American College of Physicians: Internal Medicine — Doctors for Adults ®

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ACP's response to the performance measure movement

Regents' Chair Mary T. Herald explains how the College is tackling a trend that makes many internists nervous

From the January/February ACP Observer, copyright 2004 by the American College of Physicians.

By Deborah Gesensway

Paying physicians based on their performance is one of the hottest topics among health care purchasers and payers. From private insurance companies to Medicare, health care organizations are experimenting with ways to measure everything from individual physicians' ordering and prescribing choices to how well patients with chronic conditions respond to their doctor's care.

The eventual goal is not simply to collect data for quality improvement purposes, but to financially reward—or punish—physicians based on their numbers. While the notion of pay-for-performance makes many physicians uneasy, Mary T. Herald, FACP, Chair of ACP's Board of Regents, says that the "train has left the station," and that internists—and the College—need to be on board.

In one of an occasional series of conversations with ACP Observer, Dr. Herald, who is a practicing endocrinologist in New Jersey, discussed her views on ACP's role in the performance measures movement.

Q: How sound is it to pay physicians based on performance measures?

A: I think physicians are fine with the idea of measuring what we do so we can improve, as long as we believe the measures are meaningful and relevant. We also want to be sure that each physician is held accountable only for what he or she does.

It's one thing to use measurements to improve quality, but paying for performance is a double-edged sword. It can be positive if it truly is going to improve the quality and appropriateness of health care. But if it is used to unfairly disadvantage certain practitioners based on their practice setting, their case mix and other factors outside of their control, it is a big problem.

Our goal should be to improve the care that we deliver to patients, making sure it is appropriate and adequately reimbursed. If anything, performance measures should provide incentives to move to higher quality and consistency in practice.

Q: If the idea of performance measures makes physicians so nervous, why should the College get involved?

A: Public accountability for quality outcomes is here to stay. In addition, performance measures are in the best interest of patients and physicians in the long run. Done well, this feedback can improve the quality of the care we strive to provide.

We want to make sure that useful performance measures are implemented by payers. The College wants to have input into how these measures are being developed and how they can be used for quality improvement in the least burdensome way.

Q: How is ACP responding to the pay-for-performance movement?

A: The Board of Regents this fall approved a set of recommendations from a work group that has been looking at this issue for more than a year. We anticipate that the Performance Measures Work Group (PMWG) will be a permanent subcommittee of the Education Committee, with links to the Health and Public Policy Committee and Medical Services Committee. This group's mission will be to support the development of College policy, as well as its advocacy and education efforts, by critically reviewing and disseminating performance measures.

The PMWG approved the following goals: One, only evidence-based performance measures should be used. Two, there is a need for adequate risk adjustment. Three, physician performance, not system constraints, should be measured, and four, measures should be feasible and not impose additional burdens. All that is not easy to do.

Q: Should the College be developing its own performance measures, just as it writes clinical practice guidelines?

A: Performance measures need to come from organizations with broader scope and expertise in quality assessment. A number of organizations are already doing this, like the National Committee for Quality Assurance, the National Quality Forum, the Joint Commission on Accreditation of Healthcare Organizations and some payers.

ACP has solid participation with many of these organizations. For instance, I am one of three Regents serving on the Joint Commission, which ACP helped found in 1951.

Our job is to positively influence the development of these measures. We should be developing criteria to evaluate measures, making sure they are based on evidence, and developing policy on how these measures should be used.

Q: How can performance measures be used incorrectly?

A: Because I am a specialist in diabetes care, I am referred patients whose glucose is completely out of control. If payers are collecting data on hemoglobin A1Cs and they looked at my average results, they would think I'm the worst doctor on the block or in the state. It's a good example of how these measures, if used incorrectly, can function as one more disincentive to treat sick people.

Improving quality and acknowledging that someone is doing an exceptional job seems like a good idea. But accuracy and the development of criteria to compare physicians and say that one person's care is better are very difficult. Performance measures may seem like they are telling you the real story, but that's not always the case.

Take the example of the hemoglobin A1Cs again. If you check to make sure that I'm ordering hemoglobin A1Cs on the appropriate patients at the appropriate intervals, you might feel assured I'm doing a good job. That measure alone doesn't say anything about treatment changes based on the result of the test.

It gets even murkier when you are measured on patients' health status. You may have done everything that is appropriate, but the patient didn't cooperate, didn't take the medication or didn't respond.

We don't want to throw out the idea that it is a good idea to look at the effectiveness of the care we provide. At the same time, we don't want to be judged on factors we can't control.

Q: What do you say to internists who worry that performance measures will create yet more administrative hassles for physicians?

A: We have to provide support and advocacy for our members in this new challenge. The College has to be aggressive in monitoring performance measures. We also need to be involved in how these measures are used to make sure that they focus on quality improvement and improving patient health.

We hope that through educational programs and services—presentations at Annual Session and electronic products, for example—we can prepare ACP members to work with performance measures in the least burdensome way.

Q: How does the College's decision-support tool, the Physicians' Information and Education Resource (PIER), fit into working with performance measures?

A: Wonderfully. The PIER modules already contain current practice guidelines. A next step could be including standard order sets and a way to document the actions we take, so that the gathering of the data then used in measuring performance is almost automatic. PIER is working on that.

In addition, ACP's Medical Informatics Subcommittee is also looking at ways to ease the burden on practicing physicians through the use of current technology. Eventually, electronic medical records systems will have these measurement tools embedded for smooth accessibility. As the practice environment evolves, the College will be ready to support its members.

Deborah Gesensway is a freelance writer in Glenside, Pa.

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