A Physician-Guided Approach to Transparency and P4P

by Tom Walsh

New physician performance ratings from the state’s Group Insurance Commission (GIC) are just around the corner (see Vital Signs, October 2005). Doctors in Massachusetts continue to maintain that that initiative -- and related pay-for-performance (P4P) incentive programs or public reporting efforts -- must be based on accurate patient data if they are to help improve care and curb rising health care costs.

“Physicians recognize the urgent need to address the soaring cost of health care,” said Alan M. Harvey, M.D., M.B.A., MMS president. However, Dr. Harvey added, the methodology and raw data that go into quality and cost measurements must be “transparent” -- that is, the information must be made available to physicians in a timely way.

Evaluating the Ratings In 2005, the MMS adopted a comprehensive new set of principles, summarized below, to guide the collection and reporting of physician performance data. The MMS encourages physicians to contact their plan representatives for information about how performance data was obtained and then to use these guidelines to evaluate the data. Data Quality. Programs should use objective, well validated, and clinically important measures of quality. Overcoming Technical Barriers. Technical barriers to accurate and timely measurement must be overcome. Uniform availability of electronic health records is central to improved measurement. Physician Patient Relationships. Quality measurement programs should support and improve these relationships and should protect and improve access to high quality care for all patients. Public Reporting of Physician Performance. Such reports must be accurate, statistically valid, and avoid arbitrary cut points when comparing physicians and practices. Paying for Performance. Incentives rewarding superior physician performance must contribute to higher quality and more cost-effective care.

“Physicians need to be involved in this,” Dr. Harvey declared. “Physicians determine health care quality, not payers or employers. Physicians working with their patients will define what constitutes the best care.”

Survey Finds Physicians Skeptical
The findings of a statewide physician survey by the MMS, made public in December, demonstrated that an overwhelming majority of the state’s doctors remain skeptical or unsure about the accuracy and usefulness of cost and quality measurement programs now under development.

When asked about the quality measures being developed by health plans and others to rate physician performance, 65.5 percent of respondents said the measures were either inaccurate (42.9 percent) or only somewhat accurate (22.6 percent). An additional 30.5 percent said they did not know enough about the measures to gauge accuracy. Conversely, more than half of the respondents said they’d use validated quality and cost measurements to improve their practices.

“Physicians are not opposed to good measurement programs that help us improve care,” Dr. Harvey reiterated. “But we have legitimate concerns about the accuracy, usefulness, and timeliness of the data, and how that data will be used.”

New Ratings Loom
As 2006 unfolds, new cost and quality ratings will debut. Among these are:

• Massachusetts Health Quality Partners (MHQP), a broad-based coalition that aims to improve health care, will release quality data at the medical group level (about 150 groups). That will be followed later by release of data from surveys of patient experiences at the practice site level (about 500 practices).
• The GIC, which handles health insurance for the state’s 250,000 workers and their families, expects by mid-year to charge lower out-of-pocket costs to employees who use physicians with the most favorable ratings. These ratings are based on “Episode of Treatment Group” measures. The GIC is also readying a rating system based on a proprietary set of quality measures.
• Using its website, the state government will publish information on individual physicians, starting with the volume of procedures performed by individual physicians at each hospital to which they admit patients for procedures such as angioplasties and hip and knee replacements.
• The state’s health plans, responding to employer demands to curtail annual health insurance premium increases, have already introduced incentive programs based on measures such as mammogram rates. So far, they have mostly rewarded primary care physicians for meeting certain measurement thresholds.
• At the national level, the Centers for Medicare and Medicaid Services has implemented a few voluntary incentive initiatives, but legislation to make P4P mandatory in the Medicare system didn’t survive a Congressional con ference committee.

What “Transparency” Really Means
Elaine Kirshenbaum, MMS vice president of policy, planning, and member services, said physician performance ratings are transparent “only if physicians are able to review the data to understand it and make sure it’s accurate. Physicians have to be able to suggest changes where necessary. That’s the right way to reach everyone’s goal -- improved health care.” Kirshenbaum added that the published literature makes her wary of using procedure volume to measure quality. “With the exception of a few high-risk procedures, there is still limited evidence about the relationship between volume and outcomes,” she said. “Therefore, surgical volumes should be used cautiously when choosing a physician or hospital.”

Rich Parker, M.D., medical director of the 1,400 physician Beth Israel Deaconess physician organization, appreciates the efforts to control rising costs and promote higher quality care. However, he remains skeptical of current health plan efforts to rate physician performance using claims data.

“I’d like to understand the methodology, see it in action, see that it works,” Dr. Parker said. “I’d like to see how the data from my own organization is going to be used. So far, my colleagues and I have not seen adequate data.”

Health Plan Perspectives
Marylou Buyse, M.D., president of the Massachusetts Association of Health Plans, said pay-for-performance programs are “a way for health plans to recognize the good work doctors do and reward them for meeting standards and benchmarks.”

Claiming that pay for performance “is a quality issue, not a cost issue.” Dr. Buyse said she is “puzzled” by physician reluctance to embrace P4P -- especially since she says it could be a significant source of new revenue for practices.

Dr. Harvey emphasized that “we want to create an environment in which we can continuously improve the medical care we deliver. But we can’t allow large-scale implementation of an experiment such as the one the GIC is about to embark on that hasn’t been adequately vetted through smaller, well-designed pilot projects.”

There is mutual agreement that using medical records rather than insurance claims information is the long-term answer. However, until physicians, hospitals, health plans, and electronic patient records are all connected in a usable fashion, completely realizing that goal will be difficult.

Do It Right
In the months ahead, MMS leaders will endeavor to explain the Society’s position on pay-for-performance and transparency issues to opinion leaders across the Commonwealth.

In December, the Boston Globe published an opinion article on the topic authored by Dr. Harvey. “Physicians support quality measurement and transparency,” Dr. Harvey wrote. “We want accurate and meaningful information provided publicly for our patients as they make decisions about their care. We want this information for our own use, as well, to continue to improve our own performance and provide higher quality care based on this feedback.”

While “perfection is not a prerequisite to implementation,” Dr. Harvey continued, whatever is done to measure performance “has to be done right.” The MMS president concluded, “the crush of rising health care costs requires decisive action, but all of us -- physicians, providers, insurers, employers, and policymakers -- must be careful that the cure isn’t worse than the disease.”