Quality: The Untapped Potential in Strategically Aligning Professional Organizations with Payer Value Frameworks | Part 1 of 3

Why Quality Measurement Has Not Delivered on Aspirations and Why Professional Organizations May be the Answer

Healthcare has spent decades and billions of dollars trying to measure its way to quality. The results have been underwhelming at best, and quietly destructive at worst.

The ambition was sound: if we can quantify quality, we can reward it. If we can reward it, we can accelerate it. But somewhere between the clinical guideline and the payer contract, something fundamental broke down. And unfortunately the organizations built to fix it including  NCQA, the NQF, AHRQ and other have not been able to create the level of transformation needed in the system.

This is the first in a three-part series exploring what went wrong, why FHIR-based interoperability changes the equation, and what professional medical organizations are uniquely positioned to do about it.

The Fragmentation Problem

The original sin of American healthcare quality measurement is fragmentation. Professional organizations, payers, accrediting bodies, and government agencies have each built their own quality ecosystems, often measuring the same conditions with subtly different specifications. The result is a measurement landscape where the same provider can look high-quality on one scorecard and mediocre on another, not because care changed, but because definitions did.

The National Quality Forum (NQF) was established specifically to prevent this proliferation. There are now endorses over 400 endorsed quality measures and some may say the quality problem remains elusive and seemingly compounded.

This isn't a criticism of the people involved, but rather a structural critique. Fragmented governance produces fragmented output. And fragmented output produces administrative burden with unclear proportional clinical benefit.

The Claims Data Dead End

Alongside fragmentation sits a second, more insidious problem: the persistent reliance on administrative claims data for clinical quality measurement.

Claims data were designed for billing. They capture what was done and what was charged. They do not capture why, how well, or with what clinical context. When quality measure developers use claims as their primary substrate, they are forced to approximate populations using diagnosis codes that lack the clinical granularity of the original guideline. A guideline might define a patient population using ejection fraction, biomarker thresholds, or symptom severity scores. A claims-based measure must approximate that same population using ICD codes. The result is systematic misclassification based on data asymmetry, which may be at the root of payer-provider abrasion in many cases.

Research makes this concrete: studies have found that between 27% and 94% of hospitals classified as high-quality using administrative data were reclassified as intermediate- or low-quality when richer clinical data sources were applied. For a system making payment and public reporting decisions on these classifications, that is not a measurement error, yet more of over-indexing on measures of perceived value and with consequence at scale.

The "streetlight effect" seems appropriately applied in this case. We've been measuring where the light is, but maybe not where quality actually lives.

Burden Without Benefit

The downstream effect of proliferating measures built on flawed data is a system that imposes enormous costs on providers without clear return. Primary care practices carry the weight of thousands of electronic clinical quality measures (eCQMs) developed by independent groups, many of which are inconsistent with actual clinical guidelines. Clinicians and embeded clinical quality auditors spend time on measure compliance that could be spent on care.

Analysis of AHRQ's quality indicators found that just seven of them account for 93% of total measurable population health benefit. The rest  (hundreds of measures demanding documentation, abstraction, and reporting) account for 7%. This is not a portfolio problem. It is a misallocation crisis.

Marginal Incentives, Marginal Results

Perhaps most damning is that the programs built on this measurement infrastructure haven't worked. Research on Medicare's Hospital Value-Based Purchasing program found no evidence of improved clinical process or patient experience measures in its first nine months, and no reduction in mortality in its first thirty months. Systematic reviews describe the impact of value-based purchasing broadly as "mixed and far from convincing."

The critique is not that value-based payment is wrong in principle. It's that value-based payment layered on top of flawed measurement, inadequate data, and marginal incentives produces marginal results.

Why Professional Organizations Are Different

Professional medical organizations occupy a unique position in the healthcare ecosystem. They hold clinical authority, guideline ownership, specialty registry infrastructure, and the trust of the clinicians they represent. These are exactly the assets that measurement organizations like NCQA and NQF are adjacent to and exactly the assets needed to build quality frameworks that actually work.

Where NCQA was formed largely by purchasers seeking accountability, whereas professional societies are formed by and for clinicians. Where NQF has accepted measures from multiple competing entities with different methodological standards in the past, but potential future could be led by Professional Organizations that build integrated frameworks where architected measures could flow directly from evidence-based guidelines.

The failures of the current measurement system are not evidence that quality measurement is impossible. They are evidence that quality measurement done without clinical ownership, without being harmonized with clinical practice guidelines, without appropriate data, and without meaningful incentives produces bureaucracy rather than improvement.

I look back at the great collaborative efforts among organization in Choosing Wisely where tons of great work aligned at healthcare waste and best practices. I also reflect and ponder, what if they took it one understand how payers would use this, and understand how best to steward translation of these for actuaries and utilization management teams. In my mind, professional organizations have a clear stakeholder position at the table and perhaps a critical opportunity (maybe an obligation) to build something better.

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Stay tuned

In Part 2 (link), I explore the translation gap between clinical guidelines and payer actuaries, and why FHIR and TEFCA now make it possible to close it.

In Part 3, I'll lay out what a transformed role for professional organizations could look like and a potential strategic roadmap or framework to get there.