College calls for physician-friendly quality measures
By Phyllis Maguire
NEW ORLEANS—ACP leaders have approved a broad framework for developing performance measures to improve quality without punishing physicians.
In a position paper approved at its April meeting, the Board of Regents set out sweeping recommendations to implement one of the most controversial tools in medicine today: measures that quantify the quality of care that physicians provide.
The paper notes that both private and public payers are demanding better information to help foster patient safety and standardization of care. And performance measures, the paper states, will in the future offer internists an opportunity "to regain some control" over a reimbursement system that may not adequately pay them for the care they deliver.
"Performance measures can dramatically improve overall quality of care," said Regent Stephen C. Beuttel, FACP, who works in a large Veterans Administration hospital that uses performance measures. At the same time, he pointed out that physicians' "performance" can be in conflict with patient preferences and levels of compliance.
"If I'm graded on compliance and a patient refuses my advice," he said, "it affects my outcomes."
Great benefits and potential harms
According to the College's new policy, performance measures have the potential to boost quality. At the same time, care must be taken to ensure that performance measures are not used to increase physicians' administrative burdens.
Indicators that measure care processes—not outcomes—are more appropriate for assessing internists' performance.
Here is an overview of some of the paper's key recommendations:
Evidence-based measures. Performance measures must be evidence-based and focus on those aspects of care over which physicians exert direct control. Measures must not function as disincentives for physicians to not treat patients with serious co-morbidities.
To deal with the complex care of elderly patients, the paper states that indicators that measure care processes—as opposed to care outcomes—are more appropriate for assessing the performance of internists, who treat patients with chronic conditions.
Data collection. Data collection must protect patients' privacy, be feasible and not impose further financial or administrative burdens on physicians.
The paper endorses the use of information technology and the development of electronic systems to facilitate data collection. The paper also recommends that any costs associated with data collection should be borne by health systems, not by individual physicians or practices.
Demonstration projects. The College supports the development of demonstration projects for public reporting of performance measure data, as long as those projects rely on voluntary participation by physicians and allow physicians to review data before they are publicly disclosed.
Incentives. The paper endorses the use of incentives, including financial incentives, to reward physicians who meet performance standards. According to the position paper, those rewards could come in the form of higher payments or bonuses or in reduced recertification requirements.
At the same time, the paper spells out the College's vision for its own role in implementing performance measures. ACP will develop performance measures "only under exceptional circumstances" where no appropriate measures already exist. However, the College plans to play a vigorous role in assessing the evidence base of existing measures.
Despite many physicians' fears, performance measures—which assess how well physicians adhere to evidence-based standards—can be effective, reliable and within physicians' control, according to a health policy expert who addressed the Board of Governors at Annual Session.
"There is good evidence that if done correctly, performance measures can serve the public and us," said Sheldon Greenfield, FACP, director of the Center for Health Policy and Research at the University of California, Irvine.
Dr. Greenfield, who has served with the National Diabetes Quality Improvement Alliance, outlined how performance measures have worked to improve diabetes care. Patient statistics gathered by the alliance between 1997 and 2003 show steady gains in key areas, such as blood pressure, lipid control and hemoglobin A1c control and nephropathy monitoring.
According to Dr. Greenfield, the diabetes project demonstrated that careful, well-constructed measurements can benefit both doctor and patient. One key advance was the use of aggregate scores. The use of aggregate scoring ensured that scores weren't dependent on individual performance measures, which can be unreliable, and that the physician was being assessed on overall care instead of on a single performance measure.
At the same time, Dr. Greenfield pointed out that to receive reliable results, uniform data collection must be adhered to. And measures must be based on conservative, well-proven standards of care, not emerging ideas or trends.
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