Transparent Measurement Standards Advance Quality Goals

Accurate information about the cost and quality of health care delivered by physicians and hospitals is becoming increasingly important as health care expenditures rise and governments, health plans and patients seek the best value for their dollar. This growing reliance on measuring health care by care purchasers and federal policymakers heightens the need for assessment methodologies to be valid, fair, uniform and transparent.

“Physicians and hospitals need insight into how they are measured, while health plans, the federal government, state governments and patients demand increased transparency,” said Dogu Celebi, M.D., chief medical officer, payer and government solutions, Ingenix. Because there currently is no agreed-upon set of national measurement standards to define value-based performance and different methodologies can yield different results, he suggested, meeting these needs can be difficult.

Understanding and standardizing “episodes of care” measurement methodologies used to evaluate the care delivered is integral to advancing consistency and to moving health care reform efforts forward, asserted Dan Dunn, senior vice president, payer and government solutions, Ingenix. “With President Barack Obama’s stimulus bill injecting billions of dollars to modernize the U.S. health care system, performance measurement is critical to optimizing the impact of reform,” Dunn said.

“Having consensus and common goals as we measure the quality and efficiency of care delivered is critical to demonstrating value and addressing variances in performance,” he added.

ETGs measure value in health care

Episode treatment groups (ETGs), introduced in the mid-1990s as a condition classification methodology that combines related services into a medically relevant and distinct unit describing a complete episode of care, are considered a sound unit of analysis to support transparency, measure health care quality and cost, and provide incentives for improving value.

ETGs identify clinically homogeneous, risk-adjusted episodes of care, regardless of treatment location or duration. By combining related services into clinically homogeneous units that describe complete episodes of care, ETGs provide the basis of valid comparisons, Dunn explained.

Ingenix offers a software platform, Symmetry 7.0, which streamlines analysis of ETGs and directly presents risk factors that contribute to case mix. Severity scores also provide the ability to distinguish between episodes, based on the patient’s underlying condition, episode-specific comorbidities and demographics. Further, Symmetry 7.0 calibrates the “normal” range of costs, outside of which episodes are deemed outliers.

“Essentially, ETGs allow us to map patient care from a services perspective to a medical destination,” Celebi said. Although ETGs have helped payers understand and compare episodes of care across patients, providers and populations for more than a decade, he noted, they “need to evolve to reflect the increasingly complex nature of care.”

Transparency can improve methodology, end results

To assist with that evolution and contribute to a national dialogue on health care measurement standardization, Ingenix announced March 10 that it is offering participants in the patient’s circle of care – care purchasers, governments, health plans, hospital systems and physicians – access to its ETG core content and methodologies for all 542 currently supported disease conditions.

“We’ve always had an ‘open arms’ policy regarding our methodology – if our clients wanted to know how it worked, we shared it with them,” Celebi said. “But in light of the current public policy efforts to modernize health technology systems, we believe that making ETG methodologies available for public review creates broad and immediate value.”

This online access forum established by Ingenix represents an industry first, Dunn remarked: Participants are invited not only to learn more about ETGs, but also to provide input on how to improve them. Interested parties can evaluate the methodology and content sets, including many examples of how claims are grouped into episodes and how ETGs are applied. They then can make suggestions and recommendations about how to improve the ETGs’ clinical constructs.

“We wanted to help answer the question: How do you create a marketplace where details on nationally endorsed methods, tools and standards are available to the general public, including providers and payers?” Celebi said. “Ingenix also wanted to make sure that the methods it is using are effective, which can be further validated and improved by stakeholder input.”

Although Ingenix has sought input in the past – from its staff clinicians, from a clinical advisory board and via physician feedback relayed to Ingenix payer clients – it has not had a direct channel to physicians until now. “We are confident that this direct physician input will provide intelligence that can take ETGs to a new level,” he added.

Learning about, providing input on ETGs is easy

According to Dunn, the main objectives in opening up the ETG methodology for review and comment include “not only providing the industry with how, specifically, the measurement is done, but also allowing people to better understand what factors determine how a physician is being measured and what physicians can do to improve their performance,” he said. “If physicians better understand the methodology, they should find that they can enhance the care they provide, which serves everybody better.”

Celebi agreed, saying that Ingenix believes that physicians should have greater knowledge of and input into the criteria by which they are measured. “We are trying to give physicians more of a voice in this meaningful public dialogue,” he said.

To review the methodology, provide comments and review others’ comments, individuals can go to the Ingenix Web page: http://www.ingenix.com/transparency. Some documents may be viewed without logging in with a password, but to “see the details or follow a specific condition,” commenters will need to register at the site, Dunn indicated.

After reviewing information, individuals can submit a comment via a form that allows them to select from a drop-down menu. Commenters can submit a general comment or a specific comment. Other parties’ comments can be reviewed and commenters can agree or disagree with those and add their own opinions as appropriate. “There is no deadline for input and comments can be made 24/7,” Celebi said.

Ingenix will review the comments on an ongoing basis and aggregate them periodically. When the company prepares for the next release of the ETGs, it will take the comments under careful consideration. “We are putting together an advisory council to define the future direction of the transparency site moving forward,” Dunn indicated.

Advancing standard measurement dialogue

Ingenix recognizes the importance of opening up its methodology to the physician community and the community at large. “If the ETGs are used to assess physician performance, to complete the circle physicians absolutely need to know how these tools work,” Celebi said. “To further this understanding and contribute to the national debate about measurement standards, Ingenix is willingly sharing our software tools, methods and the science behind those methods.”

With the stakes for health care measurement getting higher and health care reform initiatives emerging, the health care community “needs a methodology that all stakeholders, especially physicians, can understand, trust and contribute to,” Dunn remarked. By allowing access to and commentary on its methodology, Ingenix is optimistic that the entire health care community will benefit. Bottom line, he said, “any measurement is only useful if it is valid.”

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