Measuring Quality, Part 1: Why Members Aren’t Getting Matched With High-Quality Care

Categories: E-Books, For Employers, Quality

This white paper was co-written by Sasha Small and Nate Freese.

 

Throughout the COVID-19 pandemic, 33% of Americans canceled or postponed upcoming medical appointments. However, 97% of those who canceled appointments plan to return and visit an in-person provider when doctors’ offices reopen across the country. Given the scale of the disruption to care, it will be more important than ever for members to find care that’s high-quality, appropriate and tailored to their clinical needs. This will ensure the kind of return to care that we all want for our families, friends and colleagues.

According to a recent JAMA report, unnecessary and inappropriate care makes up a quarter of total healthcare spending in the U.S. Not only does this account for a good portion of the waste taking place in our healthcare system, but it also means that a significant number of patients all across the country aren’t receiving the best care possible—and in many cases, may be seeing sub-par doctors who are putting their patients’ health at risk.

1 McKinsey

The Problem: Members Aren’t Connecting to High-Quality Doctors

 Based on our research at Grand Rounds, the problem is less about having a sufficient supply of high-quality doctors and more about matching members to the right care when they need it. Certainly, there are some parts of the country—specifically, sparsely populated rural areas—where quality healthcare is scarce. However, in most regions of the U.S., members just aren’t connecting with high-quality doctors available in their network who are specialized in treating their specific condition. 

Too often, members select a physician based on word of mouth, an online search, or one conducted on their insurance carrier’s provider directory. Lacking the proper tools to effectively refine their search to match their specific needs, members risk settling on a doctor who may not only be unqualified but unsafe in their prescribing practices and protocols as well.

 

Pitfalls on the Path to Effectively Measuring Quality Care

An ever-growing number of players in the healthcare industry recognize this matching problem. As a result, they’ve begun to look for ways to better measure and compare doctor quality as a means of reducing waste as well as ensuring that members are able to achieve optimal health and well-being. The path to reaching the goal of effectively measuring quality, however, is still full of pitfalls. There is:

  • Still too much emphasis on surgical outcomes, rather than the effective use of nonsurgical procedures and healthcare management by a PCP.
  • Lack of adoption of leading-edge technology, specifically around machine learning.
  • An over-reliance on static doctor ratings, which doesn’t necessarily map to members’ unique situation and needs.

Considering that a whopping 2.4 million people in the U.S. visit their doctor’s office on a daily basis, it’s imperative that these issues are addressed as swiftly as possible.

 

Stay tuned for our next installment of this blog series on measuring quality. In Part 2, we’ll get into how we at Grand Rounds measure and define physician quality.

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