The Value of Quality

Kenneth A. Newell, MD, PhD, Emory University School of Medicine – AST President

In her recent Perspective article in the NEJM, Health and Human Services Secretary Dr. Sylvia Burwell outlines dramatic reforms to improve the quality and value of healthcare. Burwell notes that the fee-for-service model used by Medicare to determine reimbursement will change to a model based on quality and value metrics. By 2016, eighty percent of Medicare payments will be based on these new measures of performance. This number will increase to ninety percent by 2018.

It seems inevitable that private payers will not be far behind in adopting similar quality- and value-based models.

However, we in transplantation can rest comfortably in the knowledge that these changes will not impact us and our patients -- can't we? After all, don't we have the Scientific Registry of Transplant Recipients (SRTR), a data reporting system that is a model for other medical disciplines?

The SRTR was created in 1987 as a result of NOTA. At the time, there was little else like it in medicine. There is no doubt that much of the remarkable improvement in transplantation in 1990s and early 2000s is closely related to the SRTR and the insights derived from the data collected and reported. However, after nearly three decades, is this still the optimal tool to take transplantation into a new era in quality and value?

SRTR data are used to identify transplant programs that are underperforming. While this does provide a means of informing patients, payers, and transplant programs about important short-term performance metrics, this strategy alone may not be enough to dramatically extend the long-term survival of transplanted organs -- which I see as our next great challenge. A complementary tactic would be to introduce programs aimed at identifying and emulating the top-performing programs and their practices. An approach that is rapidly gaining traction in other areas of medicine is to capture granular data about specific events, practices, and outcomes, to analyze these data in near real-time, and provide it back to the centers with the aim of identifying and sharing the best practices of highly performing groups. This methodology shifts the focus from trying to flag a small minority of poorly performing centers (with the implied assumption that all other centers are performing at a uniformly high level) to an approach that focuses on improving the performance of all centers.

Could a system like this work? Well, this approach was adopted in the VA healthcare system, where it dramatically improved surgical outcomes across the country. In Michigan, providers, academic and private healthcare systems, and payers have collaborated to further refine this approach, resulting in both improved quality and reduced cost¹. Admittedly, this approach has not yet been applied to transplantation, and it would need to be substantially modified to reflect the longer-term combined medical and surgical practices necessary to achieve lasting success. Furthermore, it is uncertain whether this type of approach would gain traction or even be feasible in transplantation.

The one certainty I see is that increased emphasis on quality and value are imminent. Based on past experience, I predict that if our field does not lead these changes, we will be forced to follow the dictums of others.

-----

1. Share, D.A. et al. Health Affairs 2011; 30(4): 636-645