The word quality is probably one of the most subjectively defined words in the English language. A Google search for its definition returns that quality is “the standard of something as measured against other things of a similar kind; the degree of excellence of something.” Quality is also a word that is used every day especially in the context of well-being. Expressions like “quality of life”, “quality of care” and (almost redundantly) “quality of health”. This begs the million (or more aptly billion) dollar question, who gets to decide what quality means?
In my first post I mentioned that value-based healthcare (to which I will affectionately refer to as VBH from now on) is intended to provide the highest quality and most efficient care to patients by incentivizing providers. So, in general, if a doctor is providing high-quality care with minimal associated time and cost, they would be paid more for their services than a similar doctor providing similar care that is either not of the same quality or as efficient.
What’s that you say? You just heard a loud noise? Don’t worry… that is just the elephant that walked into the room. You see if providers are being judged in some manner about the quality of the care they administer then that means that quality is being measured. How exactly is it that something that is, by its definition, subjective able to be quantified in order to adjust payment for a provider’s services?
There isn’t a more critical question when it comes to VBH and how to implement it. In general, the school of thought is that only other providers practicing similarly can assess the quality of a provider’s care. The thresholds and rules associated with quality care cannot be hard and fast and determined in a draconian way. In order to best get the buy-in of medical providers everywhere, determinations of quality must be allowed to change. In fact, they should probably be organically chosen to ensure that the largest possible cross-section of providers accepts the new guidelines.
That doesn’t mean that all the country’s providers are going to be sitting together and singing “Kumbaya” either. There will always be disagreements when one person or group tells another person or group they aren’t doing a good enough job. The key to developing a system where quality is evaluated and used to take action or install change is to do it gradually. The Centers for Medicare and Medicaid Services implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA for those that don’t recognize the full name) is a great example of a gradual roll out of a new payment methodology. Slowly over years the new concepts are developed, debated and implemented with an intentional allowance for adjustment and revision over time.
VBH is a somewhat utopic concept and therefore is not easy to attain. It will require significant buy-in from not only providers but patients as well. Change is never easy, but hopefully with enough time and purposeful adjustments we can make the change to a VBH centered healthcare model painless enough that no one will remember how it “used” to be.