Don’t wait for all the answers to start measuring quality
From the June ACP Observer, copyright © 2006 by the American College of Physicians.
By Janet Colwell
PHILADELPHIA—When Kevin B. Weiss, FACP, agreed to give an 8:15 a.m. talk on performance measurement on the last day of Annual Session, he expected a handful of early risers to show up. Instead, the room was almost full—and the mood was anything but subdued.
In the early stages of pay for performance, says Kevin B. Weiss, FACP, most physicians aren’t equipped to report on outcomes.
“How can we tell how well we’re doing without electronic records?” one physician asked. Other questions quickly followed: What measures should we be using? What if we haven’t start using measures yet? What about noncompliant patients? And will pay for performance just withhold money and give it back to us if we perform well?
There are still many unanswered questions, admitted Dr. Weiss, ACP Regent and Chair of the College’s Performance Measurement Subcommittee, who outlined the complex issues surrounding measurement development, endorsement and implementation. The main goal of the College and others working on behalf of internists is to help develop clinically relevant measures and ensure that practices aren’t forced to take on too much too soon.
'The real risks now are getting too many measures and being overburdened by measures.'
—Kevin B. Weiss, FACP
“In the next five years, the most important factors are to keep the measurement set small, get uniformity among measures and understand what it is to do measurement in our practice,” said Dr. Weiss, who is also professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago and director of the Midwest Center for Health Services & Policy Research at Hines VA Hospital in Hines, Ill. “The real risks now are getting too many measures and being overburdened by measures.”
Those risks drove the College’s decision not to develop its own measurement set but to help endorse good measures and bring them to the fore, Dr. Weiss said. ACP is a key player in the Ambulatory Care Quality Alliance (AQA), a 140-member public-private coalition that has developed a starter set of 26 measurements that apply to all physicians.
“If you’re thinking about what measures to go with, think of [the AQA starter set],” said Dr. Weiss, who also chairs the AQA’s performance measurement subcommittee. “The AQA measures are being built into every health plan contract and the Centers for Medicare and Medicaid Services are writing them into their future pay-for-performance program.”
While physicians don’t want to be overburdened with too many measures in the beginning, many also worry about being evaluated on such a small number of measures. That’s a legitimate concern, said Dr. Weiss—but until physicians are ready to do large-scale measurement, “we’re stuck with the smallest set.”
Then there is the issue of using claims or administrative data for reporting, even though such data may be incomplete. At the same time, the alternative of relying on chart reviews places an undue burden on practices.
Add to that the fact that most measures being developed now are process measures that evaluate whether certain process thresholds have been achieved—asking patients about tobacco use, for example—not outcomes measures.
That rankles many physicians who “want to be rewarded for making things better,” Dr. Weiss said. “What really matters to physicians is clinical data. We don’t care about a test being done as much as we care about the results, in termsof our patient outcomes.”
In the early stages of pay for performance, however, most physicians aren’t equipped to report on outcomes, he said. It is fairly simple, for example, to create a registry and record how many diabetics received a hemoglobin A1c test in the past year. It is much harder to report on how many of those patients have their blood glucose level under control.
“We’re beginning to do that kind of reporting with electronic health records [EHRs],” Dr. Weiss said. “But only about 20% of practices nationally have EHRs—and even fewer have a built-in data management feature.”
There are also a “large number of issues about measuring performance at the physician level,” he said. For example, one practice may have only a few dozen that fit into a certain “population,” such as diabetes or hypertension, and patients within those population groups all have different health plans. That makes it hard to track care with a large enough sample to gauge performance.
And the current system also makes it tough for practices with unique patient populations, such as inner-city practices that serve mainly low-income patients, he said. These practices may not be able to reach the same performance thresholds as some suburban practices—but they should still be able to reap rewards for improving care.
"For them to improve from 30% to 50%," said Dr. Weiss, "might be the same as another practice improving from 90% to 92%.”
Part of what makes pay for performance so confusing is the many national groups working on performance measurement. Here are of some the names you’re likely to hear, with ways physicians may want to become involved:
Centers for Medicare and Medicaid Services (CMS). Physicians interested in getting involved in quality measurement should consider participating in the CMS' Physicians Voluntary Reporting Program, the agency’s primary effort to capture quality outpatient data. The program is voluntary this year but the goal is to progress to pay for reporting and pay for performance over the next few years. The program includes seven measures geared to office-based physicians, six of which are also in the starter set of the Ambulatory Care Quality Alliance (see next entry). Physicians receive confidential feedback on their performance scores.
Ambulatory Care Quality Alliance (AQA). This is a coalition of key stakeholders representing health plans, physicians, business and government that comes together several times a year. The AQA is trying to get consensus on how to measure performance at the physician level, collect and aggregate data in the least burdensome way, and report meaningful information. The College is a key player in this coalition.
AMA Physician Consortium for Quality Improvement. This group identifies, develops and advocates for evidence-based clinical performance measures.
National Committee on Quality Assurance (NCQA). A private, not-for-profit organization that acts as a “watchdog” for the managed care industry. The NCQA recognizes individual physicians and medical groups, and provides health care information to the public.
National Quality Forum (NQF). A private, not-for-profit membership organization created to develop and implement a national strategy for health care quality measurement and reporting. The mission of the NQF is to improve care by endorsing consensus-based national standards for measurement and reporting.
Bridges to Excellence (BTE). A not-for-profit organization, the BTE is made up of large employers that recognize and reward health care providers who meet certain standards of care.
The Leapfrog Group. A group of more than 170 health care purchasers that encourages its members to reward doctors and hospitals for improving the quality, safety and affordability of health care. The group is best known for its Leapfrog Hospital Quality and Safety Survey and currently has a pay-for-performance program for hospitals. It also works with Bridges to Excellence on designing reward programs for providers.
PHILADELPHIA—Despite a broad consensus that the nation’s physician reimbursement system needs to be fixed, physicians and experts alike wonder whether the current wave of pay-for-performance initiatives are the answer. That was the sentiment expressed at an Annual Session Town Hall Meeting that featured a panel of government and business leaders, as well as internists, offering sometimes conflicting views on pay for performance.
“There is too much health care spending for the quality of care that we as a nation are getting,” said panelist Kevin B. Weiss, FACP, Chair of ACP’s Performance Measurement Subcommittee and director of the Institute of Healthcare Studies at Northwestern University’s Feinberg School of Medicine in Chicago.
But while the business community thinks pay for performance will help reduce expenses, Dr. Weiss expressed some doubt. “It’s a thoughtful solution,” he said, “but it’s a little fix for a big problem.”
Addressing that root problem—the dysfunctional payment system—is complex and expensive, said panelist Barry M. Straube, MD, acting chief medical officer and acting director of the office of clinical standards and quality at the Centers for Medicare and Medicaid Services. As a result, he explained, the current focus is “increasing value and efficiency.”
In the early stages, however, performance measurement is fraught with potential hazards, conceded Dr. Weiss, who worked with the Ambulatory Care Quality Alliance on developing a starter set of 26 ambulatory quality measures. “We need a common language,” he said, “about what measurements are and why we are measuring.”
What about the exceptions?
Some of those potential problems surfaced during a question and answer session. Teresa M. Schaer, FACP, wanted to know whether pay-for-performance incentives would factor in the time she spends with patients on advance planning.
Dr. Schaer, a geriatrician in New Brunswick, N.J., said she often spends at least 40 minutes with elderly patients on end-of-life counseling. “How will quality measures account for the fact that I spent time with Parkinson’s patients on these issues when they were still able to communicate with me?” she asked.
Emily R. Transue, FACP, a general internist in Seattle, complained that there seems to be little consistency among incentive programs. “I received one report from a payer that said I was doing spectacularly, and another that said I was below average,” she said. She also asked how the medical community could guard against physicians’ "cherry picking” healthier patients to increase their scores with payers.
The power of incentives
The measurement stakes will change when insurers start deciding whether to contract with doctors based on performance scores.
According to Dr. Weiss, cherry picking should not be a problem—at least for now, while most pay-for-performance incentives are too small to affect behavior. He acknowledged that the stakes will change when insurers start deciding whether to contract with doctors based on performance scores. “Those tensions are still being worked out,” he said.
But Francois deBrantes, program leader of health care initiatives for GE Corporate Health Care who was also part of the panel, added that the financial incentives being offered by insurers are sure to grow. “It’s naive to think that token financial rewards will motivate doctors to completely reengineer their practices,” he said.
Besides, he added, experience has already shown that providing substantial incentives can yield a big payoff. “We’ve seen a 10% savings for large employers,” Mr. deBrantes explained. “They’re seeing that higher quality goes with lower costs.”
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