Measurement objectives
and strategy Identify the goals of measurement and how the results will be used.
Data preparation
Collect, standardize, and integrate information to support
measurement, including enrollment, medical and pharmacy service data, and clinical records from lab results and other sources.
Units of measurement
Select and create the units of measurement, including per episode of care, population-based, per inpatient admissions, or specific procedures.
Providers to be measured
Select the physicians and hospitals to be compared and create “peer groups” for use in comparisons – typically defined using attributes such as hospital type, physician specialty, and location.
Scope of measurement Identify the scope of measurement for each peer group; for example,
the medical condition categories for a group of specialists.
Attribution Assign patients and episodes to individual providers and groups.
Metrics Identify the metrics for use in comparisons, such as overall costs,
costs by type of service, or the utilization of specific services.
Risk or case mix adjustment
Adjust for differences in patient morbidity or case mix across providers
Communication and improvement
Create physician and hospital results and share these findings with providers and other stakeholders. Use the results to drive improvements.
Some of the steps outlined above warrant further discussion.
Measurement Objectives and Strategy
Identifying the measurement objectives is a key consideration for all steps, including selecting a measurement approach, the providers to be measured, and the metrics to be applied. Most importantly, an ACO should assess how the information will be used – whether it is to differentiate the organization, improve financial performance, enhance patient care, or all of the
above. Ideally, the measures should be meaningful (i.e., they are reflective of the health care services being measured), simple, and actionable (i.e., they can be used to drive improvement in patient care over time).
Given the central role of physicians and hospitals in measurement, methods and measure results will need to be understandable and transparent to providers. Working with providers to obtain consensus on methods and their intended uses is a key step.
Units of Measurement
The unit of measurement should be aligned with the measurement objectives. Below we discuss how several different types of units can provide insights on the effectiveness of health care delivery.
Per Capita Measures. Population, or per capita,
measurement is one approach and presents the most complete picture for members served by an ACO or a provider. Examples of these measures are cost per member per month (PMPM), cost per patient per month (PPPM), and inpatient admissions per 1,000 per year. One advantage of population-based measures is the ability to capture all of the services for a defined population, across all providers and conditions treated. This type of measurement is most meaningful where the measured entity has clear responsibility for a significant portion of a patient’s care. Health plans, provider-hospital organizations, ACOs, and primary care physicians are examples. This approach can also have advantages for patients with certain chronic conditions, such as diabetes, for which the management of a wide range of co-morbidities is of central importance in delivering good care.
Episode Measures. Some of the advantages of
population-based measures also create challenges for their use. In particular, patients often present with a number of different acute and chronic conditions – many occurring during the same period of time. Patients can also have multiple care providers, each contributing to the same or different conditions. Assessing the cost of care related to a condition or the performance of physicians who focus on a certain area of medicine requires a different approach – an approach that identifies conditions for a patient and assigns services to those conditions. Episodes of care accomplish this and support the measurement of providers on those parts of care for which they are most responsible. An episode of care can be characterized as a condition classification methodology that combines related services into a medically relevant and distinct unit describing a complete episode. An episode defines a unique clinical condition for a patient and the services involved in the diagnosis, management, and treatment of that condition. In
addition to grouping individual services to unique episodes, these methodologies also characterize episodes from a clinical perspective, including the conditions identified. Most methodologies will further differentiate episodes based on the presence of significant complications and/or co-morbidities, some assigning a level of severity to each episode. This approach enables more accurate case-mix adjustment and valid comparisons across patients and providers. Episodes of care describe a wide range of acute and chronic conditions. Examples include hypertension, diabetes, CHF, pregnancy, leukemia, spinal trauma, and minor infectious diseases.
In addition to condition-based episodes, some methodologies provide a narrower focus – they assess the services involved in delivering surgical procedures. These methodologies have value in evaluating performance around procedural care, including assessing the resources used by surgical specialists. Examples of procedural episodes include coronary artery bypass graft (CABG), knee replacement, and cataract surgery.
Most episode-of-care methodologies will determine completion and outlier status for an episode. In order to identify a complete episode, methodologies review the timing of the episode services and frame the episode by a start date and an end date, often using a clean period that notes the absence of patient care related to the episode. Assessing the completeness of an episode is most important for acute conditions, which by nature will have a beginning and an end. Chronic episodes can be assigned a start date where relevant care is first observed. However, these episodes will continue and are often parsed into annual intervals going forward to define “complete” episodes for analysis. Table 6 provides a simple example of an acute episode of care and how episodes are built.