By Edie Sonn
Measuring outcomes in meaningful and consistent ways; giving providers incentives to improve; holding them accountable for their results. Comparing providers against their peers as well as against their own historical trend. Rewarding low-performers who improve, without penalizing high-performers that dont have as far to go. Making sense of a bewildering tangle of expectations and requirements.
Thats the landscape of health care accountability, right?
Yes, and its also the landscape of school accountability. Every single balancing act described above that lies at the heart of every discussion we have about paying for value in health care echoes the challenges of measuring school performance. What can we learn from the struggle to make Colorados schools more accountable that can inform our efforts to measure and reward quality in health care?
In 2004-05, the Colorado Accountability Project convened public and private sector education leaders and policymakers to try to make sense of the confusing array of systems for measuring and reporting on public school performance in our state. Some of the challenges they faced will sound familiar:
- Differing measurement and reporting programs from the state and federal government for schools and districts. At best, each provided an incomplete picture; at worst, they provided conflicting information.
- Reporting tools (School Accountability Reports or report cards) that provided only a point-in-time picture of how a school did on the state standardized tests compared to others. These report cards didnt account for how individual students academic performance changed over time, nor did they account for the socioeconomic profile of a schools population.
- No system for rewarding consistently high performing schools or for actively helping low performers to improve.
The Accountability Project said at the time, How do we measure and report in ways that are useful to parents, educators and policymakers? And: Parents cant make good decisions, and schools cant improve, with conflicting and incomplete information.
Does all this sound familiar? Replace parents with patients and educators with providers; re-frame socioeconomic profiles of school populations to risk profiles of patient populations; change school report cards to provider profiles; and youve neatly summarized the challenges of accountability in the health care arena.
Its taken many years for some of the solutions proposed by the Accountability Project in 2004 to get implemented. And Colorados educators havent solved all the problems outlined above. Yet we can learn some useful lessons from what theyve achieved and apply it to our own needs:
- Colorados school accountability system now combines what used to be three different measurement systems and philosophies into one reporting framework. No longer do we see schools that meet federal goals for adequate yearly progress but are on accreditation probation from their district, while simultaneously showing higher-than-average performance on their School Accountability Reports.
- Sound familiar? Can we see a show of hands of physicians who receive A ratings from one health plan and C or worse from another? The key here (and yes, we and other have been beating this drum for a long time) is agreed-upon, consistent measures. A plan can use those measures to support whatever payment system it wishes just as long as providers are tracking and reporting on the same things to each plan.
- Colorados schools are now measured according to a growth model that tracks cohorts of students over time, rather than just a yearly snapshot. Crucially, this model measures across different domains: achievement and growth. It breaks down the percent of students catching up, keeping up and moving up, based on median percentages. So, low-performing schools that are nevertheless demonstrating improvement receive recognition as do high-performing schools that maintain their performance. However, low- and mid-performers that dont improve are required to make changes.
- As we move to outcomes-based payment systems and new shared savings models in health care, this is a vitally important principle to bear in mind. We want to incent improvement while recognizing that high-performing organizations have less room for upward movement. Thus, we need to ensure these new payment models reward those that keep up as well as those that are moving up.
- Schools that dont meet expectations for achievement and/or growth must conduct root cause analysis to diagnose the reasons for their under-performance, and develop/implement improvement strategies. Districts are required to support these turnaround plans.
- Perhaps no one understands root cause analysis better than clinicians. But do our payment models facilitate its use, and give clinicians the tools and resources necessary to address those causes and change their behavior? When were measuring primary care physicians on how they manage their diabetic patients Ha1C levels, are we giving them the care coordination payments that allow them to purchase and use registries, and hire the nurse educators to coach them on diet? Do we have the health information exchange platform that enables them to track those patients potentially avoidable trips to the ER?
- Schools report achievement and growth for their population as a whole as well as for specified sub-groups (e.g., English language learners, population on free and reduced-price meals, etc.). Evaluations of schools take those factors into account.
- Can you say risk-adjustment? Think about an Accountable Care Organization that covers a swath of metropolitan Denver encompassing both high- and low-income neighborhoods, and whose clinicians treat both commercially-insured and Medicaid patients. Should those clinicians strategies for hitting performance targets vary depending on the population? Should the targets? Should the payments? When every patient deserves the best care, regardless of income, how do we account for socioeconomic differences? Those arent questions to answer off-the-cuff; they demand data and discussion.
I doubt that anyone would say that Colorados public K-12 education system is the best in the country; certainly I am not arguing that it is. Yet our educators and policymakers have put in place a vital mechanism for getting us there: a consistent, meaningful and predictable way of measuring outcomes and progress.
Maybe its time for our health care leaders to go back to school.
Edie Sonn is vice president of strategic initiatives at the Center for Improving Value in Health Care or CIVHC. Contact her atesonn@civhc.org.