CMS project to measure physician quality of care

Participating practices could get CME credits, lower liability premiums or public recognition.

By Markian Hawryluk, amednews staff. March 3, 2003.

Washington -- The Medicare program is beginning to pilot-test ways to measure the quality of care provided in physician offices. But doctors remain concerned about what the program will do with those data.

Under the Doctors' Office Quality project, the Centers for Medicare & Medicaid Services is developing and testing quality measures and strategies to use those measures to help physicians improve patient care. The agency is completing a list of 10 to 20 measures to use in the project. They will focus primarily on chronic disease management and preventive services related to the treatment of diabetes, heart failure, coronary artery disease, hypertension, osteoarthritis and major depressive disorders.

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CMS has identified some 300 physicians in California, Iowa and New York who will participate in the three-year pilot, under the oversight of quality improvement organizations. QIOs are already in each state and contract with CMS to perform Medicare quality improvement and education.

Starting this summer, the physician practices will work with QIOs to gauge their performance using the measures and then to use the data to improve, said Barbara Paul, MD, director of the quality measurement and health assessment group at CMS.

"The long-range goal is to see if we can't develop some better strategies to help physicians improve the quality of care in their offices," she said.

But Dr. Paul acknowledges that the pilot has some serious challenges, not the least of which is identifying measures that physicians will accept and that will provide statistically valid data. CMS turned to the Physician Consortium for Performance Improvement, a group of more than 50 national medical specialty societies and government agencies convened by the AMA to help physicians improve quality. The consortium has developed evidence-based clinical performance measures and reporting tools. The CMS project will use some of these measures.

CMS will use 10 to 20 quality measures for the project.

But physicians are concerned about how those measures and the resulting data will be used, said AMA President Yank D. Coble Jr., MD.

"The AMA believes that data collection from use of the performance measures during the DOQ project pilots can enhance patient care if CMS uses the data for quality improvement purposes only," Dr. Coble said. "CMS must also keep in mind that there are significant methodological limits in the use of clinical performance measurement data."

A recent report on physician quality measurement by the Institute of Health Policy at Boston's Massachusetts General Hospital found few readily available performance measures based on sound evidence. The report also concluded that factors other than physician actions -- such as the severity of the patient's condition, other health problems and the patient's compliance with the prescribed treatment -- could impact the results and skew the measurement. Researchers warned that many doctors would not see enough patients with the presenting conditions to accurately measure the quality of care provided.

The report recommended against performance measures' use for purposes other than internal quality improvement efforts. "The measurement of physician clinical performance in quality improvement activities need not be precise, but only sufficiently accurate to reassure the physicians of the face validity of the data and to engage them in redesigning the processes of care ... to improve patient outcomes," the researchers said.

Avoiding the paperwork burden

Dr. Coble said the AMA also wants to prevent the project from becoming another paperwork hassle for physicians that will take time away from patient care.

"We have not and will not advocate for implementation of any performance measures that interfere with the practice of medicine or add to the [federal] regulatory burdens already imposed on physicians," he said. CMS has recognized that concern and is working to keep the reporting requirements for the project manageable, Dr. Paul said. "We're really trying to balance having a nice set of measures against the burden of trying to collect those measures."

300 doctors will take part in a 3-year pilot project.

Although limiting the data collecting and reporting burden might help ease physicians' concerns about the project, Dr. Paul said it still would be a challenge to find doctors willing to participate in the full three years of the project. CMS is working on incentives that might make it much more palatable for physician practices.

Doctors participating in the project can earn continuing medical education credits by participating in the project. The AMA and CMS are sponsoring a pilot CME effort that will cover national fees for 30 credits for 100 general practice clinicians in the three states who participate in quality assurance activities, including the DOQ project, in outpatient settings.

CMS is also working to provide physicians in the project a way to reduce their medical liability risk. The agency maintains that physicians who choose to examine their own potential risks and then correct weaknesses may have an advantage in preventing a lawsuit. The DOQ project will attempt to demonstrate improvement in their risk profiles and to link the use of assessment tools to lower premiums.

"We're actually hoping that we can partner with a malpractice insurer in at least one state who might find this compelling enough that they might be willing to offer physicians a modest premium reduction for their participation in the project," Dr. Paul said.

Additionally, CMS is asking participating physicians if they would like public recognition. But physicians groups have cautioned against citing only those physicians who do well on the quality measures or ranking physicians according to the data.

"We have concerns that public recognition could be misused against certain physicians," Dr. Coble said. "Therefore, the simple fact that a physician participated in the DOQ project should be the sole recognition offered."

Doctors will earn CME credits for participating in the project.

Given the limits of the quality measures available, using an index-scoring system to provide public recognition would be unfair, he said.

CMS has similar quality measurement and improvement initiatives in place nationwide for hospitals and nursing homes, including information provided to consumers on the level of care provided by the facilities.

But Dr. Paul said work in those settings is at a more advanced stage of development.

With physician offices, Dr. Paul said, the agency still needs to understand the measures, the data they provide, and the support needed to help physicians improve their care.

"It's only after we understand all that that we can start to talk about providing consumers with information," she said.