Key players in health care are focusing on the outcomes of care. Their efforts show momentum. But momentum alone does not fire the health care “Buy Right” reform I advocated in a previous piece. To move across the board from process and documentation-based pay-for-performance to timely, risk-adjusted — outcomes grounded — payment is not just a heavy lift; it runs against the grain of the system as we know it.
Three critical path actors have taken aim at reframing. CMS’s Innovation Center (CMMI) has a committed pathway to people-centered outcomes and is developing models. The National Committee for Quality Assurance (NCQA) is going digital with HEDIS by 2030. And the Joint Commission has cut over 700 requirements, shortening manuals and shifting from safety goals to performance aimed at measurable outcomes.
All well intentioned. Most of it is necessary. But it won’t get us to Buy Right. The momentum is real — but so are the silos. Three stand in the way.
First, separate value lanes. Those lanes make sense in our pluralistic health care system with private and public sector roles — accreditation, licensure, rating, utilization review, and payment. But the outcomes should be the outcomes. We lack a common vocabulary for outcome measures — defined once and risk adjusted. Currently there is just a maze. A whole industry of vested interests benefits from the measure status quo: a quality measurement industrial complex with vendors, measure developers, consultants, accreditors, reporting platforms, all with much to protect. Even Medicare’s own Quality Improvement Organizations (QIOs) are there to help clinicians and providers navigate the maze.
Second, the statute stifles. The main actors in the system can move but cannot compel. Yet the one actor who can compel cannot move: Medicare’s mainline quality programs are fixed by law. Retiring an exhausted readmission measure takes an act of Congress. Even where Medicare has the prerogative for experimentation in its CMMI, the agency can only move model-to-model — piecemeal and cumbersome. The single platform needed for measures that matter — the outcomes — eludes because Medicare cannot truly reform itself.
Third, digitization. Digitization is essential. But it is also setting the status quo in concrete, and the concrete is now pouring. The FY 2027 IPPS final rule issued July 31 sets providers on a pathway to digitize the current measure set as does the CY2027 PFS that is proposed for physicians. The regulatory process going forward for hospitals is final, the results are mandatory for hospitals by the CY2028 reporting year and clinicians are still to comment. At the same time CMS is asking for comments on the next generation of reporting where the needed information almost in real-time can be pulled from the electronic health records. Presumably the new approach would be low cost for providers and clinicians as well as offering a means for timely outcomes reporting. But even if the new approach goes forward its suggested start is FY2030. So, the digitizing must proceed while a different future is held out by the regulatory comments due September 14. Confusion abounds, but there is a larger strategic concern here. The issue is not just two costly builds for providers, clinicians, patients and taxpayers. Are we simply going to settle for digitizing the status quo?
Way forward. Buy Right depends on outcomes but it faces a maze, a frozen statute, and wet concrete. CMS, NCQA, the Joint Commission, and other thoughtful leaders are the momentum. But they lack the architecture for moving to a single platform, a common set of outcome measures — defined by the best medical science and what patients can rightly expect. And when reporting goes digital, who will hold the keys to the arithmetic — providers, vendors, or CMS and the payers? The framework can only come from Congress. The largest silo is current law and only Congress can bring it down. The policy needs to be dynamic by design rather than static by statute: a platform working across payers drawing on electronic records and claims in real time. Technology is there; data is there. Is there will for a reset?