Just what do payers mean by outcomes?

Measuring them is more art than science

Almost everybody has been talking about home care outcomes data for some time now, but not everyone knows precisely what outcomes are supposed to measure, says Bob Ferry, RN, MSN, senior consultant with Health Dimensions of Durango, CO.

There are financial, clinical, customer/consumer patient satisfaction, and operational outcomes, each with its peculiar yardstick. At last count at least 40 clinical assessment sets were available, containing nearly 1,300 measures required by managed care companies, public payers, and accreditation organizations.

These include the Health Care Financing Admi nistration’s (HCFA) Outcome and Assessment Information Set (OASIS). HCFA introduced OASIS, a 90-item data collection tool, a year ago through the Outcomes Based Quality Improve ment (OBQI) project, which asked 50 home care agencies to participate in gathering data for similar outcomes measurement of Medicare patients.

Agencies in the OBQI project must use OASIS to do their patient assessments and measure patient progress as a condition of participation (CoP) in the Medicare program. The goal of OBQI is to provide agencies with a means to measure what percentage of their patients have progressed and/or stabilized. A recent report on the OBQI project published by the Center for Health Services and Policy Research at the University of Colorado in Denver says the purpose of OASIS is to measure "outcomes defined as a change in health status between two or more time points."

What it all comes down to, Ferry says, is that managed care demands two basic things of home care providers: "You have to prove the care given a patient made a [positive] difference in the health status of the patient, and you have to prove that it saved money."

A payer like ChoiceCare, an 18-year-old regional health maintenance organization in Cincinnati, requires that a home care agency have disease management programs in place to even be considered for a contract. And they must have outcomes data on the programs, the HMO states.

"The greater the number of established programs, the stronger that provider looks from a contracting standpoint," says Joseph Woods, ChoiceCare’s manager of ancillary contracting services.

In addition, ChoiceCare requires a home care organization to disclose three years of audited financial statements to prove it is a stable business.

In today’s world of evaporating health care dollars, it is incumbent on home care agency directors to pay attention to outcomes. Payers, both public and private, are increasingly unwilling to spend money for services that produce marginal patient outcomes. It’s not enough for an agency to say it is measuring performance and quality. Rather, the outcomes must demonstrate concrete results.

Ferry explains: "If I’m looking at a group of 65-year-old insulin dependent diabetics, and I know that after three home health visits, 35% have been taught to pre-fill their syringes with insulin successfully, and it takes five visits to get 85% of them doing it, I know where I must focus my improvement."

Once 85% are pre-filling syringes after five visits, then you have product to sell, Ferry says.

‘Outcomes of care are products’

"If I tell [the payer] how long it takes me to get my patients at a certain level, that is my product. Outcomes of care are products themselves. I can then turn to a managed care organization and say, ‘Give us a contract.’ "

Ferry, a former outcomes planning director of the Visiting Nurse Service of Greater Woonsocket, RI, says health care has been slow to recognize the importance of measuring quality improvement.

"In any other industry, it’s a given, but not in health care. That’s a tragedy. If you don’t know how to measure quality, you can’t tell people what your product is."

Ferry says health care, home health care especially, is not entirely to blame for this failing. "Health care isn’t a concrete product; it’s tougher to measure. But that’s no excuse."

To measure clinical outcomes, Ferry says you have to take a microscopic view of what you’re doing. "What is care? Define the care you’re providing, define it at the level of the practitioner, not the global level. It’s very detailed, very tricky," he says. "The hardest part of all is to assign a measurement to quantify things."

Ferry says measuring home care quality is more of an art than a science. He compares it with measuring the success of Olympic athletes in competition: "There are two ways to measure events outcomes. If you have a sprinter in the 100 meter dash, you measure it by distance and time. It’s very exact. It’s a science, down to hundredths of a second.

"But how do you measure diving? Judges have criteria they must adhere to, but they are measuring an art form. Only experts, former divers and diving coaches, can accurately judge a diver. In home care, you to need to measure both the art and the science."

Yet, hospitals and home health care organizations have fallen into the trap of measuring quality improvement through utilization, Ferry says. "We’re stuck in that gear in home care, stuck with utilizations. Those give us data on patient demographics, like what the length of hospital stays are for heart attack patients, or mortality rates. Hospitals like to use mortality rates as quality assurance. For example, ‘We had a 3% decrease in deaths from the last quarter.’ What they’re saying really is ‘We don’t kill many people so we’re a good institution.’ "

"But what if your hospital was next to a nursing home and they sent you all their dying patients? You can’t measure quality by utilization measures. Utilization measures only count when you get the other measurements, like impact of care, along with them. We haven’t done that in health care."

‘Payers are getting pickier’

Outcomes should answer these questions: "Did my mother’s pneumonia go away? Can she manage her diabetes at home? Does she know when to take insulin? Can she inject it properly? Does she have to stay on a diet? Does she know what it feels like when her blood sugar gets low?" says Ferry.

A payer wants to know not only if you can teach patients to manage on their own, but how much it costs and how long it will take to teach them. "Payers are getting pickier," he says. "They want to know what care you provided and how it impacted on the patient’s health."

Measurements demonstrate a home health agencies’ action plans to accreditation organizations, such as the Joint Commission on Accredi tation of Healthcare Organizations, Ferry says. "If by three visits only 33% of my patients know how to pre-fill syringes with insulin, I can say, ‘I’ll come up with an action plan to improve that group to 50%.’ "

But performance improvement and outcomes should include more than clinical data, Ferry says. "How do you measure the impact of the finance department on patients? It isn’t just the nurses, it’s the person who works in finance. What is he or she doing to improve the process? We need non-clinical outcomes. That’s been left out."

Ferry’s contention is that if the internal customer is satisfied first — i.e., nurses, accountants, the management information systems (MIS) manager — then the external customers, which are the doctor, the patient, the payer, and the patient’s family, will automatically be satisfied.

Ferry recommends bringing staff together, both clinical and administrative people, and asking questions. For example, he says, "ask the billing clerk what they do. Who does their work impact if a bill isn’t sent out on time? The nurse, who doesn’t get paid? MIS? The accounting department?"

Look at efficiency, productivity, finances

Health care consultant Maureen Yadgood, RN, MSN, agrees. "We must focus on governance and practice domains in health care, not just clinical domains."

Yadgood, whose company, Maureen C. Yadgood & Associates in Wakefield, MA, is helping write assessment tools for the Council on Healthcare Provider Accreditation, compares measuring health care performance with manufacturing:

"If you were getting ready to subcontract with a widget maker, you’d look at his efficiency, productivity, and financial state — aren’t you going to do that? Why, I should hope so. And health care is even more important because we’re dealing with people’s lives."

Ferry says health care hasn’t focused on the business aspect of outcomes because it was not seen as part of health care. "The attitude was, ‘Medical records can’t be measured in the same way as nursing,’ but yes, it can," he says.

"Outcomes isn’t a new concept," he contends. "Home care has to grow up a bit, but we don’t want to. We want to be like missionaries — ‘The patient’s sick, I don’t care about costs, I’ll write a blank check.’ We’ve gotten away with that over the years. Now we have to take inventory. Health care money is running out."