My most recent blog
explained
why three prominent Dr. Bobs—Bob Wachter, Bob Berenson, and Bob Centor—are
raising important questions about the value of physician performance measures,
which, ironically, are supposed to bring greater value to the healthcare
system. Their concerns include:
·
The proliferation of measures of dubious
validity and the associated burden of reporting on them;
·
The difficulty,
even impossibility, of measuring elements of care, like physician
compassion, that patients may value the most;
·
The risk
of unintended consequences, like treating to the measure and disadvantaging
physicians who treat the underserved.
All of these are very real and genuine concerns, shared
widely by physicians, and not just those fortunate enough to be named Bob.
The question I am left with, though, is 'What’s the solution
to physicians’ anxiety about performance measures?' For practical reasons, I
don’t see the country saying, never mind,
measuring performance is an impossible or ill-advised task, let’s just repeal
the new value-based payment system created by the Medicare Access and CHIP
Reauthorization Act (MACRA), let’s abandon all efforts to link payments to
performance. Nor do I think it would be
advisable for the medical profession to declare open warfare against
performance measures. For one thing,
there are known gaps in quality and effectiveness of care, and measurement can
be one way to identify areas for improvement and progress in achieving it. Performance measurement can also help
policymakers, the public, and physicians assess the impact of new delivery and
payment models. (To be clear, the Dr.
Bobs weren’t completely calling for an end to performance measurement, but a
better approach to measuring performance).
In my opinion, Dr. Yul Ejnes, a former chair of the ACP Board
of Regents, offers a wise and appropriate balance in his
commentary
in today’s @KevinMD blog:
I have a "like-hate”
relationship with clinical metrics, performance measurements, and other such
things. By now, almost all physicians live with them in the form of insurer
“report cards,” PQRS, and “meaningful” use. Some of us have even more exposure
to them by participating in patient-centered medical homes and accountable care
organizations.
Why “like”? Because I believe they
can help you to know how you’re doing. Happy patients, full schedules, phones
ringing off the hook with new patient requests, and the belief that you’re
doing a good job delivering care aren’t enough. Few things are more sobering
than seeing data on the percentage of your diabetes patients who are not at
goal, those with hypertension whose pressures are not under control, or those
who haven’t undergone colon cancer screening. I know that many question the
relevance of some of the clinical measures, which often look at intermediate
and perhaps less meaningful outcomes or report on process, but they can be more
informative than the gut sense that we have on how we’re doing our jobs.
What I hate about the measures is
that they also get in the way of patient care. I’ve written about this in
earlier columns — concern about measures distracting us from our primary jobs,
the administrative burdens of “capturing” data so that it can be counted, and
the effect of all of this on the quality of clinical documentation are some
examples. Add to this the open question of whether the current version of
performance measures truly improves quality of care.
Instead of rejecting performance measurement, Dr. Ejnes
calls for 'a more thoughtful approach to measurement and for EHR products to
make [them] more seamless and less intrusive. The American College of
Physicians’ (ACP) 2012
paper on performance measurement had many
recommendations that, if followed, would prevent much of our current suffering.
For example, minimizing burdens in collecting data, using EHRs to facilitate
(not complicate) the process, and most importantly, that “performance measures
that have not been shown to improve value to include higher quality, better
outcomes, and reduced costs (and higher patient and physician satisfaction)
should be removed from performance–based payment programs.”'
Yesterday,
ACP
did exactly what the good Dr. Ejnes ordered, and what our 2012 paper (which is
still right on the mark!), calls for, which is to
call
on CMS to “reimagine” performance measurement—starting
with
scrapping the measures currently used for Medicare’
existing Meaningful Use, PQRS, and Value-Modifier programs:
"The College strongly
recommends that CMS actively work to improve the measures to be used in the
quality performance category of MIPS. Therefore, we believe that CMS should NOT
consider the existing quality measure sets within Physician Quality Reporting
System (PQRS), Value-Based Payment Modifier (VBM), and Meaningful Use (MU) as
the starting point for its measure development plan.
In the short term, ACP recommends
that CMS utilize the core set of
quality
measures identified and recently released by the America’s Health Insurance
Plans (AHIP) collaborative . . . Further, the College recommends that CMS
consider the
recommendations
made by ACP’s Performance Measurement Committee with regard to measure
selection within MIPS.
Over the longer term, ACP stresses
that it will be critically important for CMS to continue to improve the
measures and reporting systems to be used in MIPS to ensure that they measure
the right things; move toward clinical outcomes, patient- and family centeredness
measures, care coordination measures, and measures of population health and
prevention; and do not create unintended adverse consequences.”
Further, ACP identified the need to “constantly monitor the
evolving measurement system to identify and mitigate any potential unintended
consequences, such as increasing clinician burden and burn-out, adversely
impacting underserved populations and the clinicians that care for them, and
diverting attention disproportionately toward the things being measured to the
neglect of other critically important areas that cannot be directly measured
(e.g., empathy, humanity).”
In other words, the solution to physician anxiety over
performance measures is for the medical profession to work with policymakers to
fix performance measurement so that we are measuring the right things without
creating unintended consequences and without increasing clinician burden, not
to do away with them. As ACP first
articulated in its 2012 paper and reaffirmed in yesterday’s letter to CMS, the
medical profession must insist that measures be:
- Reliable, valid, and based on sound scientific
evidence
- Clearly defined
- Based on up-to date, accurate data
- Adjusted for variations in case mix, severity,
and risk
- Based on adequate sample size to be
representative
- Selected based on where there has been strong
consensus among stakeholders and predictive of overall quality performance
- Reflective of processes of care that physicians
and other clinicians can influence or impact
- Constructed to result in minimal or no
unintended harmful consequences (e.g., adversely affect access to care)
- As least burdensome as possible
- Related to clinical conditions prioritized to
have the greatest impact on improving patient health
Or, as Dr. Ejnes so aptly put it, “It was supposed to be
that if we provided high-quality care to our patients, the measurements would
reflect that. Instead, the mantra is that if we score well on our measures,
then that means that we provided high-quality care. In other words, the cart
has become the horse. It’s time to fix that.”
Today’s question: How would you fix performance measurement?
