Confusion exists about the quality movement, an emerging trend to improve the quality of medical care, and to link improvements to physician reimbursement. Using the limited information available, many physicians have difficulty anticipating the direct effect of a pay-for-performance program on practice workflow, productivity, and income. Nonetheless, quality measurement and performance-based payment are approaching realities with implications for both practicing and academic rheumatologists.
The entities with the greatest influence over our healthcare system, including private insurers, the federal government, and academic medicine, have embraced the philosophy of the movement and have begun to support initiatives that will ensure the integration of quality-based programs into every sector of healthcare delivery. TR spoke with four ACR members who have direct experience with quality-based initiatives to get their perspective on the subject.
As articulated in reports from the Institute of Medicine, the quality movement attempts to “close the chasm between what we know to be good quality care and what actually exists in practice,” including the overuse, misuse, and underuse of available treatments—by developing patient-care standards based on the best available scientific evidence.
Those driving the quality movement then propose to implement these standards through enhanced communication and broad-based consensus, and by building monitoring and enforcement elements into the healthcare system. These elements can be as simple as providing a bonus to a physician who ranks highly according to the standards (or, possibly, a penalty for a low ranking physician). This approach of creating and implementing quality standards assumes that everyone has agreed upon what quality is, what the standards are, how we measure quality, and how we measure the delivery of care according to quality standards.
In practice, developing and implementing standards is complicated. Evidence needed to develop and validate standards is not always available. Often, new data must be gathered and analyzed, and abstracting data from medical charts and records can be an arduous task. In addition, getting consensus between payers and providers on the valid measures of quality and performance can be challenging. However, a few pioneering institutions have had success implementing a quality improvement system.
A Pain-Free Quality Experience
Salahuddin Kazi, MD, chief of rheumatology at the Veterans Affairs (VA) Medical Center in Dallas, has considerable experience with practicing in a quality-based environment because the VA has been one of the leaders in implementing these programs. His experience has been a positive one, and he considers himself an advocate for the movement, having written an internal medical grand rounds paper for the University of Texas Southwestern Medical Center entitled “Performance Anxiety,” which is intended to allay physician fear of the issue.
“Within rheumatology, there are simple activities that should be done with every patient that are not always being done, such as tests carried out at baseline and subsequently every eight weeks for patients on methotrexate,” says Dr. Kazi. “Most rheumatologists just need a reminder. So, when a quality system is put in place, the reminder pops up at the right time. Ultimately, this type of approach will improve care for all patients.”
Dr. Kazi acknowledges that his experience through the VA has been relatively pain-free because the investment in a VA-wide electronic system to gather data and monitor performance and outcomes was spread over hundreds of physicians and multiple locations. In addition, the VA currently offers its physicians bonuses for good performance and has no penalty system.
“It’s important that the ACR offer its members a tool that can help them to efficiently meet the requirements of quality-based programs regardless of where they practice,” he says. He stresses that obtaining buy-in—convincing members that this is the way medicine will be practiced in the future—is the most important goal.
Quality Measures that Make Sense
The ACR is no stranger to the concept of quality care for rheumatic disease. For many years, the College has been at the forefront of authoring guidelines and recommendations for the diagnosis and treatment of rheumatic diseases. However, once the ACR recognized that quality measurement requirements would be linked to rheumatology reimbursement, the ACR saw a significant opportunity to gain a foothold in crafting measures that make sense.
As the quality movement gained momentum, the ACR realized that the implications of this movement are much wider than just developing criteria and treatment guidelines. In rheumatology, in particular, the ACR has the opportunity to establish evidence-based guidelines, which will then be used as the basis for performance indicators designed to measure the quality of care that is delivered.
To this end, the ACR has embarked on a comprehensive program to establish its leadership in the quality field on issues pertinent to the treatment of rheumatic disease. The initiative aims to continue to develop recommendations for the care of patients with rheumatic diseases and quality performance indicators, or QPIs, for most rheumatic diseases, as well as to educate rheumatologists and rheumatology health professionals about the quality movement.
The College will also reach out to key stakeholders (private insurers, employers, federal agencies) to educate them about the ACR’s activities, encourage adoption of the ACR’s measures, and support rheumatologists who care for patients according to the ACR’s recommended approach. The ACR recognizes that collaboration with outside organizations is vital to its goal of representing the interests of rheumatologists in the quality movement.
Mending Quality’s Bad Rap
Mark Robbins, MD, a rheumatologist with Harvard Vanguard Medical Associates in Boston, expressed possible reasons why many of his rheumatology colleagues might mistrust the linkage of quality measurement to physician reimbursement.
“Physicians have seen quality measurement and improvement initiatives that initially begin as bonus incentive systems deteriorate into reimbursement withholds or financial penalties for noncompliance,” he says. “In addition, physicians remain skeptical on the validity of quality indicators chosen and even whether action on these indicators truly leads to improvements in clinical care.
“Colleagues also ask me how, in a time-bankrupt environment—where we have little or no time to devote to anything else, much less this—they are supposed to devote more time from clinical care to quality reporting, or how such a system will address issues of differences between physicians and practices in patient severity of illness, which could skew their outcomes data,” he continues. “These are both valid concerns.”
Dr. Robbins sees ACR’s role as critical to ensuring that measures are chosen and their implementation in practice is both clinically and administratively reasonable. “Quality measurement and reporting will be another burden for the practice, but the best edge we can gain is for the ACR to develop measures that are intuitive and not too burdensome to capture,” he says. “In the end, would you rather have a group of your colleagues select and validate the measures or your local healthcare insurer?”
The ACR recognizes that developing QPIs will be a large task requiring long-term commitment and significant funding. Most importantly, the College understands that the success of its effort will depend heavily on the participation of ACR members—from supporting the ACR’s involvement in the quality movement to contributing practice data to provide a robust database on rheumatology care and outcomes, which will serve as a means to validate the quality measures.
For this reason, the ACR’s Quality of Care Subcommittee—which is chaired by Larry Anderson, MD, a rheumatologist and director of quality improvement of MaineHealth in Portland, and is part of the Quality Measures Committee—is examining options for data gathering and reporting. Its goal is to make an inexpensive, easy-to-use tool available to all members that will be provide decision support, and permit members to contribute their anonymized data to a central ACR database to analyze outcomes. Options under consideration include creating a Web-based registry that rheumatologists can log in to and working with some of the leading electronic medical record vendors to adapt one of their products for use.
A Quality Triumph
Murray Passo, MD, clinical director of rheumatology at Cincinnati Children’s Hospital, is a pediatric rheumatologist at an institution regarded as a pioneer in the quality movement. Six years ago, Children’s Hospital joined a Robert Wood Johnson Foundation initiative to improve the quality of acute and chronic patient care. The results can be clearly demonstrated in quantitative terms.
For example, prior to the quality program, only 44% to 50% of juvenile RA patients at Children’s Hospital received guideline-directed uveitis screenings; now 95% get these screenings on schedule. In addition, patient data have been entered into a Web-based registry, so children with juvenile RA (and their parents) can look up their own labs, medications, and other medical information online to help them monitor and self-manage their illness.
Dr. Passo also understands the reluctance of many rheumatologists to embrace the quality movement. “Doctors feel they’re already going above and beyond,” he says. “They think this is just one more thing that’s going to exhaust their resources—which is what I had feared, as well.” But he says that what they learned at Children’s “has become ingrained in everything we do on a day-to-day basis. It’s part of our culture.”
Importantly, pay-for-performance “remained in background,” notes Dr. Passo. He wasn’t sure that the pediatricians and faculty even recognized this was a component of the program. “All of our efforts were based on improving outcomes for kids with different diseases across the institution,” he says.
Specialists Get Ready
Dr. Anderson says large employers and the government want to identify high-quality, low-cost physicians and hospitals. “Specialists control 80% of all healthcare spending in this country. As specialists, we will be held increasingly accountable for the effectiveness and efficiency of our care.”
The Quality of Care Subcommittee is looking at options for data collection and reporting tools that will enable documentation of the quality of care. In addition to physician-based tools, the subcommittee is also looking at tools that can capture patient-generated data, such as a patient’s degree of pain. Ideally, pre-visit patient information gathered electronically and displayed appropriately to the physician may improve the efficiency of the office visit.
Dr. Anderson is a strong supporter of the quality movement, but he is well aware of the potential risks. “There are challenges in finding the balance between executing evidence-based care and protecting time to continue practicing the art of medicine, so important to all of us in rheumatology,” he says. He believes that ACR needs to carefully follow what the private payers are doing, and to work with entities such as the AMA, the National Quality Forum, the National Committee for Quality Assurance, and AQA Alliance to ensure that ACR’s measures are being adopted and that the measures are clinically relevant and feasible for implementation.
Dr. Anderson says the ACR “is working to prepare its members for what is coming in the new quality-based reimbursement environment. We will be required to measure what we do, analyze the data, and learn to change office systems to improve adherence to evidence-based care. Whatever we do should be patient centered.”
