Healthcare quality indicators for value-based reimbursement in ophthalmology

Abstract

Steadily increasing expenditures of healthcare predict an unsustainable fiscal future (Blumenthal & Dixon, 2012). Concomitantly, the municipal sector economy in countries with ageing population is stressed by the ratio of declining fertility rate and the working-age population. In this situation, healthcare cost-optimization and improving effectiveness of care is inevitable, which means that the public sector cannot afford to provide low-value healthcare service.

Traditionally, the healthcare reimbursement system has relied solely on fee-for-service payment, incentivizing the production of larger services without acknowledging the actual value produced (Porter & Lee, 2013). On the contrary, a value-based payment model would encourage the utilization of the most efficient treatment modalities in which the healthcare provider's compensations depend on both the quality and cost of care (Cutler & Ghosh, 2012; Mechanic, 2015). As a concrete model of the value-based payment model, bundled payment where the payer reimburses for the episode of care has proved to be promising in high-volume and relatively standardized elective procedures (Jacobs et al., 2015). One such is the bundled payment for phacoemulsification surgery (Hurh et al., 2017). The bundled payment contracts by, for example, Medicare, recorded significant savings for total allowed claims compared to non-bundled contracts (Dummit et al., 2016).

Unnecessary scheduled visits and testing, and excess monitoring produce low-value care that limits attempts to address the demands for access, cost and quality likewise (Eloranta & Falck, 2017; Grzybowski et al., 2020; Kissick, 1994; Nemet & Tuuminen, 2023). Furthermore, complications, unnecessary hospital stay, reoperations and unscheduled visits cause significant expenses and reduce cost-effectiveness. Importantly, a substantial proportion of hospital re-attendances and re-admissions could be avoided with significant cost savings with correctly incentivized reimbursement (Gray et al., 2019; Tucker et al., 2018). As in other sectors of the economy, a focus on value is the key to an effective and sustainable healthcare system. Society would benefit from a better quality of medical services, improved operational efficiency and lower tax burden from a value-based payment system (Daniels et al., 2022; Expert Panel on effective ways of investing in Health, 2019; Teperi et al., 2009). One of the notable megatrends in the healthcare sector is the increased freedom of choice for patients' healthcare providers using various marketing information, which is easily acceptable by the digitalized medical information. Thus, data on quality of care, as provided by Crozet et al. (2024) in this issue would benefit the patients who want to choose their healthcare provider based on the surgical outcomes, and in turn, it would also benefit physicians who provide good healthcare services.

Limitations to implementing data from studies such as that by Crozet et al. (2024) may involve infrastructure requirements, including information technology, change resistance to the current policies, scarcity of appropriate patient reported outcomes in ophthalmology and wrong incentives (Feeley & Mohta, 2018; Joynt Maddox et al., 2022; Liao & Navathe, 2022; Zaki et al., 2021). Nevertheless, policy changes to improve the efficiency of healthcare costs are inevitable to balance the fiscal challenge. Stakeholders including policymakers such as Institutes for Health and Welfare and Ministries of Social Affairs and Health, as well as Unions of university professors, medical specialty societies, payers, for example, hospital districts and patients could advocate care providers to implement, when applicable, better reporting on outcome measures. For instance, a recent study on the effects of visual field defects on vision-related quality of life (VR-QoL) in glaucoma successfully implemented National Eye Institute visual function questionnaire (NEI-VFQ-25), NEI-VFQ neuro-ophthalmology supplement, Glaucoma Quality of Life-15 and a luminance-specific questionnaire (Gazanchian & Jansonius, 2024).

The ‘big four’ in ophthalmology (age-related macular degeneration, glaucoma, retinal diseases and cataract) account for 70% of the visits and costs at tertiary Eye Centre (Tuulonen et al., 2016). Bundled payment models may incentivize provision of the most high-value care obfuscating poorer outcomes among underserved patients (Agrawal & Shrank, 2020). Concerns related to both health equity adjustments and appropriate performance measurement have been recently addressed (Jacobs et al., 2023; Liu et al., 2024). Meticulous risk stratification or adjustment across patient-related and procedure-related factors is a crucial precondition for a successful implementation. Rewarding providers caring for difficult and complicated cases is mandatory to avoid generating shifts in favour of lower risk patients (cherry-picking/lemon-dropping effect). To achieve a proper incentive system, we must implement various aspects of quality measures, including (i) 30-day all-cause risk-standardized readmission rates, (ii) risk-standardized complication rates and (iii) patient-experience scores. Otherwise, it is evident that high-risk patients would be systematically excluded from the healthcare system, as the surgery might be calculated as not cost-effective.

In conclusion, the study by Crozet et al. (2024) could help us in setting up a reward system for providing high-value care and incentivize for fewer postoperative complications, readmissions and lower-than-expected costs. By doing so, we could ease budgetary pressures associated with the ageing population, which is immediate in most countries experiencing a demographic transition.

The authors have neither proprietary nor commercial interests in any medications or materials discussed in this study. Dr. Tuuminen is a scientific adviser (advisory board, honoraria) to Alcon Laboratories, Inc., Allergan, Inc., Bayer AG, F. Hoffmann–La Roche, Ltd. and Novartis AG, and has received clinical trial support (study medicines) from Bayer AG and Laboratoires Théa.