Q: How should we think about healthcare quality?

A: There are two ways to think about quality. First, you can think of quality as avoiding harm. So if you go to the hospital to have your fractured leg set, then you shouldn't come out with pneumonia, or you shouldn't come out with a bed sore or receive the wrong blood transfusion or a drug that interacts with another drug and causes a harmful reaction while you were in the hospital. That's how quality can equate to avoiding harm.

And then there is a focus right now on quality initiatives that improve your health and help avoid future problems. You go to the doctor: Did the doctor do all of the right things? Is your blood pressure under control? How's your cholesterol? Or let's say you're diabetic. Have you had a retinal eye exam? Have you had a foot exam? How's your hemoglobin A1c? There's quality achieved by promoting health and wellness. More self-care, better exercise, and a better diet can also help improve quality of life.

Q: Pay-for-performance initiatives aim to use payment mechanisms to encourage quality outcomes, in either or both of the ways you mention. What kinds of pay-for-performance programs have been used by payers?

A: There are numerous pay-for-performance programs, many of which have been implemented by payers (or employers) to reward physicians in the office setting who follow certain processes that are associated with better outcomes or who have better patient outcomes. There are other programs that pay extra for hospitals that meet specific quality targets. And then there are Medicare-sponsored value-based purchasing programs that have multiple components. Since Medicare is the biggest payer out there, it is a significant driver of what happens and what gets adopted.

To date, most programs use the carrot rather than the stick approach. But more recently we're seeing more nonpaying for nonperformance, or withholding payment for certain kinds of egregious errors. So the stick is now in play, though it's too early to say how those programs will work since we only have 2007 and 2008 results to look at.

Q: Why is Medicare getting involved in paying for quality?

A: The growing cost of healthcare, as everyone knows, is undesirable. There's a growing desire to minimize the costs associated with Medicare. There are also concerns over improving health, minimizing disability, and saving lives, and there is a general recognition that reduced cost and improved quality are not mutually exclusive.

Medicare has initiated a number of pay-for-performance programs, most of them carrot-type programs that reward quality. But Medicare is also starting to wield the stick. Medicare now won't pay for "never events"—things that are never supposed to happen—and is limiting payment for hospital-acquired infections, which will give hospitals an incentive to avoid these preventable conditions.

Q: Are there tangible examples of the relationship between quality and cost?

A: I believe there is a real relationship. One example is a measure called door-to-balloon time, sponsored by the American College of Cardiology, which refers to the amount of time that it takes from the minute a patient hits the emergency room door (or when the incident was called in by the ambulance) until they're actually on the table getting a balloon angioplasty. A door-to-balloon time of 90 minutes or less makes quality outcomes significantly more likely and can save lives.

Another scenario involves using health plan benefit design to influence both cost and quality outcomes. For instance, the National Business Group on Health promotes benefit design tools for cervical cancer screening, back surgery, and hypertension. Using hypertension as an example, the NBGH tool offers pharmacy plan edits that have been proven to improve hypertension treatment.

We should expect more focus on benefit design as evidence-based medicine infers new connections between quality and cost. And with additional time and research, we should expect to see more plan designs that reflect the comparative effectiveness of both emerging and established technologies and treatments.

Q: Where do tools like clinical guidelines fit into the quality puzzle?

A: Guidelines are an excellent resource, especially when they're used to truly evaluate and coordinate care for the patient. They're very useful to identify omissions and delays in care, both of which can lead to quality concerns. For a patient who's had a stroke, how quickly did she have a swallowing evaluation? This is to help prevent choking in patients who have difficulty swallowing. It may sound simplistic, but the delays can affect outcomes. The patient's had surgery, now it's time to get him out of bed. Have we done that? Is his pain adequately controlled? Does he need medication that is used to prevent blood clots? Using guidelines to look at discharge readiness and transition to another level of care is very important to assess the patient, to coordinate safe discharge and prevent readmissions. Of course, guidelines are like any other tool: It's about how effectively you use them.

Q: Is there consensus over how to pay for healthcare quality?

A: There's disagreement over how we should pay for quality. There's always the question, "Are we focusing on the right things?" Sometimes what we're focusing on are process measures that may or may not be linked to outcomes. Does doing "X" actually lead to better outcomes? Sometimes there’s medical evidence, and sometimes there's not.

Some current quality efforts focus on specific conditions: heart attack, heart failure, pneumonia, and surgical site infection to name a few. But then, there's an issue of what isn't being looked at. A broader application of evidence-based guidelines can help cover more breadth than just a few conditions. It also takes a more systemic approach, or depth, from the top down, which is why some quality initiatives, such as those from the Institute for Healthcare Improvement, also focus on getting hospital boards of directors involved in quality movements.

The question will persist: Are we measuring the right things? Are we focused on the right areas? There are a lot of unanswered questions but we're learning more every day as paying for quality becomes an increasingly significant priority.

Sherrie Dulworth, CPHRM, RN, is vice president of strategic planning for Milliman Care Guidelines and has over 20 years experience in the managed care market.