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February 02, 2023 04:40pm
By Erin Hunter, Assistant Editor
In recent years, the US health care system has been shifting from a fee-for-service to a value-driven system. More simply, reimbursement will be based on the quality, rather than quantity, of services provided.
In recent years, the US health care system has been shifting from a fee-for-service to a value-driven system. More simply, reimbursement will be based on the quality, rather than quantity, of services provided. A key feature of value-driven payment is the use of performance measures to evaluate the quality of provider services. Measuring the quality of health care tells us how the health system is performing and leads to improved care. It can also help hold health care providers accountable for providing high-quality care, address disparities in health care, and help consumers make informed choices.1Establishing quality measures across the health care continuum allows us to understand how care is delivered and supports initiatives to provide the right care at the right place.
Why is quality measurement important?
The Institute of Medicine has defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”2Americans pay more for health care per individual than do residents of any other country. However, there is little evidence that this higher spending has produced better care. The typical American adult receives only 55% of recommended care; many patients do not receive the services they need, whereas others receive services that expose them to more potential harm than good.3Quality measures allow us to understand both gaps in care as well as situations where there is an overuse of unnecessary services.
How can quality measurement improve health care?
First, it prevents the overuse, underuse, and misuse of health care services and ensures patient safety. Implementing appropriate quality measures helps to ensure that every patient receives the right care at the right time and helps prevent the overuse of tests or procedures that are not medically necessary.
Second, it also identifies what works and what doesn’t in health care to drive improvement. Measuring health care quality enables us to evaluate the performance of the health care system and identify the types of improvements that are needed. Third, it drives health plan and provider accountability for delivering high-quality care. The Affordable Care Act introduced several policies that change how providers are paid and how health care is delivered. As a result, health care systems are changing how they deliver care, and quality measurement is essential to determining the impact of these changes. Accreditation and certification programs rely on quality measures, results are publicly reported, and pay-for-performance programs provide financial incentives.
Fourth, it identifies disparities in health care delivery across patient populations. Tailoring quality measurement to the particular care needs of different demographic groups is one strategy for addressing disparities in quality of care. Racial, ethnic, and economic factors can create disparities in health care outcomes, which are identified when measuring diverse populations. And last, it helps consumers make informed choices about their care. Quality measures can give consumers important information they need to make decisions regarding which health plan to select or which provider to see. Reporting quality data in ways that are easy for consumers to understand will help them make informed decisions and allow them to become active, engaged participants in their care.1
What are the types of quality measures?
The widely used framework for measuring quality of care includes metrics to analyze structure, process, outcomes, and patient experience (Online Table).4
Why are quality measures important to retail clinics?
With the growth of high-deductible health plans accelerating, the health care business model is starting to turn from wholesale to retail. Savvy health care consumers bearing higher deductibles and co-pays will with bring with them a list of expectations that come from the retail sector, including price transparency, access, convenience, and value.5
As the number of retail clinics increase, there is growing concern by physician groups about the quality of care provided in retail clinic.6However, studies have demonstrated that the quality of care is not compromised, and that it even appears superior in retail clinics for specific acute conditions. When taken together with evidence suggesting that retail clinics are more cost effective (and even cost saving) to patients, these results underscore the promise of retail clinics in offering care of high quality and lower cost at a time of primary care shortages.7
How can the quality of retail health be measured?
Using standardized quality measures is important when determining whether the quality of care is equivalent across health care settings. Although the National Quality Forum (NQF), an organization that vets quality measure sets for use by payors, has not established a retail clinic quality measure, many of the industry measures they have endorsed can be used.8NQF measures can be accessed through their measure search tool, the Quality Positioning System. The Physician Quality Reporting System (PQRS) is a quality reporting program that gives eligible professionals and group practices the opportunity to assess the quality of care they provide to their patients. The Electronic Health Record (EHR) Incentive Program (formally Meaningful Use) established requirements for the electronic capture of clinical data and use of health IT for continuous quality improvement at the point of care. Partner with your electronic medical record vendor to report and optimize your performance on PQRS and EHR incentive program measures. To be the most effective, quality measures should focus on those areas that represent the most frequent conditions treated within the retail setting. Additionally, measures should address the aspects of retail health care that are most commonly criticized.
Focus on Common Conditions
The most common reasons for visits to a retail clinic include vaccinations, upper respiratory infections, bronchitis, sinusitis, pharyngitis, otitis media, urinary tract infections, and conjunctivitis.9There are a number of existing quality measures that address these common conditions and can be used in the retail setting. For example, the Healthcare Effectiveness Data and Information Set (HEDIS), developed by the National Committee for Quality Assurance is a tool used by America’s health plans to measure performance on important dimensions of care and service. HEDIS includes measures on the appropriate use of antibiotics for bronchitis, pharyngitis, and upper respiratory infections.
Retail clinics have faced criticism on a number of fronts:
•Fragmentation:visiting a retail clinic may, over time, erode the patient—primary care physician relationship.
•Missed opportunities:fragmentation may result in missed opportunities for patients to receive appropriate preventive care and care for chronic conditions.
•Inappropriate prescribing:the proximity of clinics to retail pharmacy may motivate to inappropriately increase prescriptions.10
Multiple studies have suggested that retail clinics provide less costly treatment than physician offices or urgent care settings with no apparent adverse effects on quality of care or preventive care.7,11However, there is an opportunity to address the concerns that have raised:
1. The most consistent criticism relates to fragmentation, continuity, and coordination of care. However, a large fraction of patients at retail clinics report that they do not have a primary care physician.9To address the issue of care coordination, consider measuring the number of patients who do not have a primary care physican, the number of referrals made to a primary care provider, how often a visit summary is shared with a primary care provider, the number and type of repeat visits, the use of immunization registries, and use of electronic prescribing. To address the potential of missed opportunities regarding needed preventive or chronic care follow-up, consider measuring how often preventive care is discussed, the number of referrals made to a primary care provider, how often immunizations are provided in conjunction with an acute visit, the number of incomplete series vaccinations, or how often there is a repeat blood pressure taken during an encounter for an elevated blood pressure and subsequent referral.
3. Many of the common reasons for visits to a retail clinic are for acute conditions treated with antibiotics. Although studies have demonstrated that retail practitioners adhere to evidence-based protocols related to appropriate testing and prescribing. Reinforce those practices by reporting on appropriate use of antibiotics for bronchitis, pharyngitis, upper respiratory infections, and urinary tract infections.
The role of retail clinics will continue to evolve with the shift toward value-based care, high-deductible plans, and patients deciding on how and where they want to receive care. Measuring performance using standardized measures provides the opportunity to both demonstrate value and identify improvement opportunities. There is no shortage of quality measures from which to select, and many are applicable to the retail clinic setting. Select measures that are evidence-based, relevant to your practice, and actionable. Leverage measures to demonstrate that retail clinics not only are convenient, but also provide quality care.
Susan Gentilli, RHIA, MBA, is the manager of Quality and Regulatory reporting at Allina Health in Minneapolis, Minnesota. In her current role, she is responsible for the implementation of quality regulations and clinical data reporting for Allina Health’s primary care clinics. Prior to joining Allina, Susan was the manager of Quality and Safety for Target’s retail clinics and pharmacies. Previous roles in health plans and hospitals have provided the opportunity to lead measurement efforts in a variety of health care settings.
1. Measuring Heath Care Quality: An Introduction. www.familiesusa.org Issue Brief March 2014
2. The Institute of MedicineCrossing the Quality Chasm: National Academy of Sciences, 2001
3. The Institute of MedicinePerformance Measurement, Accelerating ImprovementNational Academy of Sciences, 2006
4. Measuring Heath Care Quality: An Overview of Quality Measures. www.familiesusa.org Issue Brief May 2014
5. “Retail Medicine a Big Shift for 2014” www.healthleadersmedia.com/health-plans/retail-medicine-big-shift-2014
6. Daniel Costello “A Checkup for Retail Medicine”Health Affairs27, no. 5 (2008)
7. William H. Shrank, et al “Quality of Care at Retail Clinics for 3 Common Conditions”American Journal of Managed Care. 20, No. 10 (2014)
8. Cheryl Clark, “As Retail Clinics Surge, Quality Metrics MIA”HealthLeaders Media, November 2014
9. Ateev Mehrotra and Judith R. Lave “Visits to Retail Clinics Grew Fourfold from 2007 to 2009, Although Their Share of Overall Outpatient Visits Remain Low.”Health Affairs31, no. 9 (2012)
10. Craig E Pollack, Courtney Gidengil and Ateev Mehrota “The Growth of Retail Clinics and the Medical Home: Two Trends in Concert or in Conflict?”Health Affairs29, no. 5 (2010)
11. Ateev Mehrotra, et al. “Comparing Costs and Quality for Care at Retail Clinics with that of Other Medical Settings for 3 Common Illnesses.“Annals of Internal Medicine. 151. no 5 (2009)