MMS Principles for Tiering of Physicians by Health Plans

The MMS strongly supports efforts to improve the quality and cost-effectiveness of health care and is committed to working closely with other parties to these ends.

In the Society's view, the essential elements of effective programs for monitoring the quality and costs of health care include the following:

General Principles

Derived from these critical elements, the Society believes that all programs aimed at quality monitoring or public reporting should:

1. Aim to Strengthen Patient-Physician Relationships: Programs that report on the quality and efficiency of health care should be directed at supporting and improving patient-physician relationships and facilitating access to care regardless of the health condition, demographics, ethnicity, economic circumstances, or treatment adherence patterns.

2. Involve Physicians in the Design and Implementation of All Programs: Practicing physicians, hospitals, and their professional organizations should be intimately involved in the design and implementation of such programs. Criteria used to judge physician performance should be jointly developed and approved by physicians and other involved parties. Moreover, physicians should be involved in monitoring ongoing programs, evaluating their effects, and modifying them in response to evidence of their effectiveness.

3. Use Clinically Important and Sound Performance Measures: All quality, cost-effectiveness, and efficiency measures should be evidence-based to the maximum extent feasible, valid, reliable, broadly accepted, and clinically meaningful. To facilitate alignment of measurement goals, selected measures should be consistent with the principles and measures supported by major national or regional organizations, including the AMA's Physician Performance Consortium, Ambulatory Care Quality Alliance (AQA) Beneficiary Quality Improvement (BQI), National Quality Forum, the Joint Commission, Massachusetts Health Quality Partners, and the Centers for Medicare and Medicaid Services. Moreover, every effort should be made to select measures that will avoid unintended harmful consequences.

4. Ensure Sample Sizes Adequate to Support Meaningful Data Analysis: Variations among practices and small sample sizes often preclude meaningful assessment and public reporting of physician performance at the level of individual physician practices. In these cases, analyses should be directed at group practices, integrated health care systems, or independent physician associations with sample sizes sufficient to adequately "power" analyses.

5. Rely on Meaningful Data and Analytic Techniques:

• Analyses should adjust for differences in clinical case-mix, socioeconomic factors, and outliers that may distort overall results.
• Data attributed to an individual physician should be directly attributable to patients, diagnoses, and care provided by that physician. If the data apply to care received by patients treated by a practice or network, results should be attributed to that practice or network and not to individual physicians.
• Evaluation of efficiency measures should be adjusted for variations in the cost of delivering care that are outside the provider's control (e.g., variations in payer mix, area wage-index, and state-mandated requirements).
• Timely feedback should be provided to physician practices to permit errors to be corrected prior to public release to facilitate improvement in the quality and efficiency of care.

6. Share and Review Data with Physicians or Practices Prior to Public Release: Results should be shared with the physicians or hospitals being monitored before public reporting or decisions about levels of performance. The inherent tension between the need for timely data and data accuracy needs to be addressed. At the same time, reasonable efforts need to be made to limit undue burdens on physician practices to provide or evaluate data.

7. Ensure Transparency of All Quality and Cost-Effectiveness Measures and Methods: Complete descriptions of all measures, criteria, algorithms, methodologies, and data sources should be made available in writing to all parties. Preferably, these should also be Web-available.

8. Identify and Consider Practice Characteristics That May Require Special Attention in Quality and Cost-Effectiveness Monitoring: Physician practices that are new, small, located in rural locations, or serve socioeconomically deprived populations or racial minorities may need to be assessed by different criteria than other practices.

9. Use Uniform Reporting Formats: Standardized and easily understood reporting formats are critical to achieving adequate understanding and appropriate use of reports by all involved parties: physicians, health care organizations, insurers, and the public.

10. Minimize Unintended Harmful Consequences of Quality and Cost-Effectiveness Monitoring and Public Reporting: Programs aimed at improving access, quality, and/or the cost-effectiveness of health care need to have in place explicit efforts to identify and correct any unintended adverse consequences.

11. Be Pre-Tested Before Implementation: It is critical that all quality and cost-effectiveness monitoring and public-reporting initiatives receive thorough and independent pre-testing prior to implementation. Such pre-testing should be applied to individual measures, program strategies, and efforts to rank or reward individual practices or physicians.