The AcademyHealth Quality and Value Interest Group is composed of a broad range of members all interested in measuring, improving and incentivizing quality and value in healthcare. As health service researchers, we have the opportunity to bring together all perspectives in order to establish frameworks and research agendas that are embedded in real world experiences of those working within and being served by the health care system. Because of the broadness of such concepts and value and quality, however, we have started a webinar series on Perspectives on Quality and Value, to invite speakers with different backgrounds and expertise to join a panel discussion and provide their take. Our hope is to continue this series as a space to reflect on whether we are really measuring what matters and inspire new ideas for our members and audience.
This blog post summarizes our inaugural panel discussion, hosted by our Advisory Group member Daniel Maeng, Ph.D. Associate Professor in the Department of Psychiatry at the University of Rochester Medical Center. The discussants were John Williford, CEO of Accountable Health Partners (AHP), and Enrique Martinez-Vidal, Vice President for Quality and Operations at the Association for Community Affiliated Plans (ACAP). Health insurance in the US is dominated by private insurers, which cover more than 66 percent of the U.S. population as of 2024. For health systems and health plans operating on the front lines of care delivery and financing, quality and value are often operational concepts embedded in contracts, workflows, technology, and real-world constraints. The discussion highlighted an important theme: while metrics and measurement are essential, true improvements in quality often depend on system transformation rather than simply optimizing performance on individual indicators.
Understanding Quality and Value from the Payer Perspective
Private employers and insurers play a central role in the complex U.S. health care financing system. For John Williford, whose organization operates at the intersection of payer and provider roles, quality begins with the delivery of evidence-based, patient-centered care.
“We define quality as the delivery of evidence-based, patient-centered care that improves health outcomes, enhances the patient experience, and reduces unnecessary variation in care delivery,” he explained. Value, in turn, reflects the relationship between outcomes and spending. “Value equates to the health outcomes achieved per dollar spent. It’s not necessarily about cutting costs—it’s about optimizing outcomes relative to the resources invested.” One of the greatest challenges in defining value lies in the temporal mismatch between investments and outcomes. Preventive interventions often require substantial upfront investment; yet the benefits may not become visible much later. As a result, health plans lack incentives to invest in their current members’ long-term health outcomes.
Metrics Versus System Transformation
Over the past several decades, the US healthcare system has developed robust and extensive sets of quality and performance metrics, devoting considerable amounts of resources dedicated to collecting and reporting of the information to a wide array of audiences and stakeholders. Nevertheless, Martinez-Vidal emphasized that focusing exclusively on metrics can obscure the larger goal. Drawing on his experience at ACAP and previously at AcademyHealth, Martinez-Vidal described how his own thinking about quality has evolved over time. Early in his career, working with the Maryland Health Care Commission, quality improvement efforts were largely metric-driven, centered on standardized reporting systems for hospitals, health plans, and nursing homes. But his perspective broadened during a project called the State Quality Improvement Institute, launched at AcademyHealth in 2008. One participating state pushed back against the narrow focus on individual measures. “They said, ‘We don’t want to just focus on these little metrics,’” Martinez-Vidal recalled. Instead of targeting specific indicators, the state aimed to redesign the underlying infrastructure of health care delivery — improving data systems, strengthening community engagement, and aligning financing with population health goals. This experience reinforced a broader lesson: metrics should serve as signals, not endpoints.
Operationalizing Quality in Health Systems
Within health systems and accountable care organizations, quality measurement often relies on a combination of metrics designed to capture both cost and clinical performance. Williford described three categories of indicators commonly used at AHP:
1) Total Cost of Care: AHP tracks risk-adjusted total cost of care, which provides a holistic measure of value by incorporating spending across the entire continuum of care. While this metric offers a broad view of efficiency, it has limitations in that if it’s not balanced with quality measures, it can create incentives for underutilization.
2) Composite Quality Measures: AHP also monitors a range of preventive and chronic disease management indicators. Although evidence-based, they can impose significant documentation burdens while ignoring important aspects of care, such as functional status and patient experience.
3) Avoidable Utilization: AHP tracks measures such as emergency department (ED) visits and preventable hospital admissions, as these metrics have not only direct clinical implications but also financial implications as high-cost “big ticket” items. Yet, variation in these metrics may be driven by factors beyond efficiency and quality, rendering them difficult to interpret.
Opportunities for Research Collaboration
Both speakers emphasized there are ample opportunities for collaboration between researchers and payers. For Williford, collaborative research could focus on evaluating value-based payment models, testing targeted interventions for high-risk populations, or studying innovative care delivery models. Similarly, Martinez-Vidal highlighted the need for implementation research — studies that examine how evidence-based interventions can be adapted and applied in real-world health care settings. He believes more investment is needed in studies that focus on health system operations and policy implementation, rather than solely clinical effectiveness. Health plans, he noted, often possess vast amounts of data but lack the analytical resources to fully leverage it.
For health services researchers, the conversation underscored a critical insight: improving health care quality requires more than better metrics. It requires understanding the operational realities faced by health systems and health plans. By partnering more closely with health systems and payers, researchers can help generate the evidence needed to evaluate these initiatives.
Blog post summary & outline:
- Although the U.S. health system is dominated by private payers, there has been a lack of clarity on the concept of quality and value from their perspectives.
- Traditional quality measurement relies heavily on standardized metrics such as HEDIS, CMS Star Ratings, and CAHPS, but focusing solely on these indicators can obscure broader goals of improving health care systems.
- Private payers often operationalize quality and value using three types of metrics: total cost of care, composite clinical quality measures, and avoidable utilization (e.g., ED visits and preventable admissions), each with strengths but also limitations in interpretation and administrative burden.
- Greater collaboration between researchers and payers is needed, particularly in areas such as value-based payment evaluation, interventions for high-risk populations, and implementation research that studies how evidence-based practices function in real-world health care systems.