Understanding quality metrics under value-based care

Anyone who has managed multiple value-based care contracts knows that success metrics can vary wildly from payer to payer. And every provider organization must manage its unique specialties, patient population, and culture.

For the better part of two decades, healthcare has been slowly transitioning from fee-for-service to fee-for-value, with the promise of making healthcare better not only for patients but also those who deliver or pay for their care. But in the alphabet soup that is VBC, the KPIs that define quality are — more often than not — murky.

Three healthcare leaders recently shared with athenahealth how their organizations define goals and success in value-based care, what quantitative and qualitative data they consider most important, and the tools and technology that support their goals.

Is there a simple definition of quality?

Aligning around an organization’s mission statement or specialty is one way to streamline the quality conversation.   

For SC House Calls founder Scott Middleton, having the majority of his 40,000 patients in the same senior citizen demographic somewhat reduces complexity. “I think quality is difficult to define,” he said. “But for us, quality is going to be a reduced number of hospitalizations for our patient population.”   

Middleton also carefully tracks payer data and risk adjustment factors for a total effectiveness score, he said.

Beth Greenwood, M.D., vice president of medical affairs and regional medical director for both Consensus Medical Group and Partners in Care in New Jersey, thinks of quality as an equation. For the patients of 150 providers spread across 55 locations, “Value equals quality over cost. Hopefully you can increase the numerator and decrease the denominator,” she said. “I’m really thinking about what are the best outcomes that are going to enhance a patient’s life, whether it’s preventative services or chronic disease management, that will decrease resource utilization beyond what's necessary, to keep the cost down.”   

Clive Fields, M.D., co-founder and chief medical officer of VillageMD, also underscores enhancing quality of life. A system of inbox management delegating physician tasks that aren’t top of license to other care team members allows their doctors to take less work home while delivering more hands-on care. Scribes who relieve the charting burden from urgent care physicians are another part of VillageMD’s model.   

“Doctors have time to set up their own suture kits, draw blood, take vital signs — that’s actually direct patient care,” Dr. Fields said. “It’s really been a good selling point. Patients can have a different perception of value when care is delivered by a physician as opposed to a nurse.” 

Rethinking how and where care is delivered

SC House Calls’ business model provides in-home medical services to primarily private residences, with the ultimate goal of using technology like remote patient monitoring to increase patient-to-provider touches. As Middleton explains, higher quality outcomes come from data:  

“By having so many care team members involved (NPs, nurses and pharmacists), eventually we get closer to the truth,” Middleton said. “The data really does tell us that we need to have providers see the patients. And they need to have all of the information in front of them.”  

Consensus Medical Group’s model drew Dr. Greenwood in immediately because in addition to data, it places value on people and workflows: “We have multiple teams of different people whose entire roles are to support the providers, and specifically around our goals, a lot of which are value-based care and risk-based contracting,” she said.  

Those roles include a large team of care coordinators and practice transformation specialists who help providers understand the patients, addressing common metrics like A1C or medication adherence. “Well visits are a big push; they make up a lot of the value-based care gaps that we're trying to close,” Dr. Greenwood added.

The right people in the right jobs with the right tools

For SC House Calls, technical solutions need to be part of the conversation, and their team of software engineers works with athenahealth’s open APIs to customize their platform and pull in data from disparate sources like various EHRs, payer platforms, and Medicare. “We can click on a patient and display their needs,” Middleton said. “If someone has been hospitalized, it will show up in the care team view. If they have or haven’t taken their medications, it’s going to show.”  

For Consensus Medical Group, which is still in a growth phase, solutions that benefit both practices and patients add value.  

“athenahealth has a lot of resources that make it easier for doctors to document and track care gaps and enhance value,” Dr. Greenwood said. “Our patients really prefer things like online scheduling and the patient portal. Anytime you’re increasing access to that primary care you’re going to, down the road, really help with quality outcomes.”

Progress, but with more promise

All three of the organizations’ leaders noted progress in the evolution of care and look toward the future with ambitious goals in mind, including enhancing connections — human and otherwise — across the ecosystem. 

Middleton praised the investigative work done by his care teams’ pharmacists and hopes to hire more. “They identify things that could make better impacts on patients,” he said. 

VillageMD echoes that belief by partnering with Walgreens for on-site or near-site primary care and pharmacy services integration, where broadening access to communication tools and patient records has had a major impact. Pharmacists can provide generic and formulary substitutions, and gap refills. This “example of interoperability,” Dr. Fields said, “has not only improved the patient experience, but we've also dramatically improved the physician experience.” 

As technology and the regulatory landscape evolve, Dr. Fields sees even more promise when it comes to patients engaging in their own quality outcomes. “We need regulatory working, continuing to enforce regulations so people have to share data with the patient who owns it,” he said. “And if we do that, we're going to engage with patients in a way that actually helps them derive the outcomes they want, instead of [physicians] being constantly responsible for what happens.” 

Dr. Greenwood endorses common value-based care quality measures — like cancer screenings, diabetes, asthma, and pediatric immunizations — but thinks more should be added. “Physical activity and obesity are huge, huge hurdles,” she said. “There's a lot of room for improvement in our country, in our society, and a lot of chronic diseases that are related to obesity and lack of movement.” 

Others are identifying quality measures that could support value-based care with conditions that similarly have potential complications, such as chronic kidney disease. Though approximately one in three adults with diabetes and one in five adults with high blood pressure may have kidney disease, some consider it an under-recognized public health crisis. 

There’s also a growing recognition of the impact that mental health plays on a patient’s overall health, although there are significant value assessment challenges due to a lack of uniform outcome measures. 

“The challenge, of course, is that all of the measurements are so subjective,” said Deborah Fernandez-Turner, deputy chief psychiatric officer at CVS Health’s Aetna, during the 2023 Behavioral Health Business VALUE conference. “It’s based on a person expressing how they feel. We don’t have that clear, quantitative [measure]. We can’t look at a hemoglobin A1C and say, ‘Oh, that depression is better.’” 

One more-than-small step toward progress in measuring value-based care? The curation — not simple culling — of information, according to Dr. Fields. As technology gets better, “and we get better at taking information and putting it into a place that can be managed at the point of contact,” he said, “I think we can create a different primary care experience, a different workforce experience, and a different patient experience that should benefit everyone.”