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

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Quality measures shouldn't conflict with quality care

From the January-February ACP Observer, copyright 2007 by the American College of Physicians.

By Lynn Kirk, FACP

Internists take their professional responsibility to provide patients with the highest quality care very seriously. Thus, many physicians naturally resent the current trend toward tying reimbursements to how well we meet a standard set of performance measurements. Why should internists be forced to add this administrative burden, the reasoning goes, when they are already applying the latest evidence-based medicine to the care of their patients?

The fact is that, as a group, we are not providing the best-possible care. Studies show that evidence-based care is provided only about 55% of the time (McGlynn, E., et al., New England Journal of Medicine, June 26, 2003). When analyzed regionally, the quality of care provided to Medicare patients is inversely proportional to the amount spent on that care (Commonwealth Fund, 2005). Although care by internists has not been independently analyzed in these studies, one can safely infer that we aren't always living up to our intentions.

There are many possible reasons for this, including working within a health care system that does not value the time it takes to coordinate care for patients with chronic diseases. In fact, over the years we have been forced to see more patients in less time just to cover the cost of running a practice. This volume-driven system does not provide the incentives or basic financial support necessary to deliver high-quality care.

Policy makers, payers and employers are well aware of the disparity between guidelines and practice. They are also faced with rapidly rising health care costs in both the public and private sectors. Many have concluded that performance measures should be tied to how physicians are paid for medical care. Pay for performance (P4P) is already a reality in many regions of the country. Medicare, too, has taken a step toward P4P with the Physician Voluntary Reporting System implemented in 2006. Congress has also considered several proposals to link reform of the Sustainable Growth Rate formula to a phase-in of P4P.

When I was a young, nave faculty member directing a resident continuity clinic, I did a study on influenza vaccination. At the time, I was resistant to issuing standing orders for flu vaccine, because it took away an important learning experience for the residents. My research showed that, in the beginning, residents adhered to guidelines on vaccine orders 100% of the time. But their adherence declined precipitously during peak times when they were seeing eight patients per session. The residents, while competent and well-intentioned, fell short of their own high standards when the clinic got busy.

Most internists have experienced this in their own practice as they attempt to provide high-quality care in a rushed 15-minute office visit. But with appropriate systems and measurements in place, we can increase our adherence to evidence-based care. These systems can help us identify our population of diabetic patients, for example, and help ensure that they receive appropriate glycated hemoglobin testing and blood pressure and lipid lowering medications, as well as orders for appropriate preventative services.

It is extremely important for physicians to be involved in decisions about P4P and that's why the College has taken a prominent role in developing universal standards. The College participates in the Ambulatory Care Quality Alliance (AQA), the National Quality Forum and the AMA's Physician Consortium for Performance Improvement, as well as discussions with payers, employers and legislators. The College has developed policy to ensure that quality measures used to evaluate physician performance are:

  • evidence-based,
  • relevant to the physician's clinical responsibilities,
  • valid and reliable,
  • practical,
  • clearly defined,
  • have actionable measurement goals,
  • stable over time, and
  • related to clinical conditions with the greatest impact.

Most physicians, appropriately, have concerns about how performance measures will influence reimbursement decisions. Many of these concerns have been explored in a paper from the ACP Ethics and Human Rights Committee entitled "Pay-for Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto." The report points out that we know very little about actual outcomes of programs on patient care, especially potential unintended consequences producing adverse outcomes. Such consequences include deselection of patients who can't easily reach performance goals, "gaming the system" rather than focusing on what is appropriate for the patient, misalignment of perceptions between patient and physicians, and the potential for increasing unnecessary care and medical costs. P4P may set up conflicts between our duty to do the best for our patient and the need to achieve a certain performance threshold.

The report outlines several principles relevant to P4P:

  • Recognize and support the physician's duty to act in the best interests of their patients.
  • Promote high quality, evidence-based care in the context of a strong patient-physician relationship.
  • Support patient decision-making about their care.
  • Facilitate collaboration among members of the health care team and across health care settings.
  • Respect confidentiality and patient privacy in data collection.
  • Address the goals and treatment of varied patient populations, especially those with multiple complex, chronic diseases.
  • Disclose to patients quality processes and potential conflicts of interest.
  • Not limit access to care or engender "deselection" of patients.
  • Recognize the potential for unintended consequences.
  • Adhere to the ethical principles of beneficence, nonmaleficence, patient autonomy, and social justice.

My hope is that in the process of implementing these new measurement systems and documenting the care we provide, we will gradually eliminate some of the hassles inherent in our current health care system. Systems that give me immediate access to appropriate information and decision support on evidence-based care will help me provide more consistently high quality care for all of my patients. In turn, the documentation I create will enable my health care team to assess the care we provide and make continual improvements. That documentation should be all that's required to for me to receive adequate payment for my time, knowledge and skills, and should serve as proof of my competence for all payers.

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