The third case study from our recently published book chapter in Service Business Model Innovation

As we a couple weeks ago, M2HCC authored a chapter entitled “Essential Characteristics of Service Business Model Innovation in Healthcare: A Case-Study Approach” in Service Business Model Innovation in Healthcare and Hospital Management published by Springer. Today we share highlights from the third case study we feature in the chapter.

The Massachusetts General Physicians Organization

The Massachusetts General Physicians Organization (MGPO) is a multi-specialty medical group that provides patient care, teaching, and research in partnership with the Massachusetts General Hospital and in cooperation with Partners HealthCare. Several of the hospitals in the Partners HealthCare system, including the Massachusetts General Hospital, are teaching affiliates of Harvard Medical School.

We talked with Dr. Daniel M. Horn, Assistant Medical Director for Ambulatory Quality at the MGPO whose work is focused on the next steps in quality in his role leading efforts to improve the quality of care for 160,000 patients across 21 primary care practices.

Quality measures and the binary fail

Measuring quality is a building block for payment and delivery system reforms, such as accountable care, integrated delivery, shared-savings or value-based approaches. However, there is a difference between true quality of care and quality measures. Improving patient outcomes is likely to represent high quality of care, but how would that be measured?

At MGPO, the organization is using the current “binary fail” method of measuring quality as an opportunity to build trust. For example, most healthcare providers are in some way subject to quality measures designed for health plans called the Healthcare Effectiveness Data and Information Set (HEDIS). Dr. Horn used the example of the HEDIS measure for controlling blood pressure to explain the problem of the “binary fail.” Heart disease and stroke is the leading cause of death in the U.S., and because high blood pressure (hypertension) increases the risk for heart disease and stroke, there is no question that controlling high blood pressure is important. What is at issue is the way providers are measured on the concept of “controlling.”

Controlling high blood pressure, according to HEDIS, is the measurement of the percentage of patients 18–85 years of age who had a diagnosis of hypertension and whose blood pressure (BP) was adequately controlled during the measurement year, for example, by showing the patient’s blood pressure was less than 140/90 mm Hg. In a clinical practice, this means the denominator is the number of patients who come into the practice in the first 6 months of the year where the clinician submitted a bill with the appropriate ICD-10 code related to an abnormal blood pressure reading without a hypertension diagnosis, and the numerator is the number of patients who come into the practice in the second 6 months of the year and have a blood pressure reading below 140/90 mm Hg.

Even a non-clinical reader can quickly see various patient scenarios that would fall outside of this narrow consideration of the quality measure called controlling high blood pressure; hence, Dr. Horn’s pronouncement that the HEDIS measure creates a binary fail for measuring the control of a patient’s blood pressure.

Building trust, then, is accomplished by rewriting the measures with an algorithm for all of your patients. MGPO developed a measure that is clinically valid and acknowledges what the clinician knows, which is that it might have taken 18 months to control a patient’s blood pressure, for example.

Dr. Horn explained that building trust and cooperation in order to achieve service business model innovation requires: 1) Building better quality measures; 2) Changing the mentality; and 3) Providing usable data.

Build better quality measures

Dr. Horn explained that in response to the changing healthcare environment, and in an effort to build trust with clinicians to show that their work and interest in patient care is paramount to the organization’s success, MGPO addressed the gap between payer-defined measures, such as HEDIS, and clinically valid and meaningful quality measures. His team, in close cooperation with other clinicians, has helped the organization rewrite measures used internally so they would be clinically valid in the healthcare provider’s point-of-view. “We have electronic health record (EHR)-based data sets to manage clinical care, so let’s build better measures, then maybe build that into contracts,” said Dr. Horn.

Change the mentality

Thinking first about how clinicians work and why they choose to serve patients, meant changing the rhetoric and mentality around payer-driven measures. Dr. Horn explained, “We want to empower you to do this work and we want to define it in clinically meaningful terms.” By doing this over the past 3 years, the system is, in a way, divorcing itself from the market-driven quality measures when it comes to thinking about true quality and patient outcomes

Provide usable data

Trust is also bolstered when data being used to measure quality and performance is actually usable. Clinicians are more likely to trust data with three characteristics, according to Dr. Horn. First, it must be reliable. Second, the measurement criteria being used “must represent something they believe in as a physician.” Third, the data must be timely. To incentivize behavior change, showing a clinician or clinical practice information from 6 to 12 months ago is simply too old. The data should be real-time, valid and represent clinician values. In Dr. Horn’s experience, showing data that has even a single mistake or two is enough to create some distrust with clinicians.

As we grapple with ways to improve health care quality and lower costs, the MGPO approach to quality measures is certainly an innovation. To create truly accountable care, quality measures that are valid, valued and usable by clinicians are needed to improve the provision of primary care.

*Daniel M. Horn, M.D., is the Assistant Medical Director for Ambulatory Quality at the Massachusetts General Physicians Organization (MGPO). Dr. Horn is also a primary care physician and Unit Chief at Internal Medicine Associates, where he provides comprehensive primary care and helps with day-to-day leadership of the largest primary care practices at Massachusetts General Hospital (MGH).