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How performance measures can actually help internists

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

By Robert B. Doherty

Performance measurement is the latest exciting "new" idea that is grabbing the attention of policy-makers in Washington.

The concept of measuring clinicians' outcomes has been around for a long time, of course. For years, many health care organizations have incorporated performance measures into their internal quality improvement activities.

Now, however, major purchasers including Medicare want to make performance measurement a central part of the nation's strategy to improve quality, reduce medical errors and control costs. Instead of viewing performance measurement as an internal tool that health care organizations can use to assess and improve quality, many purchasers are looking at performance measurement as a way to hold physicians and health care organizations accountable for the care they provide.

Accountability defined

This notion of accountability differs from traditional quality improvement in several critical ways.

Quality improvement has traditionally meant giving clinicians data on how well they meet certain clinical guidelines and how their practice patterns compare with those of their peers. Based on this information, clinicians would be motivated to make improvements in areas where their care was less than optimal. The exercise was primarily educational, and physicians were promised that any resulting "report cards" would be kept confidential.

Accountability, by contrast, means that performance data will be reported not only to physicians, but to payers and the public. Purchasers argue that they have a right to know about the quality of care they are paying for. Patients want that information to help them choose a physician, hospital or nursing home.

Physician concerns

The medical profession has largely resisted the idea of releasing physician report cards to the public. Doctors worry that the public release of this information will increase their risk of being sued. They also lack confidence in the validity of the performance measures themselves. (See "EMRs and performance measures offer promise—and problems.")

Already busy practices dread the potential administrative burdens they will have to meet to measure and report their performance to outside entities. And perhaps most importantly, internists worry that performance measures will unfairly tarnish the reputations of good doctors who care for large numbers of seriously ill patients.

All these concerns are legitimate. Performance measurement could turn out to be another unfunded and unwanted regulatory hassle for physicians. The last thing internists need are more hassles, more liability and more finger-pointing when things go wrong.

Performance measures, however, could also create an opportunity for the medical profession. Instead of allowing MBAs and government regulators to decide how to hold physicians accountable, the medical profession itself could lead a thought revolution on how to measure and report clinical performance to benefit both patients and the profession.

More specifically, medicine could use performance measures as the vehicle to channel tangible rewards—increased reimbursement and less regulatory oversight—to physicians who are willing to have their performance measured and reported based on evidence-based clinical measures.

Incentives for physicians

The College already advocates for better reimbursement and fewer regulatory hassles for internists. Given continued cuts in Medicare reimbursement and the growing federal deficit, however, we need an approach that goes beyond asking Congress for a slightly bigger piece of a shrinking reimbursement pool.

Payers are not going to raise internists' reimbursement or reduce red tape unless they see an interest in doing so. The performance measurement movement provides an opportunity to align our interests of better pay and fewer hassles with payers' interest in improving quality and saving money through better management of costly illnesses.

The Medicare Payment Advisory Commission (MedPAC) recently issued a report that describes how quality improvement and accountability could be linked to incentives for practitioners. The MedPAC report stated that if performance measurement is going to succeed, the health care system needs to make three key changes:

  • Adopt a leadership commitment to a culture of quality and safety.

  • Create a blame-free environment.

  • Embrace information technology to measure and improve patient care. Tools include electronic health record; software patient registries and computerized provider order entry, as well as e-mail and other patient communication technologies.

Moreover, MedPAC proposed that Medicare create incentives to reward physicians and health care organizations that make a commitment to measure and improve quality based on accepted clinical measures.

Under such a plan, physicians and insurers could receive bonuses or higher payments for meeting quality measures. They could also receive a share of any savings that quality improvements generate.

Medicare could also offer to modify burdensome regulatory requirements for physician groups that demonstrate top-quality performance. Payers could also develop alternative reimbursement methods to reward physicians for managing chronically ill patients over time and different settings.

Taking the lead

The College's Health and Public Policy and Medical Services committees recently concluded that internal medicine will be better off if ACP actively shapes the accountability movement to achieve our desired ends, rather than reacting to the agenda of business and government. Over the next year, these two committees will develop recommendations for public policies that reward internists with higher reimbursement and less regulatory oversight-as long as they voluntarily participate in quality improvement and performance measurement based on valid clinical measures.

The College's Practice Management Center and Medical Informatics Subcommittee will also work together to give internists the practical support they will need—including access to information technology—to perform well in the new world of performance measurement. On a parallel track, ACP's Performance Measurement Work Group is proposing that the College develop a program to study and validate performance measures.

The committees and work group are keenly aware of the risk that performance measures may be misused in a way that will hurt both internists and their patients. They also believe that to prevent this scenario, the College needs to take the lead in defining what will be measured and how it will be reported—and in proposing concrete incentives to reward internists who participate in performance measurement programs.

If we do this right, the College can help revitalize internal medicine by helping internists be rewarded for doing the right thing for their patients. Internists who agree to performance measures will potentially benefit by having an opportunity to obtain higher pay and fewer regulatory hassles. The public will benefit by improved quality and lower costs. Purchasers will gain by being assured they are paying for the highest quality medical care. That would be a "win-win-win" outcome for internists, patients and purchasers.

Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.

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