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Facing Reimbursement Challenges

Delivering solid, validated evidence of treatment can be achieved by utilizing an outcomes measurement system.
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Today’s health care professional, already faced with reimbursement challenges, is under continuing pressure to demonstrate and document the effectiveness of treatment. No discipline is under more pressure than that of chronic pain management. Payors, ever aware of the need to control costs, are rapidly eroding traditional practices and will continue to do so. The emphasis by regulators, public and private accreditation bodies, employers, and patient groups on the improvement of quality of care, along with reduction of associated cost, challenges the practitioner to execute valid models of therapeutic care and to furnish measures of the results of that care. The recent focus on patient satisfaction and health-related quality of life has further increased the demand for documentation of results. The clinician who cannot deliver solid, validated evidence of successful treatment will find it increasingly difficult to survive. Further, those seeking to define treatment protocols must have evidence of efficiency to support clinical applications.

Given the widely differing requirements of an outcomes measurement system suited for general clinical use, the challenge to those embarking on the creation or selection of such a system is to address a variety of audiences and factors with a single research design.

According to Slater,1 outcomes research is any research that attempts to link either structure or process, or both, to the outcomes of medical care at the community, system, institution, or patient level. Slater refers to the framework offered by Donabedian for describing the elements of care that may be considered when assessing quality.2

The concept of structure, the settings in which medical care takes place and the organization of which it is a product, encompasses all of the environment as well as the participants in the delivery of care + human, physical, and financial resources.2 System characteristics include the number and geographical disposition of hospitals and facilities, the availability and training of professionals, and the means of payment for medical services. The scope of examination may be national, regional, institutional, or a combination that includes specific diagnostic, delivery and/or reimbursement groups.

Among provider characteristics that influence the quality of care are availability, specialty training, and preferences, as well as job satisfaction and workload. The consideration of provider characteristics other than availability and discipline is rarely seen in outcomes measurement instruments currently available.

Patient factors to be considered concerning structure include diagnosis or condition, severity, comorbidity, and health knowledge and habits. Patient self-reports and provider’s assessments comprise the elements of this level.

Process, specifically the technical aspect, is the area of measurement that has traditionally received the most attention in the discussion of quality in medical care.

As part of the approval by the FDA for the marketing of both medical devices and pharmaceuticals, clinical trials still are the reason for much of the outcomes research carried on today. Clinical trials traditionally have not considered the interpersonal aspects of the provider/patient relationship, and of course do not seek to emulate normal treatment settings and their accompanying logistical restrictions. Results of clinical trials are a definition of efficacy, whereas the results of clinical processes are an indication of effectiveness.

Process measures are frequently used in evaluating performance. They are generally easier to use, and are more understandable by both clinicians and patients. They are the basis for developing programs of continuous quality improvement (CQI) that seek to enhance care by reducing variation in treatment and cost of care.

Along with procedures and tests, there is an interpersonal aspect to process that affects both the provider’s and the patient’s impressions of quality. While those impressions cannot be said to reflect on the actual quality of care from a medical standpoint, they contribute to therapeutic success in that they impact compliance and the patient’s attention to treatment as well as feelings of satisfaction with care. In the evaluation of the process of care, the interpersonal aspect is generally overlooked, or perhaps more precisely, avoided, primarily due to the difficulty in expressing and measuring the quality of the relationship and the participants’ abilities in interpersonal communication.

The final area of investigation is the obvious one, the outcome of treatment in terms of changes in patient status. The measurement of change implies a baseline assessment followed by at least one post-treatment measure and possibly interim measures as well. Areas of inquiry include clinical endpoints, health-related quality of life, and patient satisfaction with care.


The reasons for adoption of a medical outcomes measurement system may be classified as follows:

  • Regulatory/statutory requirements
  • Accreditation requirements
  • Quality control and improvement
  • Development of protocols/evidence-based practice
  • Reimbursement and plan participation requirements
  • Marketing

The current climate in which medical decisions are made is subject to turbulence in a number of areas, as suggested by the range of justifications for measuring outcomes detailed above. As may be seen, a variety of motivations exists for measuring and documenting medical treatment outcomes. Depending on the primary motivating factor, the weight of emphasis on the elements defined above will vary, but a comprehensive outcomes measurement system will consider most, if not all, of them.

Accrediting bodies for health care facilities impose their own requirements for outcomes measures. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted its ORXY initiative for incorporating outcomes and performance measures into the accreditation process in 1973. The Commission on Accreditation of Rehabilitation Facilities (CARF) introduced similar requirements at about the same time. Since 1992, the American Academy of Pain Management (AAPM) has required outcomes measures, using the National Pain Data Bank (NPDB), as a part of a comprehensive chronic pain management program.4

Last updated on: May 16, 2011
First published on: July 1, 2001