MMS Guidelines for Measuring, Reporting, and Rewarding Physician Performance

The Massachusetts Medical Society adopted in May 2005 a comprehensive new set of principles to guide the collection and reporting of physician performance data.

The May 2005 principles build on physician profiling principles the MMS developed in 1998, which have been referred to as a standard by many organizations, such as the American Medical Association's Physician Consortium for Performance Improvement, Massachusetts health plans, Massachusetts Health Quality Partnership (MHQP), and the National Committee on Quality Assurance (NCQA).

Since these principles were established, considerable energy and resources have been devoted to measuring the quality of medical practices, as well as efficiencies in health care practices. Nationally, efforts include the NCQA's monitoring of Health Plan Employer Data Information Set measures in the health plans it certifies, Joint Commission on the Accreditation of Healthcare Organization's monitoring of the quality of hospital care, and Centers for Medicare and Medicaid Services' (CMS) activities aimed at documenting the quality of care provided to Medicare beneficiaries. 

Locally, MHQP has developed a "Roadmap" for 2005-2010 to document and report health care quality information on clinical performance and patient experiences in both primary and specialty care and in ambulatory care and hospital settings. The results of the first phase of public reporting on large physician groups was published in The Boston Globe in February 2005. In addition, individual health plans and purchasers are reporting data for participating networks and physicians. The MMS and the physician community generally have the opportunity and responsibility to take leadership roles in efforts aimed at quality measurement, quality improvement, and efficiency measurements.

There is consensus among health care stakeholders that information technology, such as electronic health records (EHRs), can make important contributions to data collection, quality improvement, readiness for incentives aimed at paying for performance (P4P), and improving the efficiency of health care practices. The MMS should play a key role in assisting physicians with the implementation of EHRs and readiness for P4P.

There is also consensus among physicians, health services researchers, and health care leaders that current clinical data collected to assess the quality of clinical practices are too often inaccurate, incomplete, and of marginal relevance to the true quality of care. There is also widespread agreement that there is an urgent need to standardize measures and data reports, ensure proper attribution of responsibility for measured care, and include adequate numbers of observations to meet tests of statistical significance. Data that physicians are measured and reported on should be clinically important, accurate, timely, appropriately attributed, and risk-adjusted for clinical, cultural, and socioeconomic differences.

MMS Guidelines for Measuring, Reporting, and Rewarding Physician Performance

Improving the Quality of Health Care

Increasingly, physicians are being judged by systematic measurement and reporting of their performance on selected quality indicators, by patient experiences with the care received, and by assessment of the appropriateness and cost-effectiveness of care. Quality improvement programs that have these goals should:

  • use objective, well-validated, and clinically important measures of quality;
  • ensure accurate and timely assessment of these measures;
  • include physicians in both primary care and medical specialties;
  • provide for timely review of reports by involved physicians prior to public release;
  • ensure that reports released to the public can be easily and accurately interpreted;
  • make appropriate use of risk-adjustment and statistical methods when reports aim to compare performance among clinical practices or hospitals or make clear notation that population differences make direct comparisons difficult or impossible;
  • use appropriate incentives to reward superior performance and stimulate continuous improvement in the quality of care being provided;
  • promote and facilitate the adoption of information technology (IT) tools including electronic health records (EHRs). 

Measuring Quality

  • Many quality measures used today, including Health Plan Employer Data and Information Set measures, represent "low-hanging fruit" and are of marginal clinical importance. They provide a starting point, however, until better measures can be implemented. Such data should not be used in the physician peer-review process. Physician peer review should be conducted in accordance with the Society's "Model Principles for Incident-Based Peer Review for Health Care Facilities."
  • Technical barriers to accurate and timely measurement of quality need to be confronted. As sources of data, claims data have the advantages of being readily available, relatively low in cost, and inclusive of important parameters such as diagnostic and procedure codes. Shortcomings include delays in obtaining access to the data, inaccuracies, and inadequate information on the clinical needs of patients and socioeconomic indicators that may affect outcomes. Uniform availability of EHRs are central to improved measurement. The development of such systems should be a high priority.
  • The costs of quality measurement can be considerable. Costs should be justified by tangible evidence of resulting improvements in health care quality and/or savings in the costs of health care. Measures of cost should include the added clerical burdens on physician practices or managed care organizations.

Patient-Physician Relationships

  • Quality-measurement programs should be directed at supporting and improving patient-physician relationships. To these ends, they must reflect the vital importance of sound medical judgments as well as adherence to defined guidelines.
  • Programs should protect and improve access to high-quality health care for all patients. Program developers should be especially sensitive to minimizing barriers to access among patients who are disadvantaged by reason of ethnic, cultural, and socioeconomic barriers, or who have especially complex medical conditions, and should take positive steps to improve access to care for such patients.
  • Programs should aim to achieve equity in quality assessment for patients and their physicians, regardless of the setting in which care is delivered or the location of the population served (for example, inner city or rural areas). This challenge will be particularly difficult in practice settings that lack the needed infrastructure, including EHRs.
  • Programs should be "risk-adjusted" to reflect the important effects of patient non-adherence on performance outcomes. This is especially important when patient adherence is not reasonably under the control of the physician.

Public Reporting of Physician Performance

  • The public expects and deserves valid reports on the performance of all health care providers: medical practices, managed care organizations, hospitals, nursing homes, and other services.
  • Reports for public release must meet high standards for accuracy and statistical validity. They should receive timely review by involved practices prior to release, and should be corrected for discovered errors or risks of misinterpretation. Particular attention should be given to ensure that physicians are held accountable only for care for which they are, in fact, responsible.
  • Reports that compare performance of physicians or practices to each other or to benchmarks must avoid using arbitrary cutpoints that designate practices as being "superior," "above average," "average," or the like. Instead, performance should be rank-ordered according to the quality measure under consideration. Ranking should be based on clinically important and statistically significant differences.
  • Reports must pay careful attention to differences in sociodemographic and socioeconomic classes and cultural divides that may affect patient attitudes toward health care and adherence to recommendations of their physicians.

Paying for Performance (P4P)

  • Use of incentives to reward superior physician performance or improvements in performance over time make intuitive sense. Solid evidence is needed, however, to establish that these rewards actually contribute to higher quality and more cost-effective health care. Evidence supporting the value of such incentives in health care is, at present, limited.
  • Criteria, methodology, and background data for P4P on measures of quality and cost should be transparent to all involved. Practices involved with these incentives should have an opportunity to review their data and, preferably, begin improvement prior to the implementation of the incentives.
  • Requirements to achieve P4P goals should be made known to physicians in a timeframe that will allow them to safely alter the care they deliver in order to meet the goals.
  • Incentives should seek to move practices to the "next level" in terms of acquiring essential structural components (for example tracking systems or EHRs) that will improve processes or outcomes of care.
  • P4P pilots should use incentives of sufficient magnitude to influence physician behaviors. Results should be carefully monitored to ensure that the intended objectives are met and that unexpected detrimental effects have not been introduced.
  • P4P incentives will be most effective in improving patient care if they are aligned and standardized across payers, physician practices, and hospitals.
  • Funding of P4P initiatives should come from additional resources. Financial incentives should not come from a redistribution of current physician and other health care provider reimbursement.

References

American Medical Association, Guidelines for Pay-for-Pay-for-Performance Programs, February 24, 2005. http://www.ama-assn.org/ama1/pub/upload/mm/-1/finalpfpguidelines.pdf

McGlynn EA, et al. The Quality of Health Care Delivered to Adults in the United States. NEnglJMed. 2003; 348:2635-45. http://content.nejm.org/cgi/content/full/348/26/2635

Walter LC, et al. Pitfalls of Converting Practice Guidelines into Quality Measures. Lessons Learned from a VA Performance Measure. JAMA. 2004; 291:2466-70. http://jama.ama-assn.org/cgi/content/full/291/20/2466

Marshall MN, et al. The Public Release of Performance Data. What Do We Expect to Gain? A Review of the Evidence. JAMA. 2000; 283:1866-74. http://jama.ama-assn.org/cgi/content/full/283/14/1866

Marshall MN, et al. Public Reporting on Quality in the United States and the United Kingdom. Health Affairs. 2003; 22:134-148. http://content.healthaffairs.org/cgi/content/full/22/3/134

Landon BF, et al. Physician Clinical Performance Assessment. Prospects and Barriers. JAMA. 2003; 290:1183-89. http://jama.ama-assn.org/cgi/content/full/290/9/1183

Lee TH, et al. A Middle Ground on Public Accountability. NEnglJMed. 2004; 350:2409-12. http://content.nejm.org/cgi/content/full/350/23/2409

Roland M. Linking Physicians' Pay to the Quality of Care -- a Major Experiment in the United Kingdom. NEnglJMed. 2004; 351: 1448-54. http://content.nejm.org/cgi/content/full/351/14/1448

Rosenthal MB et al. Paying for Quality: Providers' Incentives for Quality Improvement. Health Affairs. 2004; 23:127-37. http://content.healthaffairs.org/cgi/content/full/23/2/127

Epstein AM, et al Paying Physicians for High-Quality Care.NEnglJMed.2004; 350:406-409.http://content.nejm.org/cgi/content/full/350/4/406

 

 

 

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