The problem, say hospitals and some analysts, is that rating hospital quality is not so straightforward. How a hospital delivers care is multifactorial and complex, they argue, so trying to cram that into a single score is misleading and can end up like rating a restaurant on its parking.
The measures most often used today to assess care quality are process measures. Actual outcomes, of course, are harder to measure than whether a certain action has been taken—checking the feet of a patient with diabetes, for example. But many experts don’t think process measures get at the heart of quality.
After 25 years, the Healthcare Effectiveness Data and Information Set (HEDIS) is still criticized for focusing on process and taking up doctors’ time. But it has been incorporated into physicians’ workflow and may yet be instrumental in bringing about value-based care.
There is momentum building to use observational studies to investigate the safety and efficacy of medications in new ways. Drug companies are using them to establish the value of medicines in negotiating prices, rebates, and formulary placement with payers.
But most insurers are taking a wait-and-see attitude even though in some clinical areas, such as diabetes, real-world evidence (RWE) has been a true game-changer. Payers have a pessimistic view that RWE can help them. It doesn’t help that respected voices in health care agree.
Ideally, real-world evidence would be continually looped back into the drug development process. There is a deep reservoir of information about side effects, adherence, and differences in efficacy among subpopulations embedded in the various sources of real-world evidence. Extracting it will take hard work.
If insurers insist that doctors use older, lower-cost drugs first, the burden is on the health plan to respond to doctors’ request for different medications quickly, nimbly, and appropriately. But quick and nimble do not often describe insurers’ step-therapy efforts.
The challenges include not overburdening physicians and fitting into an increasingly complex, multilayered informatics ecosystem. Innovative health care entities that neglect health care’s reliance on evidence-based medicine and go to market without the benefit of any peer review do so at their own peril.