Decades of quality measurement efforts have improved health care processes but not outcomes because a key factor – equity – has not been an integral part of those efforts. The health care delivery system of 2024 needs an overhaul to provide all patients the care they deserve, said Karen E. Joynt Maddox, MD, MPH, FACC, during her ACC.24 James T. Dove Keynote.

"Health reform focused on quality measurement has not been successful in improving health because it has micromanaged and focused on the wrong things – check boxes rather than relationships," said Joynt Maddox, a practicing cardiologist at Barnes-Jewish Hospital and co-director of the Center for Advancing Health Services, Policy and Economics Research at Washington University's Institute for Public Health. "Administrative burden and financial pressure have driven our health system in the wrong direction."

Measurement Morass

The burdensome administrative process is one of the biggest problems, consuming 25% to 30% of health care spending in the U.S., according to Joynt Maddox.

"This is a very different health care infrastructure than we had just 20 to 30 years ago. This administrative complexity is untenable," she noted. "If you take into account all the different ways all the different payers measure all the different things, there are thousands of ways we are requiring people to measure and report quality."

The idea of measuring treatment quality started in the 1950s with the introduction of minimum standards. In the early 2000s, the Hospital Quality Alliance, a public-private partnership, led hospitals to measure their actions to improve cardiac treatment for diseases such as acute myocardial infarction and heart failure.

In 2008, hospitals began reporting their data publicly. While there may have been some improvement in care, or at least documentation, and probably improvement in quality, it became clear that all of these steps didn't improve outcomes, said Joynt Maddox.

Value-based payment didn't improve outcomes either, even though it was introduced in 2011 based on the theory that financial incentives would make a difference. Importantly, she noted that, "nothing in value-based payment addressed access or equity."

"We have persistent, profound health inequities in this country. We have known about these problems this entire time. This is not news to anybody in this room, yet we have no progress," said Joynt Maddox.

What's Next?

What the efforts to report and analyze treatment data did accomplish was the corporatization of cardiology, According to Joynt Maddox, all the coding required to report treatment data has helped increase administrative spending 1,533% since 1970.

"Private equity is excellent at these sorts of things," she said referring to coding. "While I think there are some excellent things private equity can bring to cardiology in terms of thinking about different ways to deliver care, there is a profit motive that is very very different than how we all grew up learning how to practice."

Noting the untenable administrative costs, Joynt Maddox suggested solutions to improve care delivery must "honor values beyond the check box," including belonging, relationships and wellness. Specific actions include developing ways to explicitly measure and incentivize team-based care, longitudinal care and community-based care, as well as including clinicians from excluded groups and geographic areas to ensure care is delivered to people who need it.

Health policy is also a "crucial tool" to improve outcomes in cardiology, provided it's used the right way, she said. Specifically, Joynt Maddox noted policy solution to improve care should:

• Prioritize and reward access, outpatient care, and the highest risk groups
• Provide resources to historically marginalized groups rather than take them away
• Bake data and quality into the norms, then free up clinicians to care for patients in innovative ways
• Leverage clinician and patient engagement rather than thwart it

"Health outcomes are not only about health care quality and access," Joynt Maddox stated. "We need to acknowledge as clinicians that health is much broader than checking the boxes in clinic and we need to advocate for health for our patients even when that feels broad."

Clinical Topics: Cardiovascular Care Team, Prevention, Stress

Keywords: Cardiology Magazine, ACC Publications, Health Equity, Health Care Reform, Financial Stress, Delivery of Health Care, Public Health

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