Health status can be defined succinctly as, “the range of manifestation of disease in a given patient including symptoms, functional limitation, and quality of life, in which quality of life is the discrepancy between actual and desired function.” 1 Physicians spend their lives focused on the diagnosis of patient symptoms and, since clinical classification models are primarily structured for and by physicians, most models measuring variation in population health rely on reported diagnoses. Functional limitations, limitations in activities of daily living (ADLs) or instrumental activities of daily living (IADLs), are measured (either by the patient or the health professional) by a variety of tools utilizing a variety of scales.
Recognizing the importance of functional health, we have incorporated functional health measures into both our Clinical Risk Group and Patient-Focused Episode classification methodologies. We identified interaction between functional health domains (Mobility, Self-Care, Incontinence and Cognitive Impairment) with enrollee costs both within functional domain severity and with underlying chronic conditions.2 We also identified variation in cost attributed to functional status groups when examining episodes of illness or bundled payment.3 The insertion of functional status into diagnosis-based risk-adjustment is therefore feasible, can improve equity in payment and can overcome the variable and incomplete nature of reporting functional status.
The measures we cite, while important, address only the static picture of enrollee health. They observe a variation in enrollee cost associated with a snapshot of functional limitations and target payment accordingly. We have long held that changes in health status are an important dimension to track, both for those interested in linking outcomes quality to payment and those that are trying to understand how differences in approach can lead to better long-term outcomes. It is for this reason that we have outlined the use of changes in CRG status, derived by diagnoses, as a suitable measure for rewarding long-term outcomes to managed care plan payments.4 In future blogs we will also discuss the impact of health care and non-health care interventions on health status.
We also expect risk-adjusted changes in functional limitations to be the direct result of treatment – particularly for surgical interventions. Put simply, we should expect similar patients undergoing similar procedures to achieve similar outcomes, not simply the absence of complications or readmissions but the return to desired function. This is the “quality of life” component that patient-centric care needs to address. This can be measured using comparative rates, produced under standardized measurement, which are both tied to payment and publicly reported. Payment provides incentives for all stakeholders to come together as a team to do better. Comparative reporting enables providers to both know when they are doing poorly and where to look for those that are doing well.
The incorporation of measures that examine changes in health status and the use of transparent, comparative rates for patient outcomes (i.e., return to desired function) will both improve overall health and quality of life for patients while creating more equitable payment for care delivered. This approach can help us move beyond the rhetoric of patient-centric care and surveys of patient satisfaction to the use of patient-centered outcome measures that truly improve patient lives.
Richard Fuller, MS, is an economist with 3M Clinical and Economic Research.
Norbert Goldfield, MD, is medical director for 3M Clinical and Economic Research.
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¹Rumsfeld JS. Health Status and Clinical Practice: When Will They Meet? Circulation. 2002;106(1):5-7. doi:10.1161/01.CIR.0000020805.31531.48.
²Fuller RL, Hughes JS, Goldfield NI. Adjusting population risk for functional health status. Popul Health Manag. http://www.ncbi.nlm.nih.gov/pubmed/26348621.
³Vertrees JC, Averill RF, Eisenhandler J, Quain A, Switalski J, Gannon D. The Ability of Event-Based Episodes to Explain Variation in Charges and Medicare Payments for Various Post Acute Service Bundles.; 2013. http://www.medpac.gov/documents/contractor-reports/sept13_episodebundle_contractor.pdf?sfvrsn=0.
4Fuller RL, Goldfield NI, Averill RF, Eisenhandler J, Vertrees JC. Adjusting Medicaid Managed Care Payments for Changes in Health Status. Med Care Res Rev. September 2012. doi:10.1177/1077558712458540.