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As NCQA turns its attention to physicians, performance measures find some ready takers

Why six internists volunteered for the program, and how it affected their practices

From the December ACP Observer, copyright 2003 by the American College of Physicians.

By Tim Gray

When Jennifer Hone, MD, heard several years ago about a new quality measurement program being offered by the National Committee for Quality Assurance (NCQA), she jumped at the chance to participate.

The Arvada, Colo., endocrinologist thought she was providing excellent patient care. She figured that participating in the program—which recognizes physicians who meet specific quality standards in diabetes care—might give her some leverage in negotiations with health plans.

Four years later, Dr. Hone has yet to realize that increased leverage. Nevertheless, she has decided to extend her participation in the NCQA program. Paying closer attention to patients' hemoglobin A1c and blood pressure levels, she said, has improved her practice. And because performance measures will likely become a fact of every physician's life, she figured she might as well get an early start.

Dr. Hone's calculation is typical of many of the physicians participating in the NCQA's voluntary performance measurement programs. Launched in 1997, the NCQA's diabetes care program has attracted nearly 1,800 physicians. A new heart/stroke care program that debuted this summer already has more than 40 participating physicians.

While few physicians have seen any financial gains from these and other performance measurement programs, change is coming. Payers from Medicare to large health plans in California are talking about linking reimbursement to performance measures, and a handful have started paying bonuses based on how physicians score on quality measures.

To be sure, not all physicians are embracing the measures. Some complain that meeting standards for only one disease may not improve care for patients with more than one illness. And many remain leery of having their pay linked to performance.

Slowly, however, physicians are beginning to welcome a chance to demonstrate better quality and lobby for better payment. Some even say that performance measures—at least in the form being promoted by the NCQA—could help physicians regain some control of a payment system that doesn't adequately compensate internists for their efforts.

We talked to some physicians taking part in the NCQA programs to find out what it takes to participate—and what payoffs they've found for themselves and their patients.

The fee-for-service treadmill

Quality experts warn that if physicians don't get involved in developing and implementing good performance measures, others will be only too glad to develop those programs and impose them on physicians. That's why a number of physician organizations, including the College, are taking a much more active role in deciding how performance measures should be structured and how they should affect physician reimbursement.

(For more on the College's efforts with performance measures, see "Performance measures should help, not punish, doctors" in the November 2003 ACP Observer.

For internists like Thomas Knight, MD, medical director for quality improvement at Forsyth Medical Group in Winston-Salem, N.C., the answer to when to get involved was simple: as soon as possible. Convinced that performance standards are here to stay, he and his colleagues decided to participate in both NCQA projects.

Like a growing number of physicians, Dr. Knight is betting that Forsyth's physicians will be able to turn program standards to their advantage. "We see it as a way to get off the fee-for-service treadmill," he explained. "For the last two decades, physicians have progressively lost control. The pay-for-quality movement is a chance to take a little bit of control back and be rewarded accordingly. It's a way to continue to demonstrate our value within the system."

The NCQA recognizes physicians and groups who meet its performance measures by posting their names—which are searchable by state for the diabetes program—on its Web site. According to some doctors, the NCQA programs are the first wave of a not-too-distant future in which recognition and reimbursement will be based to some degree on physicians' ability to meet specific quality standards.

"Consumers and employers who pay for medical care are going to demand something in writing to explain why it costs what it does," said Allen Wong, ACP Member, an internist affiliated with Presbyterian Hospital in Charlotte, N.C. Dr. Wong is participating in the NCQA's heart/stroke care program. "That's not unreasonable, and there's really nothing else out there that measures how we're doing."

To get physician buy-in, it helps that the clinical standards set by the NCQA programs are relatively noncontroversial. They are, said Dr. Knight, the sort of guidelines that any physician should already adhere to. "Getting diabetics to better control their blood sugar—you're not going to get a lot of argument from physicians on that."

(For more information on the NCQA programs, see "NCQA's physician recognition programs.")

Significant effort

While physicians may find little controversy in the NCQA's performance measures, program participation still requires significant effort.

For the diabetes program, for instance, individual physicians in groups of up to six doctors must cull through their records to collect data on 35 diabetic patients they have seen for at least a year. (Groups of seven or more must submit data on 210 patients.) The necessary data include patients' hemoglobin A1c results, their blood pressure and cholesterol levels, and whether they've recently had eye and foot exams.

Physicians also have to pay an application fee and an additional charge for program materials, which run $375 and $80 respectively. Application fees are capped at $2,500 for groups of seven or more.

Because physicians must submit patient data, larger groups with more staff resources or practices with electronic medical record systems have a distinct advantage. For instance, Dr. Knight's group—with 185 physicians—received money from its parent organization, Novant Health, to improve diabetes care and education. It used part of that grant to cover application fees and administrative costs of participating in the NCQA diabetes program.

"We made it painless," said Dr. Knight. All the physicians had to do was pick a date on which their chart surveys would begin. From there, the administrative staff took over.

As a result, more than 30 of Forsyth's physicians appear on the NCQA's physician list for diabetes. Dr. Knight expects that number to top 50 by the end of the year.

With such a strong showing, Forsyth was picked by the NCQA as one of the pilot sites for its heart/stroke programs. And the NCQA waived its application fees for Forsyth's initial physician group.

As a solo practitioner, however, Colorado's Dr. Hone found participating in the diabetes program to be much more difficult. Even with the help of an office staffer and diabetes-patient-management software, Dr. Hone said submitting the required patient data took "a substantial amount of work."

Susan S. Braithwaite, FACP, an endocrinologist now with the University of North Carolina at Chapel Hill, echoed that assessment. When she prepared her application for NCQA's diabetes program, she was a private practitioner at the Luther Midelfort Medical Center in Eau Claire, Wis.

She didn't have secretarial support to keep track of paper reports from outside hospitals. Working only with the front desk staff who helped collect patient satisfaction questionnaires and a nurse who pulled charts, she prepared the application on her own.

"It took about 20 hours," she said. "I did it at the end of the day for several weeks." The NCQA estimates that the application process can take anywhere from 10 to 30 hours.

The payoff

Do those efforts pay off? Dr. Wong, the Charlotte internist enrolled in the heart/stroke program, said that one reason to participate is public relations value. While the NCQA encourages physicians to tout their recognition to hospital systems and local media, Dr. Wong said that none of his patients has mentioned seeing his name on the NCQA Web site. He also noted that his hospital hasn't started to publicize its physicians' involvement.

"We got some 'attaboys' from the people who own the hospital," Dr. Wong said. "The CEO sent a very nice letter."

For Dr. Hone, her hard work has yet to bring any financial dividends. However, she chalked at least some of that up to her own inability to effectively use her program recognition. "Until recently," she said, "I didn't have a sufficiently savvy financial manager to take advantage of it in negotiations."

Still, she said she considers the recognition to be valuable. At the very least, she said the application process gave her a chance to compare herself to national standards. She also believes a nod from the NCQA will eventually yield better reimbursements.

Dr. Braithwaite is likewise glad she participated because her hospital, Luther Midelfort, and its parent company, Mayo Health System in Rochester, Minn., put a "very high premium" on demonstrating quality care. NCQA recognition, she said, was a way to prove she was providing that care.

But she received more than just a certificate of recognition that she could point to during her annual review. The application process, Dr. Braithwaite said, made her a more conscientious physician.

"We generally overestimate our own excellence," she explained. "But once you review your charts, you realize that excuses really bring your performance levels down. Since I completed the application, I've been more aware of myself finding excuses."

When caring for diabetics, she pointed out, it's easy to gloss over some essential details, particularly in crammed 15-minute appointments.

"You've got to search the record every time and make sure you've done the annual things like the dilated retinal exam, the foot exam, the lipid profile," Dr. Braithwaite said. "You have to do the A1c quarterly and a smoking history every time."

And if the patient wants to talk about other medical matters? "Either you put this all on the shelf, or you let other patients get angry in the waiting room," she replied. "If you want to adhere to the standards, there's no such thing as a visit where you don't do the preventive things."

Potential downsides

Despite such endorsements, performance measurement programs have their critics. Some physicians claim that the strengths of the NCQA programs—the fact that they are voluntary and nonpunitive—may turn out to be major flaws.

Critics point out that only physicians who are confident they will make the grade apply to the programs in the first place. The NCQA doesn't publish the names of doctors who apply but don't meet program standards, critics add, so physicians who most need to improve patient care aren't being reached or motivated to change.

Others point out that quality programs may be too simplistic to accurately assess—and reward—complex care. Christine Sinsky, MD, for instance, an internist at Medical Associates Clinic in Dubuque, Iowa, works with both NCQA programs. (She appears individually on the heart/stroke list and, through her practice, on the diabetes list.)

On balance, she supports the NCQA's goal of highlighting quality care and the physicians who provide it. She said she worries, however, that too much importance may be attached to simply meeting guidelines.

She pointed out that paradoxically, a narrow focus on meeting specific performance measures could lead to a drop in overall quality. That's because physicians might spend too much time checking off boxes rather than taking a "holistic perspective" with patients, she said.

"Guidelines have to be applied with clinical wisdom," Dr. Sinsky explained. "There's a risk that practice guidelines will be viewed rigidly."

Consider, for example, elderly, frail patients with multiple medical problems. "It may no longer be appropriate to continue to add medication to bring their A1c into guidelines," she said. "But guidelines could review that care negatively."

Upping the ante

One project launched earlier this year may counteract some reservations and promote wider physician participation.

Bridges to Excellence is a coalition of large national employers that includes General Electric, Procter & Gamble, UPS, Ford Motor and Verizon. The coalition has begun paying bonuses to physicians in Louisville, Ky., and Cincinnati, who have been recognized by the NCQA for diabetes care.

Big employers are determined to find a way to reward doctors for quality care of employees, employees' families and retirees, said Lisa Joyner, NCQA's director of recognition programs. Under the Bridges program, an NCQA-recognized physician can be eligible for a bonus of $100 per diabetic patient per year. (The program applies only to patients covered by health plans used by participating employers.)

Physicians who care for 100 eligible patients, for example, could receive a bonus of up to $10,000. "This is new money," Ms. Joyner said. "It's not a shuffle game." Employers can afford to pony up additional funds because the program produces big savings. The coalition estimates that employers save $350 per diabetic patient every year, according to Ms. Joyner. Subtract the $100 reward and the $50 of administrative costs, and purchasers net $200 annually per patient.

(More information on the program, including an application, is online.

So far, the reward program is available only in Louisville and Cincinnati, two cities with large numbers of coalition-member employees. It's being rolled out in Boston, however, and will be added in other cities as employers step forward to sponsor it. Bridges and the NCQA are developing a similar program for heart/stroke care.

The first bonus checks were mailed this fall. They averaged thousands of dollars, according to Jon Conklin, a vice president at the Ann Arbor, Mich.-based MedStat, the health care information and database company that is administering the program.

David E. Bybee, FACP, an endocrinologist in Louisville and ACP Governor for the Kentucky Chapter, received one of them.

"It was nice of them to recognize us and pay for the quality, but it didn't make us do it," Dr. Bybee said. He and the three other endocrinologists in his practice had received NCQA recognition before Bridges existed. And Dr. Bybee said he has long believed in care standards for treating diabetics.

"You have to look at your entire practice as a population and understand what's going on with different categories—people who don't follow a diet, people who don't take their medications, people whose pressures aren't controlled," he explained. "Then design systems to address those problems."

While individual patients must still receive physicians' art of medicine, he added, "Doctors have to look at their entire population too, and standards help us do that."

Tim Gray is a freelance writer based in Philadelphia.

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NCQA's physician recognition programs

Since 1997, the National Committee on Quality Assurance (NCQA) has run the diabetes physician recognition program in conjunction with the American Diabetes Association. Individual physicians and medical groups can apply to be recognized.

Applicants must supply clinical data, such as hemoglobin A1c and blood pressure levels, for a sample of their diabetic patients. Physicians whose patients meet specific measures are then recognized by having their names and addresses, which are searchable by state, posted on the NCQA's Web site.

They also receive a certificate of recognition that they can display. More information, including specific measures, application materials and recognized physicians, is online.

The NCQA's heart/stroke recognition program was launched this summer with help from the American Heart Association/American Stroke Association. The program recognizes—and lists on the Internet—physicians and groups who meet specific performance measures.

The measures relate to patients' blood pressure, lipid and cholesterol levels; the use of aspirin or other antithrombotics; and smoking status and smoking cessation advice.

More information on the program is online.

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