How are Standards of Care Used?

Public reporting: Providers and health plans are making quality measurement data available to the public in an effort to increase provider accountability and to help consumers make informed choices about their providers of medical care. As an example, the Centers for Medicare and Medicaid Services (CMS) provides quality data for hospitals treating Medicare patients on its Hospital Compare website. CMS also reports quality data for the Medicare program on nursing homes, home health agencies, and Medicare Advantage plans, as well as some others. And as we have seen in the last few years, private health plans are also reporting provider performance on quality measures, combined with price and cost data.

Provider incentive programs: Adherence to standards of care-derived quality measures are frequently used to award performance-based bonuses and penalties to providers. For example, rather than paying providers for the volume of care they deliver or the number of patients they care for, payers now frequently link payments to the quality of care that is delivered. And different payment models from the traditional fee-for-service, including accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), use quality measurement as the principal method of allocating payments to their providers.

Accreditation and certification: Now let’s examine accreditation and certification: Standards of care are frequently used as the basis for many of the quality measures used by organizations like NCQA and JCAHO in their accreditation or certification of providers and health plans. And the Affordable Care Act specifies that all qualified health plans sold in their marketplaces be accredited or certified by one of these organizations.

Using the Standard of Care to Measure Performance

So, once the standards are in place, how is the performance of those using them measured? Are they accurately adhering to the standard? Is there a measurable improvement in the quality of care provided? And how do you measure that?

Assessing Quality of Care

The quality of the health care given by a provider can be judged by its outcome, the technical performance of the care, and by interpersonal relationships.

For our purposes here, we can define an "outcome" as a change in the patients' health such as a reduction in pain, relapses,. or death rates. Outcomes can be measured for individual medical providers, or by studying larger medical practices or other forms of providers, like home care companies. There have been significant initiatives undertaken to improve healthcare quality outcomes that include clinical practice guidelines, cost efficiency, critical pathways, and risk management.

Results suggested that this simplified tool could be considered to score patient experience in the hospital setting. Authors suggested expanded testing to assure its usability as a management tool through the ability to discriminate between different patient experiences at a ward or unit level. While this type of tool may be used for internal organization improvement, other tools are used to rank patient experience and care quality in an effort to provide transparency to consumers who may have a choice of health care providers.

Clinical Practice Guidelines

Clinical Practice Guidelines define "technical performance" or the extent to which a provider adhered to the standard of care. By having providers follow established standards of care it is assumed that the quality of that care will increase, while lowering costs and realizing better outcomes. Technical performance is measured from the perspective of quality of care without regard to the actual outcome. By way of explaining, a provider who follows a standard of care to the letter, but does not see the patient’s health improve is still scoring high in technical performance. A Cochrane review found that computer-generated reminders improved doctors' adherence to the standard of care (technical performance); but lacked evidence to determine if this improved outcomes.

Risk Management

One aspect of the provision of care that is influenced by the incorporation of standards of care is that of risk management. While we assume that a provider wants to provide the best care possible, and wants to do so in the cheapest way possible for the payer and the patient, the idea of risk management says that a provider will minimize their exposure to medical malpractice litigation through the use of defensive medicine.

Defensive medicine introduces the idea that providers will order additional imaging, for instance, to make absolutely sure that the procedure they are going to perform is necessary and is the correct thing to do at this particular time. This diagnostic imaging is costly, and can lead to other treatments which are ancillary to the patient’s current medical need. Some of these treatments may be dangerous for the patient as well, which only adds to the importance of risk management approaches including cost efficiency guidelines along with their standardized practice guidelines.