The Value Dilemma

The oft-used phrase, “from volume to value,” was coined here in Pittsburgh by our own Harold Miller as the title of a framing paper for our first of three Payment Reform summits. It clearly had resonance. I hear it in every venue where health reform advocates gather. “Value” is hot, and the Centers for Medicare & Medicaid Services (CMS) is moving rapidly to a value-based payment system in which provider payments are linked to quality and costs. Purchasers demand value. Accountable Care Organizations (ACOs) promise to deliver value.

But I am having trouble with value as the foundational North Star for all that we do in health care. Here’s why: It’s still very hard to measure quality in any comprehensive way. We can measure cost—that is, we could if health providers would make it public. However, when we went looking for the best “quality” hospitals in Pennsylvania so that we could better understand leadership in high-performing organizations, we hit a wall.

Surely, there are lots of rankings that purport to measure quality. But, using upwards of a dozen ranking measures, we discovered that there were almost no hospitals that scored high across the board. We analyzed CMS data on mortality, readmissions, hospital-acquired conditions, payment, and patient experience; Pennsylvania Health Care Cost Containment Council measures of mortality and readmissions; the Leapfrog Group’s hospital safety scores based on process and outcomes measured related to medical errors and patient harm; and U.S. News ratings for common and specialty care. High performance was so randomly scattered across the different measures that it seemed as if a hospital could only concentrate on one feature at a time: patient satisfaction and perception; or safety; or clinical quality. It was whack-a-mole.

An article in the March 2015 issue of Health Affairs by an esteemed team featuring Matthew Austin, Ashish Jha, Patrick Romano, Sara Singer, Timothy Vogus, Robert Wachter, and Peter Pronovost reinforced our own discovery. They compared four prominent, national hospital ratings systems (Consumer Reports, HealthGrades, Leapfrog, and U.S. News) and found that no hospital was ranked as a high performer by all four. Only one in ten hospitals rated as a high performer by one rating system managed to get top honors from any of the others. Each ranking system has its own “secret sauce,” placing different values on different components of care processes and outcomes. Even when they seemingly emphasize the same components, their definitions of those terms differ.

If renowned researchers are grasping to define quality and value, imagine the confusion felt by consumers looking to identify the best institutions for themselves or their loved ones before scheduling care. A nearby hospital could be ranked as the best—and, simultaneously, the worst—depending on the ranking system. For further confusion, units and surgical teams within the same organization can differ dramatically. Hospitals turn their positive rankings into marketing campaigns, at times paying their evaluators for the right to do so. We have created confusion, rather than clarity, for those tasked with making what could be a life-altering decision on where to seek treatment. How can we base our reimbursements on “quality?”

In recent chats with some of the leading players of the health reform era, we found no shortage of measurement skeptics. The most noted researcher of medical error believes that it is, in fact, almost impossible to get a valid estimate of preventable errors or lives saved, and that there’s a certain amount of “gaming” that occurs. Another force in health policy and financing humorously referred to the “Quality Industrial Complex:” We keep cranking out dubious metrics, tie them to payment, and then pat ourselves on the back for creating value. With hundreds of measures out there, we’re also burying providers in paperwork and contributing to burnout. Perhaps we should take the problem more seriously.Maybe some of you have resolved this dilemma. Maybe you are using an index or other composite score that gives you assurance. I welcome your thoughts—we might indeed be playing with a house of cards.

Karen Wolk Feinstein is President and CEO of the Jewish Healthcare Foundation and Pittsburgh Regional Health Initiative​.