November 16, 2015

Studying the 1,400 pages of the Final Fee Schedule Rule for 2016, which CMS released on October 30, has made us stop to think about the status and benefits of quality measurement in healthcare.  In particular, the ever-growing complexity of the Physician Quality Reporting Program (PQRS) and the newer Value Based Payment Modifier seems more likely to generate frustration than to lead to major improvements in healthcare safety and outcomes.

As noted in last week’s Announcement (The Anesthesia Conversion Factor and PQRS Changes in the Final Medicare Fee Schedule Rule for 2016), CMS is adding five items advocated by ASA to the list of PQRS measures that can be reported to a registry:

• Measure # 404:  Anesthesiology Smoking Abstinence;
• Measure # 424:  Perioperative Temperature Management  (which revises and replaces Measure # 193);
• Measure # 426:  Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU) (using a checklist or protocol);
• Measure # 427:  Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU), and
• Measure # 430:  Prevention of Post-Operative Nausea and Vomiting (PONV) – Combination Therapy.

Together with the current measures that will remain available for anesthesiologists’ PQRS reporting—Measure #76 (Prevention of Central Venous Catheter Related Bloodstream Infections) and Measure #44 (Preoperative Beta-Blocker in Patients with Isolated CABG Surgery; reportable only through a registry beginning in 2016)—and the various “cross-cutting” measures such as inquiring into the existence of an Advance Care Plan (Measure #47), at least one of which must be reported if the physician submits claims for any visit services, do the items on this list give real understanding into the quality of anesthesia care?  And should they be the basis for financial incentives or penalties?

Ashish Jha, MD, MPH wrote on his blog An Ounce of Evidence on March 20, 2014 (What makes a good doctor, and can we measure it?) that the effective use of beta-blockers or good hemoglobin A1C control are important,

But I’m not sure they really measure the quality of the physician.  They measure quality of the system in which the physician practices.  You can have a mediocre physician, but on a good team with excellent clinical support staff, those things get done.  Even the smartest physician who knows the evidence perfectly can’t deliver consistently reliable care if there isn’t a system built around him or her to do so.

The inability of current quality measures to capture the quality of the physician’s work is one of the factors considered by Sabriya Rice in her article Physician Quality Pay Not Paying Off  published in Modern Healthcare on May 15, 2015.  As various observers have noted, the science of measuring quality is still very immature—and thus linking the existing measures to compensation, Rice writes, “might be premature.  Improvements seen on easily tracked process measures such as checklist use or giving discharge instructions may not lead to improvements in patient outcomes such as lower mortality and lower readmission rates.” 

In addition to the lack of well-defined and actionable measures that make sense to the physicians being assessed, overly complex compensation designs and poor alignment of goals have led to disappointing results for a number of pay-for-performance programs.  Not understanding the actual barriers to desired behaviors and results—lack of knowledge, resources or motivation, for example—is also an impediment.  Rice cites several examples  of programs that failed to deliver, including that of Fairview Health Services in Minnesota, which tied 40 percent of clinician compensation to performance on a suite of metrics required by state law, with salary increases based on overall group performance on benchmarks for diabetes, cardiovascular and asthma care and select cancer screenings.  The compensation model was most effective with the poorest-performing physicians, who improved six times more than the higher performers.  Overall, quality at Fairview improved no more than it did at competing system that did not institute any pay-for-performance programs.  

On the other hand, some health systems are encountering success in paying their physicians for meeting quality measures and otherwise participating in population health improvement programs.  Gregory A. Freeman, writing in the September 2015 issue of HealthLeaders magazine (Financial Incentives for Physicians), points to three such systems and to the lessons learned from each:

1. Lodi Health, operating a single hospital in California, has been involved with Medicare’s Bundled Payments for Care Improvement Initiative for total joint procedures for two years.  During the first year of participation, the only one for which results are currently available, Lodi’s costs covering 30 days of postoperative care came in under the CMS benchmarks in every quarter, enabling Lodi to share in the savings.  Initially reluctant to collaborate in designing more standardized perioperative care, Lodi’s orthopedic surgeons are now showing interest in participating in the hospital’s gainsharing program and in the increased volume of cases going to the orthopedic surgeons who are already on board.  What Lodi plans to do as it considers additional bundled payment initiatives is to secure earlier physician buy-in so that the doctors will help design and take ownership of the program.
2. The chief medical officer at Texas Health Physicians Group, which counts nearly 850 primary care physicians in 250 clinics across the state, realized the importance of involving physicians from the beginning.  The physicians wrote, and the organization adopted, a “compact” defining the parties’ expectations of each other and addressing topics such as clinical excellence.  Among other things, the organization’s physicians are now required to demonstrate training and proficiency in high-reliability principles.  The organization provides physicians with a data analysis tool that allows them to examine their own patient data and identify gaps in care and requires that they use the tool as a condition to participating in a new quality bonus program that offers up to 15 percent of salary for meeting 13 basic measures.
3. At Bon Secours Health System in Marriottville, Maryland, all 250 physicians who were eligible for the Primary Care Quality Incentive Program launched this year opted to participate.  The incentive is based on three components:  citizenship (attending 75 percent of relevant meetings and completing required training on topics such as infection control and HIPAA);  successful attestation to meaningful use of Bon Secours’ electronic health records, and compliance with the 33 quality measures for which Bon Secours is accountable as an ACO participating in the Medicare Shared Savings Program.  If the physician only satisfies one or two of the three requirements, he or she is eligible for a partial bonus.

Unlike the pay-for-performance programs summarized above, Medicare’s PQRS has never had physician buy-in.  The incentive payments have for many physicians been less than the costs of compliance.  Now that there are no payments for meeting the requirements but only a penalty—which for some large practices may go as high as six percent based on performance in 2015—the calculus may change.  Nevertheless, participation is apt to remain grudging as long as the measures do not equate to physicians’ own perception of quality.  As stated in a Health Affairs Health Policy Brief on Physician Compare published online on December 11, 2014,

Physician accountability and quality improvement advocates complain that the field has been stuck for many years with too many measures of the processes of care and not actual patient outcomes. For example, it is important and relatively easy to measure how many patients in a group practice get a blood sugar test. More difficult but more meaningful is how many of that practice's diabetes patients suffer, over time, the problems (such as blindness and heart disease) that result from poor blood sugar control.

Indeed, after ten years of "measure development," most of the measures of physician performance still fall into the "process" category.

One vehicle that bypasses the issues of validity around individual physician quality measures is the Perioperative Surgical Home (PSH) model.  “The overall goal of the PSH is to provide improved clinical outcomes and better perioperative service at lower cost.”  (Kain ZN. et al., The Perioperative Surgical Home as a Future Perioperative Practice Model, Anesth Analg 2014;118:1126-1130.)  The PSH route to improved clinical outcomes is the use of procedure-specific integrated care pathways and/or standardized clinical assessment and management plans (SCAMPs) rather than a set of process measures.  (See Vetter TR, et al.  The Perioperative Surgical Home: How Anesthesiology Can Collaboratively Achieve and Leverage the Triple Aim in Health Care,  Anesth Analg 2014;118:1131-1136.)  Measures have an important role to play in the PSH.  Internally reported (private) measures—that is, measures of operational efficiency such as case postponement and cancellation rates, safety measures  such as sepsis and patient experience measures such as prevention of postoperative nausea and vomiting—will provide the PSH members with performance information at the level of the organization, team or individual provider.  Externally reported measures, including those available through the PQRS, “will demonstrate the success of the PSH concept over time, by showing an increase in the value of care.”  (ASA Committee on Future Models of Anesthesia Practice, Perioperative Surgical Home Brief, 7/15/13).  The real determinant of success in the various PSH initiatives developing around the country, however, will be the quantified improvement in patient outcomes and reduced costs through the PSH’s team-based system of coordinated care that guides the patient throughout the entire surgical experience.  That improvement, and not the number of process measures checked off on a record created for traditional fee-for-service payment purposes, will be the best gauge of quality.

With best wishes,

Tony Mira
President and CEO