It’s Difficult to Use Claims Databases to Measure the Value of Neurological Care

Health care reimbursement is moving from volume-based fee-for-service to value-based systems. Value is defined as (quality + patient experience) divided by cost. This shift from volume to value is the central innovation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Both pathways of MACRA’s Medicare Quality Payment Program (QPP), the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs), preferentially reward high quality, low cost care.

In order for QPP and similar programs from other payers to be effective, there has to be a consensus on how to measure the value of healthcare provided to patients with different diagnoses by physicians and other qualified health care professionals. While cost assessment is built into the current reimbursement system, quality measurement is problematic. How can we define meaningful quality measures and determine if quality goals are achieved? Do visits to specialists improve patient care, and, if so, at what cost? Some cynics say that quality measurement is so difficult that “health care value” may just mean “low cost” to some stakeholders.

Callaghan et al studied a large claims database to determine the association of a neurologist visit with headache healthcare utilization and costs. They attempted to eliminate confounding variables in selecting which patients’ data to analyze. They found that the yearly probabilities of hospitalizations; receiving abortive, prophylactic and opioid medications; and total, headache related, and non-headache related costs were higher when neurologists were involved. Does this mean that neurologists do not add value to the care of headache patients? The authors make a compelling argument that the headache patients neurologists care for have more severe disease than those who did not see neurologists. Despite their diligent efforts, the severity of illness of patients in the claims database could not be determined accurately.

The interpretation of this and other claims data on other neurologic conditions has profound consequences for neurologists under QPP. If we are not considered high value providers we will be penalized under MIPS and excluded from APMs.

We need prospective studies on the value of neurological care using databases designed to measure quality . The best method for measuring and reporting health care quality measures may be a Qualified Clinical Data Registry (QCDR), such as the AAN’s Axon Registry. Future studies are needed to determine if QCDRs accurately measure quality and/or lead to improved patient outcomes.

Neil Busis, MD

Neil Busis, MD

University of Pittsburgh School of Medicine, Department of Neurology

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