Quality Basics

Despite our high costs, the quality of healthcare in Connecticut is average, and it’s not improving. There is little connection between high prices and better quality in healthcare. Good quality measurement is critical to lowering costs, avoiding unnecessary care, improving healthcare value, and overall population health.

Quality is complicated to measure, but very good, evidence-based metrics available. Quality measurement is constantly improving to focus on improving health outcomes, promoting health equity, and to support patients in healing.

Quality Deeper Dive

How is healthcare quality measured?

Measuring quality is complex. Unlike healthcare spending, which is measured in dollars, quality is measured over thousands of different metrics. However, there are evidence-based, proven metrics and processes to measure quality and improve it. The National Quality Forum (NQF),  a nonprofit nonpartisan organization created in 1999 to promote healthcare quality measurement and reporting. NQF sets standards for healthcare quality metrics and has endorsed over 700 different performance measures.

In healthcare, we don’t get what we pay for; prices and quality do not correlate well. A research synthesis found that roughly a third of measures and prices were aligned, another third with no relationship, and in the last  third prices were higher for worse quality care. Another study found no relationship between high hospital prices and lower mortality.

There is a growing consensus that quality measurement needs to shift from process metrics, based on provider actions which are easy to measure and often self-reported, to emphasize more outcome measures, that reflect improvement in health status. While evidence-based healthcare treatments are important, the primary goal is to improve people’s health. It is more important to measure how many patients quit smoking cigarettes than how many were advised to by their provider and counting whether patients’ blood pressure was controlled rather than the number blood pressure screens.

The potential for quality measurement to improve health equity is adding focus to the field. New measures specifically designed to reduce disparities and the data capacity to collect them are developing. Targeted populations include race/ethnicity, gender and sexual orientation, disability, and urban/rural, among others. Measuring the impact of interventions designed to reduce disparities will be key to building a health system that works for everyone.

There is also movement toward measuring quality and setting goals that matter to patients. This is especially important to reducing health disparities. Patients must be engaged in their healing. Patient-centered goals such as “being able to leave the house on my own” are far more likely to be achieved than a set of clinical metrics. Person-driven care is more likely to reduce costly and unnecessary care that doesn’t improve health.

Patient satisfaction, or patient experience of care, surveys allow evaluators to see across health outcomes and populations to find challenges and successes they didn’t know to look for. The gold-standard Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey was developed decades ago by independent researchers at the federal Agency for Healthcare Research and Quality. Based on over 400 studies, it has been updated for multiple populations to ensure its value in improving healthcare quality. It is used by Medicare, most health care systems, insurers, and 46 other state Medicaid programs. Unfortunately, Connecticut Medicaid made a decision in 2021 to move from CAHPS to a new, physician-centered survey with little information to improve the quality of care.

How is Connecticut’s healthcare quality?

The latest federal 2022 National Healthcare Quality and Disparities Report from the Agency for Healthcare Research and Quality rates healthcare in Connecticut as average. Across 159 measures of quality, Connecticut was above the US average on 39, below average on 38, and average for the remaining 82. Unfortunately, we are not improving. Compared with baseline years for each measure (which varies), Connecticut improved on just 13, declined on 39, and 102 didn’t change.

According to the report, Connecticut’s strongest quality areas are in the health of nursing home and home health care patients. Our weakest areas involve the quality of care for opioid-related hospital stays, senior admissions for vaccine-preventable flu, opioid-related ED visits, opioid overdoses, and overdose deaths.

Only eight Connecticut hospitals received A grades in 2022 for social responsibility from the Lown Institute, down from twelve in 2021. No Connecticut hospitals were in Lown’s or US News’ top 20 hospitals in the US. The best among Connecticut hospitals, Griffin Hospital ranked #157 in Lown’s composite ranking this year among 3,606 US hospitals.

Equity was the biggest challenge for Connecticut hospitals. Lown’s equity score includes pay equity between executives and healthcare workers, community benefits, and how well the hospital serves people of color, people with lower incomes, and lower education in the community.

Connecticut’s community health centers (also called Federally Qualified Health Centers, FQHCs) are not doing as well as their counterparts in providing quality care. From 2016 to 2018, Medicaid FQHC patients were more likely to visit an ER than Medicaid patients cared for by either PCMH or non-PCMH practices. Child Medicaid members with asthma cared for at an FQHC were more likely to visit the ER than other Medicaid members.

The new 2022 March of Dimes Report Card also gives Connecticut average marks on how well we care for new moms and babies. With a pre-term birth rate of 9.6% of live births in 2021, Connecticut is behind nine other states. Babies born too early can have serious long-term health problems including cerebral palsy, impaired learning, behavioral and psychological problems, hearing and vision problems. Unfortunately, Black and Hispanic Connecticut moms are 53% and 9.2% more likely to have a preterm birth than white women, respectively. And that gap hasn’t changed over time.

While Connecticut’s preterm birth rate has been stable since 2011, our infant mortality rate is declining. It was down to 4.2 per 1,000 live births in 2020 from a high of 5.7 in 2015. In comparison, the US average was 5.4 in 2020.

How is quality affecting patients?

Over the last century US life expectancy had been rising, but it reversed course in 2014 and is now declining, even before COVID. The US is now far behind other developed countries in health status. Americans live four years less long than residents of other developed countries, on average, but we spend 177% more per person on healthcare than other countries.

Even with an eased formula due to COVID, all but one Connecticut acute care hospital will be penalized by Medicare in 2023 for higher-than-expected readmission rates.

Since 2012, the Hospital Readmissions Reduction Program has penalized hospitals with a higher than expected rate of discharged Medicare patients who are readmitted within 30 days over the last three years. Medicare payments to hospitals in the next year are reduced proportionately to their readmission rates. Created under the Affordable Care Act, the program is an important quality improvement metric designed to ensure that hospitals work to ensure patients continue recovering after they leave. Recognizing the impact of COVID on hospitals, CMS excluded the first half of 2020 from the latest calculations.

Connecticut hospitals will be docked by 0.456% on their Medicare payments in 2023, higher than the US average of 0.428%. Connecticut hospital average readmission penalties have been higher than the US average since 2019.

Only Griffin Hospital escaped a Medicare readmission penalty for 2023. Backus will experience the highest penalty for next year. In 2022, all Connecticut hospitals were penalized.

Trends

• There is potential to improve healthcare quality with value-based purchasing
• If we pay more for better quality care
• However, we must move from easy process metrics to meaningful health outcome measures that impact patients’ health