• April 2008 FEATURE ARTICLES •
Health Plans and Technology
Measuring Physician Performance
Building an effective physician performance system starts with transparency.
By Jeff Hanson
Measuring physician performance is right up
there with religion and politics as a topic to avoid at cocktail
parties. It's sure to raise a few hackles. On one side, health
plans, employers and government agencies are concerned about the
alarming cost of healthcare and want to ensure they are paying
for cost-effective, high-quality healthcare. On another side,
physicians are concerned with rating systems that seem to be
more about cutting costs than raising quality. These
paint-by-number approaches to measuring performance don't
adequately account for a patient's level of sickness or whether
patients comply with treatment plans. These approaches also
often rely on unreliable data, that vary from health plan to
health plan, and which don't teach anybody anything.
However, like politics and religion,
measuring physician performance is here to stay. It has been
going on for well over a decade and its use is expanding. If
this effort is to bear fruit over the long term, stakeholders
will have to agree on a methodology that effectively and fairly
assesses and improves the delivery of healthcare. In the
meantime, as we work toward that day, it's essential that the
metrics used to evaluate physician performance are entirely
transparent.
What's the Motivation?
As healthcare costs rise, the organizations
that pay for that care — employers, health plans and governments
— are driven to evaluate what they are getting for their money,
and to look for ways to control costs and improve quality.
I understand this drive. When I was northeast
regional healthcare manager of benefits strategy and design at
Verizon Communications, I experienced the frustration of payer
organizations seeking some way to justify the rising cost of
healthcare with no apparent improvement in the health of
employees. At the time, Verizon spent $3.5 billion on
healthcare, yet absenteeism and chronic disease persisted.
Employers formed programs, such as The
Leapfrog Group and Bridges to Excellence, to influence the
affordability and quality of healthcare. Health plans responded
by developing incentive programs to reward effective and
efficient care. In its "Incentives and Rewards Compendium," The
Leapfrog Group lists more than 50 such programs for physicians
and 30 for hospitals. Increasingly, health plans create tiered
networks that peg some healthcare providers as "preferred," and
modify benefit plans to drive patients to these doctors and
hospitals. The country's largest payer, the Centers for Medicare
& Medicaid Services (CMS), initiated the Physician Group
Practice Demonstration to explore the effectiveness of financial
incentives for high-quality, cost-effective care.
Long-established physician evaluation programs, such as continuing education and recertification, are evolving and converging with evidence-based medicine measurement systems...which are based on physicians’ actual practices and the disease burden of their patients.
Consumers, like payers, also want information
about who will provide them the best care. They have always
wanted that information, which they have pieced together from
family or friends, referral services or other practitioners. Now
that many health plans require high deductibles, consumers want
to know where their money is going and whether they are paying
for the best care. In addition, more consumers have grown used
to having information instantly available to them on the
Internet. If they can compare car prices and shop for real
estate on a computer, then they expect to find information on
the quality and cost of hospitals and physicians there, too.
Governments, both state and federal, have
weighed in on making healthcare cost and quality information
available. President Bush's Executive Order No. 13410, issued in
August 2006, instructs federal departments to implement more
transparent and high-quality healthcare by demanding that their
contracted hospitals, physicians and other providers adhere to
"four cornerstones" of healthcare improvement: the use of
interconnected, interoperable information technology; common
measures to evaluate performance and cost; transparency through
distribution of this information to consumers; and, payment
reform.
Performance Measurement
Measuring physician performance is not a new
idea. Physician organizations have developed ways to monitor and
improve performance, including continuing medical education,
which has evolved into "continuous physician professional
development," and board recertification, now referred to as
"maintenance of certification."
The Physician Consortium for Quality Improvement — convened by
the AMA and representing nearly all the national specialty
societies — is dedicated to developing and testing
evidence-based measures of physician performance. The Physician
Consortium has released an initial set of measures endorsed by
the National Quality Forum (NQF) and is currently working to
develop measurement sets for various sub-specialties and
diseases.
Whether pay-for-performance is an effective tool to improve physician performance has yet to be determined. At the moment, there is not much peer-reviewed research on P4P, however, there has been quite a lot of media attention with accompanying commentary and criticism from doctors.
Long-established physician evaluation
programs, such as continuing education and recertification, are
evolving and converging with evidence-based medicine measurement
systems that require life-long learning and which are based on
physicians' actual practices and the disease burden of their
patients.
Measuring clinical outcomes has also evolved.
In 1999, the publication of the Institute of Medicine (IOM)
report, "To Err Is Human," exposed the extent and human cost of
medical mistakes to a wide audience of healthcare consumers. In
the years since the report, every component of the healthcare
system (hospitals, health plans, physicians and other providers)
has come under increased scrutiny. Several initiatives to
address the underlying causes of medical errors resulted from
that wake-up call and from the recommendations offered in the
IOM's next report, "Crossing the Quality Chasm." That IOM report
recommended that healthcare system processes be redesigned
following certain rules, among them, shared knowledge and the
free flow of information, evidence-based decision making and
transparency. The authors of the report urged the healthcare
system to focus greater attention on the development of care
processes for the 15 most common conditions that afflict people.
Following the IOM report, groups like the
NQF, AQA Alliance and The National Committee for Quality
Assurance began to develop nationally vetted, evidence-based
clinical measures for the most common and prevalent diseases.
These are the measures on which physician performance will be
evaluated. Currently, health plans may customize indicators of
performance to accommodate differences in member population, but
eventually one library of clinical measures will dominate.
Health plans mine health claims and billing
data, using sophisticated programs to analyze which doctors
provide effective and efficient care. They have long had the
capability to steer patients to care that they rate as both high
quality and sensibly priced. Many have developed physician
"report cards" and have initiated pay-for-performance (P4P)
programs that offer monetary incentives to physicians who
provide high-quality, cost effective care. Whether P4P is an
effective tool to improve physician performance has yet to be
determined. At the moment, there is not much peer-reviewed
research on the subject, however, there has been quite a lot of
media attention with accompanying commentary and criticism from
doctors.
P4P, apparently, is still evolving.
Shortcomings
If the progression of physician performance
measurement follows the usual evolutionary path of the survival
of the fittest, a nationally accepted system will eventually
emerge without the shortcomings of the current tools.
One obvious shortcoming of the current batch
is the sheer number and variety of standards. The good news is
that evidence-based clinical standards have been developed for a
number of common conditions and diseases and eventually there
will be one standard set of clinical measures. To be sure, some
diseases and conditions will fall outside the standard
guidelines. Treatment of depression, for example, is not as
clear-cut as treatment of diabetes.
While standard clinical guidelines are
emerging, the method for analyzing data is still evolving and a
number of methodologies exist. Even now, CMS and the Agency for
Healthcare Research Quality are testing these methodologies in
different programs and comparing the outcomes. Eventually, like
the measures themselves, a consensus will emerge on a standard
methodology.
At present, many health plans have physician
report cards based on an assortment of rating systems, the
variety of which can frustrate physicians who no longer wish to
accept 10 different (and often conflicting) report cards from 10
different payers with whom they have contracts. If their
performance is to be measured, they want one report card based
on one set of indicators. That demand challenges payers to pool
information they have never shared before, and, in fact, have
closely guarded. However, payers are already joining regional
collaboratives, such as those in Massachusetts, California and
New York. As physician performance measurement evolves, a single
report will be a reality.
Another bump in the evolutionary path to
effective and fair physician performance measurement is the
patchy capability of collecting all the data points that
measurement requires. Adoption of healthcare information
technology at the physician practice level is slow, due, in no
small part, to its cost. In addition, there is currently no
standard coding of patients, physicians and procedures, or
clinical status of the patient.
And, some data — such as socio-economic
impacts — resist capture all together.
The Right Path
Insistence on a perfect physician performance
measurement system should not paralyze us. Rather, we should
continue plodding along the bumpy road toward the best solution,
doing the hard work and making the compromises that would result
in a fair, constructive and useful measurement process.
In the interim, before the industry adopts a
standard set of measures and methodologies, data transparency is
the key to successful physician performance evaluation. For this
to happen, payers and providers must pool data, without
compromising patient privacy, to ensure that physicians are
evaluated on an adequate volume of results. And, the data must
be trustworthy.
Performance measurement is one of the four
cornerstones of healthcare system transparency that the
President's executive order sets forth as a national priority.
It must be a funded mandate. We are not talking about a simple
software solution here, but a difficult and complex challenge
that requires patience and a robust dialogue among all
stakeholders.
Transforming our healthcare system is the
right challenge at the right time. It will take a lot of effort.
But we have no other choice.
Jeff Hanson, M.P.H., is a vice president with
Thomson Healthcare, which is headquartered in Stamford, Conn.
Contact him at jeffrey
hanson@thomson.com.