Quality Measurement & Reporting
National health insurers, employer health care coalitions, the Centers for Medicare and Medicaid Services (CMS) and others have been trying to measure the quality of services provided by hospitals, physicians and other health care providers for decades. These measurements are usually based on analyses of administrative data. Although the level of sophistication of physician quality analysis has lagged behind that in other health care sectors, it has improved, primarily as a result of better quality measures, such as those developed by the AMA-convened Physician Consortium for Quality Improvement® (PCPI™).These measures, created by physicians for physicians, are based on scientific information which ensures that physician performance is judged against standards developed by the consensus of peers. For more information about PCPI™ and its measures, consult the AMA-developed resource, “PCPI: Ahead of the curve.”
There are two types of physician quality measures: (1) process measures, which track whether the services called for in the performance measure were provided; and (2) outcome measures, which track the patient’s results. Most current physician quality measurement systems rely on the former, rather than the latter.
Physicians generally agree that high compliance rates with process measures denote some indication of quality care. However, many point out that because these measures cover such a limited portion of patient care, mere compliance does not offer a complete picture of the quality of care provided.
Most physicians (as well as insurers, employers and other concerned entities) would much prefer to judge quality on outcome measures. Unfortunately, outcome measures are much more difficult to use than process measures. Generally, outcomes are not captured by claims data. Moreover, a patient’s outcome is dependent on a myriad of factors, many of which cannot be objectively identified.
To have any value, outcome measures require effective risk adjustment systems—that is, systems designed to take into account the varying severity of patients’ medical conditions and other factors that may affect the patient outcomes, regardless of the physician’s efforts. Current risk adjustment systems are unable to account for most of these patient population variations, so the use of outcomes to measure quality cannot only be woefully inaccurate, but also produce dangerous disincentives to covering and treating the sickest patients.
Although physician quality process measures have improved the accuracy of physician quality measurement, inaccuracies in rating physicians on quality persist for many reasons. The primary source of these inaccuracies is the conspiracy of small numbers: Most rating entities simply do not have enough data on the specific services provided by individual physicians to ensure that their ratings are reflective of their entire practice and not unduly influenced by idiosyncratic populations. Another problem relates to the difficulty of removing exceptional cases—for instance, excluding patients with double mastectomies from measurements of mammogram rates. Finally, the rating entity’s data is often incomplete or incorrect.
Although the AMA believes that quality measurement is still too imprecise to publicly report or to use in steering patients to certain physicians, we do strongly support using it to identify quality improvement opportunities for individual physicians and practices.
The drive for increased quality and efficiency in health care delivery, coupled with increasing demands for transparency, will make it increasingly necessary for physicians to become actively involved in the collection and evaluation of their quality data. Most importantly, this data can be used for process improvement and patient engagement to improve patient outcomes. In addition, physicians can also use this data to justify pay-for-performance bonuses, or to defend against unfair quality ratings.
The AMA has many resources for physicians who are interested in evaluating electronic health record and patient registry options that may assist them in this regard.
- Learn more about the use of Health Information Technology
CMS has developed a new website, Physician Compare, which will publicly post physician quality ratings as determined by the agency’s Physician Quality Reporting System (PQRS). Currently, PQRS is paying a small Medicare bonus to physicians who report their data to CMS on certain quality measures, but that bonus will turn into a penalty in 2014 for physicians who do not participate. These quality data will eventually be publicly displayed on Physician Compare.
Visit the AMA’s Performance improvement center for more information about PQRS. The AMA has also developed an analysis of the PQRS as compared with AMA’s Principles and guidelines for pay-for-performance programs.
Access information on the AMA’s federal advocacy on PQRS and other federal patient safety and quality improvement activities.