Specialty Care and Achieving Optimal Patient Outcomes

As someone who’s spent the past 12 years focused on improving healthcare value and quality, perhaps what’s most surprising is that, even with the presence of numerous federal and industry initiatives and programs focusing on quality reporting, quality improvement and value-based payment, we – patients, providers and payers – still know very little about quality of care. Not knowing enough about quality of care has limited patients, providers and payers’ collective ability to make the right care decision at the right time. The lack of understanding is even more profound for specialty care.

There are two main reasons for the lack of understanding of quality of care in specialty care:

First, there are very few established measures to assess quality. “Quality of care”, as a multi-dimensional concept, requires evidence-based structures and processes to achieve desirable patient outcomes. Ideal quality measures should directly assess patient outcomes. In musculoskeletal (MSK) care for example, the most established and widely used quality measures focus on the patient’s risk of complication and readmission to a hospital after elective joint replacement surgery. These measures, by definition, are applicable to patients who undergo surgery, who represent 10% of all patients seeking care for MSK conditions. On the other hand, the vast majority of patients would receive conservative or non-surgical treatments such as physical therapy or knee or spine injections for which no standard quality measures at the national scale are available to assess the efficacy of the treatments and compare performance across providers.

Second, quality information is typically not readily available at the time the patient and their provider make the care decision. Cohere Health interviewed 9 patients with musculoskeletal conditions and 8 primary care doctors and revealed that a shared pain point is lack of trusted data-driven recommendations for which type of specialists the patient should see and whom they should see to receive the best quality of specialty care.

Not knowing enough about quality of care has limited patients, providers and payors’ collective ability to make the right care decision at the right time. Addressing this issue requires solutions to both reasons mentioned above:

First, specialty care needs standard outcome-focused quality measures that can track the patient along their entire care journey. For example, pain and other symptoms and their interference with activities of daily living are critical outcomes that patients who seek musculoskeletal care want to improve and they matter at every phase of the care journey, e.g., conservative therapy, non-surgical pain management and surgical treatments. Several national registries, including the American Academy of Orthopaedic Surgeons (AAOS) American Joint Replacement Registry (AJRR), collect patient reported pain and function outcomes using standard assessment tools before and after joint replacement surgery. The data can be potentially leveraged to ensure the patient receives high quality surgical care with the appropriate implant from the right surgeon. However, addressing the question whether the patient receives the optimized care journey by choosing surgery at the right time requires a more longitudinal view. Many upstream providers such as physical therapy and pain management practices also assess patient outcomes, sometimes to fulfill the payer’s requirement, but lack of standardization prohibits tracking the patient’s condition progression from end to end to optimize the care journey.

Second, standard quality and outcome information needs to be easily accessible for patients and providers at the point of care. This year, the Centers for Medicare & Medicaid Services Interoperability and Patient Access final rule establishes policies that break down barriers to enable better patient access to their health information and improve interoperability across systems, providers and payors. This major policy development, combined with the advancement in health information technology standard and data exchange technology, sets the foundation for shared decision making driven by quality and outcome.

As we continue to move toward value-based care, patients, providers and payers’ needs for more standard outcome-focused quality measures are aligned. I expect technology to enable faster movement toward outcome-driven strategies for quality improvement in specialty care. In my opinion, it’s about time.