to reducing health care-acquired conditions, and provisions for many demonstration projects on payment tightly linked to better care and better patient outcomes."

There is a huge emphasis on public reporting and pay-for-performance programs, she continues. "That just provides even greater incentives for quality improvement, greater reinforcement for improving quality, and doing the best for patients," Corrigan says.

But a different kind of "day" has arrived for purchasers, says Leah Binder, CEO of The Leapfrog Group. "The moment for purchasers to act has arrived," she declares. "The new law could be detrimental or helpful to quality; it could raise costs considerably — and is likely to do that for purchasers if they don't act aggressively."

For purchasers, she continues, "It will no longer be acceptable to sit back and wait for the federal government to manage a benefits program and make sure it works for your employees; from a purchaser's point of view, they are all scrambling to be compliant and see if it costs more — and it will, at first. [Fees on] pharma, devices, and so on, will raise premiums almost immediately."

Now is the time, she says, for purchasers to begin to manage benefits so they get their money's worth. "The cost-cutting measures are five years away — and those are only pilot programs," Binder notes. "The quality measures are years away, so the QI and cost-cutting measures are long-term. That's a problem for purchasers; unless purchasers look at the actual performance of providers in the community and negotiate pay-for-performance contracts, they won't get value for their purchasing dollar."

Addressing quality

In terms of timing, says Benjamin, "over a two- to five-year timeline, there are a lot of elements in the bill that have implications for those who do health care quality work. First is the way in which we start thinking about health care; overall, there is much more about quality of care, measurements, and value of care."

As you start talking about value, he explains, "there will be a greater need to measure quality, safety, outcomes, and defects in a way that has a lot more accountability."

For example, he notes, beginning in 2012 there will be more penalties for excessive readmissions. "Many folks in quality leadership are already trying to understand the root causes behind readmissions and ways to reduce them," notes Benjamin. "There is also language we need to pay attention to around bundling. This talks about establishing many pilots around bundled payments to hospitals and providers. A large portion of that will be around measurement of health care quality; there will be a single payment, and we will be responsible for quality outcomes and efficiency."

The bill, he continues, also promotes more value-based purchasing. "And quality managers will have to be aware of more value-based purchasing for Medicare."

In addition, he notes, "There are words in the bill around adding a 1% penalty to hospitals that have higher rates of hospital-acquired conditions, which could be significant for many hospitals." Accordingly, he says, it will be important for quality managers to stay on top of the clinical as well as administrative aspects of health care.

Other advantages seen

Corrigan also notes several positive aspects of the law. "First of all, there is support for what many of us are calling the quality enterprises — a set of functions many different groups participate in," she notes. "There is a set of national priorities and goals for improving quality, safety, and affordability of care. It directs the secretary [of the Department of Health and Human Services] to establish a national strategy and priorities — in conversations with multi-stakeholder private groups." This excites Corrigan, she says, because "it could help align private and public sector leaders."

Second, she continues, there is support for measure development and maintenance. "I think that can be really critical," she says. "It is expensive to develop really good evidence-based measures in the field and maintain them over time."

Third, notes Corrigan, the concept of "consultative partnership" is built into the legislation. "This is a multi-stakeholder group put together to advise the secretary on the selection of measures for public reporting and payment programs," she explains, "So a better-developed mechanism around measures will be used."

Finally, she says, the law includes a number of other important provisions, such as expansion of the Hospitalcompare website. "This will really enhance that site and its usefulness to patients and families and others," says Corrigan. "And we will see continued active development and enhancement of public reporting."

Binder, however, is not quite so sanguine. "There's lots of talk in the bill about how to do pilots for bundling payment arrangements and other changes in the way of pay rewarding performance, which we want to see; that's great, we support it," she says. "We also agree the idea of value is in the bill, but the idea of covering more Americans is in it now, whereas for the other aspects it's 'Five years from now, we'll think about it.' That's progress, but if you're a purchaser and you get next year's rate increase, you do not care what happens five years from now; you want to know why it costs so much and what you can do about it."

In summary, says Binder, "We would agree there's a lot [that's good] in there, but it's five years away."

[For more information, contact:

Evan Benjamin, MD, FACP, Senior Vice President of Healthcare Quality, Baystate Health, Springfield, MA. Phone: (413) 794-2527.

Leah Binder, CEO, The Leapfrog Group, Washington, DC. Phone: (202) 292-6713.

Janet Corrigan, PhD, President and CEO, National Quality Forum, Washington, DC. Phone: (202) 783-4160.]