The afternoon sessions of the workshop featured two moderated panel discussions with individuals who would be involved in implementing an integrated framework of quality performance measures. This chapter reports on the discussions moderated by Suzanne Bakken, alumni professor of nursing and professor of biomedical informatics at Columbia University. The panelists were Cara James, director of OMH at CMS; Andrew Sanderson, medical officer at OMH in HHS; Michael Currie, vice president for the Health Equity Services Program at UnitedHealth Group; Foster Gesten, retired from his position as chief medical officer in the Office of Quality and Patient Safety for the New York Department of Health; and Margaret VanAmringe, executive vice president of public policy and government relations for the Joint Commission.
WILL THE PROPOSED APPROACH FACILITATE LITERACY, CULTURALLY, AND LINGUISTICALLY SENSITIVE PERSON-CENTERED CARE?
James responded that this framework is shifting the focus of efforts into patient-centered care, but it will be important to keep track of what will be
1 This section is based on the comments of Cara James, director of OMH at CMS; Andrew Sanderson, medical officer at OMH at HHS; Michael Currie, vice president for the Health Equity Services Program at UnitedHealth Group; Foster Gesten, retired from his position as chief medical officer in the Office of Quality and Patient Safety for the New York Department of Health; and Margaret VanAmringe, executive vice president of public policy and government relations for the Joint Commission, and the statements are not endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
lost in terms of monitoring with an integrated approach to measurement. Sanderson said that he believes this type of work takes health literacy, cultural competence, and language access services out of the space of people addressing them out of the goodness of their hearts and puts it in the space of surviving as an organization in a changing environment that mandates health equity. In his opinion, it is wonderful to hear people talking about the lack of equity measures and the need to develop such measures as tools that hospitals and clinicians can use to fulfill accreditation requirements and, thus, as something essential to the business of health care.
Currie, speaking from the perspective of an insurer, said that the answer to this question depends on how well a particular organization can implement the proposed guidelines. “For a health insurance company in the business of care management and care support, trying to implement guidelines that are more specific toward care delivery organizations is sometimes a challenge,” said Currie. “Sometimes, it is left up to interpretation and other times we morph and adjust them to fit our needs.” His suggestion was to think about how these recommendations would apply to care delivery organizations separately from how they would apply to care facilitators or insurance organizations, given that they support patients and members in different ways.
In Gesten’s opinion, the proposed framework is clearly helpful, if for no other reason than that it has already stimulated great discussion, but also because it shows the connectivity between health literacy, cultural competency, and language access services. However, he continued, there are many issues that sit between a conceptual framework and implementation that must be addressed, including the one that Currie raised about how to frame these concepts for different parts of the delivery system and their different responsibilities and opportunities for change. That said, the proposed framework should be helpful in thinking about the specific actions organizations need to take to integrate health equity into their core missions. Gesten noted that the PCMH would be a “tremendous vehicle” through which to integrate these concepts, and he wondered if that idea belongs in the framework as a conceptual add-on or whether the PCMH could serve as a means for implementing these measures. One of the strengths of the commissioned paper is that it points out that, while there is an evidence base to support these activities, uptake is still an issue. “My concern is whether the framework addresses the major barrier or issues that are preventing that kind of uptake,” said Gesten. “To what degree are they aimed in that direction? That is my cautionary note about the framework and thinking about implementation.”
In VanAmringe’s opinion, the proposed framework can facilitate change by serving as an organizing principle for complex activities and concepts and by enabling a cohesive plan for moving forward and answering the
“what, where, when, why, and how questions.” As an example, she said that the framework should prompt organizations or clinicians to identify the population they serve, and consider what that population needs to reach the goal of high-quality care, how they can help the patient reach that goal, and what services they need to deliver to make the goal attainable for the patient. The framework can help identify which services are essential and how to measure progress toward delivering those services. In addition, the framework provides a process for using data to feed into a quality improvement process. She also noted that placing patient-centered care as an overarching principle is particularly valuable in today’s health care climate, where clinicians often spend more time looking at digital information at the expense of time for talking to patients, learning who they are, and developing an understanding of the barriers they face to accessing care.
WHEN YOU THINK ABOUT THIS APPROACH, IS THERE ANYTHING YOU WOULD LIKE TO CHANGE SO THAT IT WOULD LEAD TO DESIRED DELIVERY CHANGES?
James suggested that it would be helpful from a strategic standpoint to embed these concepts into the PCMH model and to map what might be lost by adopting that model of care delivery. Her other suggestion was to identify the essential elements of the framework and the specific measures to move those elements forward. “If it is really extensive, I do not think we are going to be successful,” said James.
Sanderson did not have anything specific that he would change, but he wanted to emphasize collecting data on race, ethnicity, and language. One question he had was whether those should be administrative data or come directly from patient self-reports. Regardless of the answer to that question, he said that having a uniform way of collecting data would be the first step to being able to stratify the data and look for disparities using electronic health records. He noted that the HHS OMH is working with the Office of the National Coordinator for Health Information Technology to try to understand how to leverage or change the electronic health record to make those data more accessible to the providers who are inputting those data.
As an aside, he pointed out that the HHS OMH has compiled state legislative activities around the enhanced CLAS standards and provides that information on a state-by-state basis. This type of dashboard, said Sanderson, could provide peer-to-peer information that would enable health care organizations to compare their progress with comparable peers and learn from those comparisons. Currie endorsed this idea as something that would help drive change.
One suggestion Currie made, again from the perspective of an insurer, would be to create a centralized portal that would make the evidence base
for specific interventions available. Health insurance organizations and those that are in the business of facilitating and coordinating care could then have access to information that would enable them to work with providers to drive evidence-based care around evidence-based protocols. He also suggested establishing a systematic requirement associated with the recommendations for cultural competency training and to develop separate measures on whether an organization delivers culturally competent care and on member experience and satisfaction. “As we know, you can deliver quality care but not drive satisfaction, and conversely, you can be extremely satisfying to someone and deliver subpar care,” said Currie. “We need to determine how best to measure both of those because they are both important, and they go together in addressing health disparities in a systematic way.”
Gesten’s suggestion was for the framework to more explicitly address measures and approaches appropriate for payers, for integrated networks, and perhaps even for community-based organizations. He recognized that these are not mutually exclusive categories, but specifying subsets of measures appropriate for different types of organizational structures might help with implementation. In the same vein, he wondered if some of the issues of concern might be different in the delivery of acute care, chronic care, preventive care, and behavioral health care given the different challenges of navigating each of these sectors of the delivery system. He also wondered why there was no specific mention about issues related to substance abuse, mental health, or reproductive health and if there was a need to call them out in some manner. “I think in some cases they demand special attention and maybe even particular measures,” said Gesten.
One concern, which he said was mentioned in the preamble to the commissioned paper, was the problem of “measure madness” and the difficulty of choosing which measures to use when they are not mandated, even while there are so many measures that are not voluntary. “It is not clear to me how the framework helps to reduce or condense the number of measures,” said Gesten. “I understand the concept of integration, but I think it would be helpful as a document to more clearly demonstrate or show how use of the framework actually can lead to or support that kind of refinement or focus of measures.” He also noted that while the preamble does a good job of discussing value-based purchasing and the challenge of potential unintended consequences, it does not articulate how to use the framework as a way to mitigate or mediate those unintended effects.
VanAmringe said she would have liked the paper to have identified the different measures that have demonstrated high levels of effectiveness, as well as those that have not been studied at all, though she acknowledged that doing so would have made the paper very long. She also wished the commissioned paper had acknowledged the complexity of the transforma-
tion that would have to occur to implement the framework. “This is more than just a collection of activities. There is also a culture change that has to occur at the same time,” said VanAmringe. From her experience at the Joint Commission, she has seen how difficult it is to drive the culture change needed to achieve high reliability in health care that has a greater focus on zero harm. Achieving such a culture change requires a roadmap, she said, and the process requires several pieces. In the short term, she said, there needs to be a prioritization of the activities that will exhibit new behaviors and reinforce the new culture. Also needed are process improvement changes that embed the most essential changes needed into the day-to-day practices within an organization so they become the natural thing to do. It also requires the use of change management to ensure that the changes are durable and sustainable. In her opinion, it will be important to stress that there will be a maturation process involved, that not all organizations are going to be at the same place, and that an identification of the steps to take to move from a low level of maturity to a higher state is necessary. It is also important to show what the end state looks like when organizations have an embedded culture of equity and actually engage in the desired activities.
WHAT DO YOU THINK IS THE RIGHT BALANCE OF STRUCTURE, PROCESS, AND TYPE OF OUTCOME PATIENT EXPERIENCE MEASURES?
Sanderson responded that while the most important consideration is clinical outcome, “measures for outcome (from literacy, cultural competency, and language interventions) are few and far between and probably the most difficult thing would be to use the (current) structure we are proposing to figure out outcome.” From the perspective of what will have the greatest utility, he said, the structural measures would carry the most weight. “As we make the structure more uniform, then down the line we will see the outcomes we are looking for,” he predicted. He also noted that aligning business interests, patient safety, and quality interests comes down to the bottom line. The HHS OMH, as well as other federal offices and agencies, have been trying to implement and adopt the CLAS standards since 2000. “We do not have any regulatory authority or mandate to make them happen, so we have to make sure that we align the positive things that are within those standards to things that a health care organization would do anyway to improve their patient care services,” said Sanderson.
Currie said that structure is going to morph and needs to be adapted based on the particular organization that is trying to integrate these concepts in how they do what they do and serve who they serve. Therefore, he believes that outcome measures are the most important from his perspective as an insurer because outcomes can be used in evidence-based protocols
deployed within the culture of his organization and permeate those areas associated directly with the service it provides to its members.
Gesten agreed with Currie that outcome measures matter most because the bottom line, as is the case with patient-centered care, is that “you are not there until the patient and family says you are there, until they decide they have received culturally competent care.” That said, he believes there is a point to structure and process outcomes and that those have a role to play together with outcome measures in driving organizational change. For Gesten, the structural components analyze the capacity, the intent, the will, the infrastructure, and the resources, and the organization has to do the right thing. Process measures, he said, evaluate whether an organization was able to draw on those resources, intent, leadership, and policies to build a culture of equity. “It is hard to think about trying to improve on outcomes if you do not have access to the structural measures or the process measures,” said Gesten. “We do not talk about this much, but I think structure and process measures can help the delivery system try to figure out why it is getting or not getting the outcomes it wants.” Toward that end, he said that the domains in the framework are instructive and helpful for thinking about improvement. Outcome measures, he added, are the ultimate test of whether change has produced the desired result, and in the end there needs to be a balance of structure, process, and outcome measures.
VanAmringe agreed that all three types of measures are needed and, if done well, will inform each other. “If you find out that the outcomes are not what you had hoped, you may see that you need to make some different structural changes in what you are doing,” she said. The balance of the three types of measures will change, she added, depending on which problem an organization is trying to solve. However, she noted, getting the right balance will be a moot point unless organizations are able to collect reliable and valid data with good denominators. For example, people often equate preferred language with limited English proficiency, but they are in fact two different things. Measuring the wrong one will provide inaccurate information about how many people need translation services. James suggested that one structural measure could assess whether an organization is capturing the right data.
James then commented that it is important to identify the goal for the framework. The discussion so far, she said, has identified equity as an end goal, but it also delved into the provision of culturally and linguistically appropriate services and addressing health literacy needs. Deciding on an end goal will help determine what the balance of measures should look like and which measures should be selected, she said. The other issue she discussed was burden and how to ask people to participate in the process of gathering data on patient experience. Patient experience is important to measure to provide a different perspective from that of the provider or the organization.
Currie responded that he was not sure how UnitedHealth Group would use this framework. “What we would do is evaluate it and assess it and its applicability in the various businesses that we have to determine how we best leverage whatever pieces of it we think are cost-effectively leveragable to drive the desired result,” said Currie. “If there are things within the document that can help us cost-effectively drive individuals and motivate and engage and outreach with individuals to live healthier lives, we incorporate those. If they are not cost-effectively leveragable, we do not.”
Speaking from his past experiences with the New York Department of Health and what he thinks states, in their role as purchasers and regulators, can do with the caveat about data limitations, Gesten said the ability to stratify quality metrics with some transparency would be a positive use of the framework. In his opinion, clearly integrating measures and quality improvement work into value-based purchasing strategies is a way to create the pressure or traction to adopt these measures. He noted there are efforts to make elements of the PCMH requirements related to the issues of language, cultural competence, and language access services a must-pass element in the language of NCQA. He also said that the structural aspects of the framework lend themselves to thinking about contractual requirements. One of the strengths of the domains in the framework is that they point to the breadth of activities required to make great things happen. At a more focused level, organizations that are not doing well on issues of equity can use these standardized quality measures to identify where they need to improve and what evidence-based interventions they need to use to make improvements.
VanAmringe noted that the Joint Commission has a number of programs that cut across many of the ideas in the commissioned paper, including measurement programs, accreditation standards, safety goals, and primary care homes and integrated programs. “This report has given us a great deal to chew on, so it is a wonderful start,” she said, adding that she is looking forward to the future planned report on implementation. VanAmringe reminded the workshop that the Joint Commission is an accrediting body with boots on the ground to see that requirements have been implemented. “This is an important construct because it is not just putting things out there and hoping people are complying,” she said. To evaluate compliance, her organization heeds standards and requirements that are easy to evaluate on site. “We need achievable standards and I think this report is a good start on that,” she added.
In 2017, the Joint Commission conducted a project to see where it can improve on disparity issues, including those it introduced more than
a decade ago on cultural and linguistic competency standards. “We are always looking to see where we can improve on those and I think some of the domains and constructs in the report will be useful for us to consider,” said VanAmringe. Another ongoing activity that might benefit from the ideas in the framework is exploring the use of patient tracers to follow patients who need language services and see how well an organization does at providing those services throughout the patient’s care experience.
VanAmringe said that the Joint Commission is especially interested in structural standards that can help it understand how to put in requirements to measure whether an organization has achieved this integrated approach. Toward that end, she hoped that the next report would include examples of such measures, as well as best practices for applying those measures. As a final point, she said that measures must be cost-effective for organizations to deploy and use to identify the most effective actions they can take. “We have to be very conscious of the economic system out there,” she said.
James commented that the proposed framework affirms some of the activities that the CMS OMH has under way, such as stratified reporting in the Medicare Advantage program. She noted that her office had been developing a portfolio of work called Building an Organizational Response to Health Disparities that aims to provide tools that providers can use to address disparities. The framework might also help with her office’s ability to have continued conversations about MIPS as a means of achieving health equity and how to put more of a health equity focus into its work, as well as with her office’s work with Medicare Advantage plans to support their efforts in the equity space. In her opinion, the framework provides some additional directions to think about with respect to developing tools to support those organizations that are trying to achieve health equity.
Sanderson echoed James’s comment about the framework being affirming. “To read the report and see the number of times the national CLAS standards are referenced is particularly heartening,” he said. In his opinion, the framework provides additional weight behind efforts to get buy-in from senior leadership in a health care organization or to convince the Association of American Medical Colleges to make sure cultural competency is included in medical school curricula. “This report is going to be helpful for us,” said Sanderson. He added that these measures will also help its work with the RAND Corporation that identifies specific outcomes of the structural and procedural elements it puts in place.
Before asking Gesten for his response to this question, Bakken noted that the panelists had already started answering this question in their previous comments. Summarizing those earlier remarks, she said she heard the
need for an information technology infrastructure, evidence, a roadmap, incentives, tools, and technical assistance. Agreeing that those are important for implementation, Gesten added there is also a need for benchmarks so that organizations know what score on a measure represents something good. He also called for testing how measures perform with respect to accountability and utility for the intended purpose and audience. Another need is a framework to integrate the results. “The reality is, you have results, but how do you put them together? What do they mean?” he asked. “The more measures you have in a particular area, the less likely it is that all the arrows are going in one direction and the more work that has to be done to interpret them. I think that is an area in which more work is needed,” said Gesten. Another area of need concerns CHWs. Though CHWs can address many issues facing the health care enterprise, they are a means, not an end, said Gesten. While there is existing evidence to support the value of CHWs, the quality of care they deliver is likely variable (like all health care providers) and could potentially benefit from quality measures if only for purposes of improvement, if not accountability, he said.
VanAmringe said she would like to see more information identifying good practices and cost-effective practices. James said she would like more information on why already existing measures are not being used and why people choose certain measures and not others. Sanderson said there needs to be significant community engagement to obtain input on the type of measures community members find valuable for this integrated approach to work. Currie, making the final suggestion, asked for guidance that is relevant to the health insurance industry and that would provide a comparison against similar organizations. Such guidance would identify who is doing well, and, more importantly, what they are doing well.
William Elwood, commenting on the need for measures relevant to CHWs, noted that they were deployed as part of President Lyndon Johnson’s Great Society programs and suggested that it was likely some of the quality assurance and effectiveness measures developed at that time might be useful today. He then asked the panelists if they had ideas on what type of research is needed to reduce redundancies and ensure that the measures are answering important questions. James said that she was interested in having research aimed at matching existing measures to the domains in the proposed framework as a means of reducing redundancy. She also would like to see research exploring how organizations with a PCMH designation perform on CAHPS measures for communication and patient experience compared to organizations without that designation.
Sarah Scholle, one of the co-authors of the commissioned paper,
responded that there is evidence that PCMHs can improve the experiences of care for their patients. The question that investigators are looking at now, she said, is whether that improvement is consistent across different populations, and if not, what factors explain that inconsistency. One of the challenges of this research is that payers and states are giving organizations substantial flexibility as to how they achieve the PCMH designation, and she said that having effectiveness measures could provide purchasers with leverage to require that certain standards are met by all PCMHs.
Bernard Rosof noted that little work has been done looking at diverse populations and outcomes in PCMHs, accountability organizations, or other similar organizations. When Scholle said that is because the data are not available to ask that question, Rosof responded, “That is always a good excuse, but we are not going to have the data unless we ask for them.”
Sanderson replied to the research question by saying that he would like to see it in two areas. The first would examine whether quality measures can be used to account for social determinants of health in risk-adjustment models. The second would aim to quantify the benefits of deploying culturally competent CHWs and identify the features that account for those benefits.
Brach remarked that one of the main purposes of this activity is to reduce disparities, and there are two schools of thought on how to do that. One school focuses on trying to make sure that all providers deliver appropriate care for the populations they serve and that they are not disadvantaging certain groups. The second approach is to target those organizations that serve a large proportion of vulnerable and disadvantaged individuals and try to improve quality at these underresourced places. Given those two possibilities, she asked the panelists if they had any ideas on targeting implementation. “We tend to think that we are going to have a payment incentive for everybody, but are there ways in which we could try to target places where we could get the most benefit for the vulnerable populations that we are thinking about?” she asked.
Sanderson replied that the second approach would be the most efficient way to allocate limited resources and get the biggest benefit, and the key will be having demographic data to help identify hotspots based on income level or language proficiency level. That type of stratification is possible, James added. “I think we have some evidence that some vulnerable populations are clustered in organizations that may be providing lower-quality care across the board,” said James. “As we think about the resources it takes and what they have in terms of their ability, interest, and support for implementing a framework such as this, I think this is something we would need to look at.” Her only caution is that it will be challenging to change the culture of these organizations so that it becomes second nature to think
about health literacy, cultural competence, and language access services when providing care.
Given the generally low level of health literacy in the United States, VanAmringe said she believes it is imperative to make sure every organization is “up to snuff as much as possible.” Having said that, she added that there is nothing wrong with thinking locally and focusing resources on specific organizations. She also noted that the tendency in this country is to focus resources on cutting-edge organizations to enable them to do more research and innovate, while those organizations that need additional resources are left to struggle. In her opinion, Brach’s second approach affords the opportunity to have a bigger impact on large populations experiencing health disparities.
Rosof pointed out that in specific zip codes, vulnerable populations seek most of their acute, after-hours care in emergency departments, and he wondered how often programs to address equity, health literacy, cultural competence, and language access services reach the emergency department. James did not address emergency departments but noted that there are organizations collecting data on language, transportation needs, day care needs, social risk factors, immigration needs, legal needs, and other factors that might help support patients. In her opinion, the proposed framework combined with those data should afford the opportunity to improve health outcomes and improve health equity.
Sanderson agreed with Rosof that the emergency department is an important setting in which vulnerable populations receive care, and as an example, he noted that individuals with sickle cell disease often go to the emergency department. The HHS OMH is trying to leverage electronic health records so that the providers who see these patients have the information needed to provide them with the best care. He also said that it is surprising to him how many emergency room physicians are in the health policy space. “They understand that the policies that come from government and other entities are very important in terms of the quality of care they are able to provide,” said Sanderson.
Andrew Pleasant from the Canyon Ranch Institute asked whether there is enough evidence and proven methodologies to justify allocating resources on implementation planning. Gesten replied that he believes there is enough evidence, though the discussions have not spent much time reviewing the evidence. He acknowledged that the framework is probably not complete, that it needs some tinkering, and that it will not be the only answer, but it can contribute meaningfully to address gaps in care and health equity. Rosof stated that the purpose of this workshop was to bring forth information that would help finalize or at least reframe the document. To that end, Rosof said he heard mostly constructive criticism aimed at making the framework workable. As a final comment, Kelly said she believes that there
is an opportunity to step back, look at the framework, and identify what gaps exist. In her view, the goal should be to identify existing measures that would fill these gaps and offer the possibility of combining measures to avoid measurement overload, rather than looking for new ones.