There has recently been significant discussion among ACR members about quality measurement, reporting, and improvement, especially in the context of the current national debate on healthcare. Some argue that quality reporting is impractical, burdensome to providers, and, most importantly, has not been shown to yield meaningful benefit to patients. They point to the imperfect science of quality measurement that, if improperly implemented, may actually worsen outcomes.1 They suggest that the current rheumatology quality indicators are more apt to improve quality in primary care than rheumatology, and that rheumatologists ought to demonstrate their commitment to quality by using more consequential measures. Many practitioners can’t fathom how they would fit even the most basic measurement into their days. They wonder what happened to physician autonomy in decision making—a skill that involves both science and art, and thus may not be quantifiable.
Over the past decade there has been an increasing awareness that the quality of medical care delivered in the United States is inadequate. Indeed, the Institute of Medicine (IOM) recently concluded that, “The immediate and dominant issue of greatest threat to the health and economic security of Americans is the failure of our healthcare system to deliver the value [quality/cost] that should be expected from the heath care we receive.”2 It is also clear that while per capita expenditures are higher than any other country in the world, healthcare in the United States consistently underperforms when compared with other countries. In its seminal document, the IOM described a quality “chasm.”3 Simply stated, often Americans do not receive the healthcare that they need, and often the care they do receive is not really needed. The recognition of the magnitude of the gap between the care that is delivered and the care that ought to be led to the development of quality-of-care measures and the use of such measures for the purposes of quality improvement. In the recently passed economics stimulus package, billions of dollars were allocated towards initiatives to improve healthcare. While the concerns expressed are all valid, the national imperative to improve healthcare quality is a train that has already left the station. I believe it is the ACR’s responsibility to jump on the train and work to influence its direction on behalf of its members.
Accurate and meaningful measurement of quality of care for rheumatic disease patients is an appealing concept, but the complexity of modern clinical practice makes it difficult.
Trials and Troubles of Real-World Quality Measurement
Accurate and meaningful measurement of quality of care for rheumatic disease patients is an appealing concept, but the complexity of modern clinical practice makes it difficult. Much of the care for rheumatology patients is delivered in settings that are out of their control. Patients are sent to other sites for lab testing or imaging studies, and other providers are often involved in their care. In addition, patient outcomes are affected by patient factors such as compliance and social factors. Health information systems can only partially influence quality, especially when these systems differ across providers and do not communicate with each other. So, rheumatologists have only a limited ability to fully control her or his patients’ quality of care.
Nonetheless, many are calling for individual physician accountability. The Centers for Medicare and Medicaid Services (CMS) has put into place its Physician Quality Reporting Initiative (PQRI), a pay-for-reporting program that is optional now but will likely become mandatory. Private payers have developed many similar programs that require providers to meet minimal reporting requirements in return for preferred placement on tiered provider lists that affect patient access and copayments. Employers have implemented pay-for-performance programs like Bridges to Excellence. All of these programs are based on quality indicators. Quality indicators are only a first step towards quality improvement because they represent minimal standards that convey only the most basic level of care, focusing on the processes of care rather than the outcomes. They do not reflect ideal care or even recommended care.
However, no one has figured out how to measure the system to fairly and accurately hold all parts accountable. Current approaches that evaluate individual providers, like a blind man feeling only one part of the elephant, can provide misleading information. Successful quality improvement must involve a comprehensive examination of the entire system. Although such an approach is a long way off, we must keep it in our sights, because it affords the best chance to have a major impact on health outcomes.
What Can the ACR Do?
As this movement evolves, the ACR must ensure its members are informed and have an opportunity to engage in the discussion. The ACR provides a forum for discussion through many avenues, including the list serves, where the dialogue may be informative, lively, and often controversial. The ACR also attempts to influence national decisions. We assert publicly that providers should be accountable for only one set of provider-approved measures. Although providers must recognize their responsibility to provide the best care at the lowest possible cost, their first responsibility is to their patients. Therefore, we consistently argue for measures that focus on processes and outcomes, rather than efficiency.4 Finally, we argue that any performance-reporting program from payers should compensate providers in exchange for their participation. This compensation could be in the form of additional payments for meeting quality requirements or reduced administrative burden (e.g., decreased prior authorization requirements), or both.
As these vital discussions continue, the ACR is developing products to help members deal with reporting requirements and improve quality within their practices. Here are some examples.
- ACR rheumatoid arthritis and gout practice improvement modules (PIMs) help practitioners meet ABIM Maintenance of Certification requirements.
- The ACR Rheumatology Clinical Registry will debut this spring. It will offer practices the benefit of PQRI reporting by taking advantage of the new registry reporting option.
- An evaluation of existing rheumatoid arthritis clinical disease activity measures will provide feedback on which measures are best for various purposes in a practice setting.
- Development of a quality-measures white paper to outline ACR positions on quality measurement and reporting. Members will have an opportunity to provide feedback on a draft of the paper via the ACR Web site.
- Development of relationships with electronic medical record (EMR) vendors to better influence their inclusion of a standard rheumatology template in their products. The goal is to make available EMRs more rheumatology friendly and interoperable with the clinical registry. ACR members can currently share their experiences with EMRs on the “EMR Review” section of the ACR Web site.
What the Future Holds
Rheumatologists practice in an environment where quality measurement and reporting are recognized to be imperfect but are expected. CMS and other payers have affirmed positions that favor value-based purchasing. National organizations that develop and implement quality measures have shifted from a process to an outcome orientation, with increased emphasis on care coordination that addresses systems issues. President Barack Obama and congressional leaders have stated their commitment to increased EMR implementation and other avenues directed at improved healthcare value. There is an increased emphasis on the central role of patients, which will lead to even greater calls for provider accountability.
These demands are real and warranted but will be extremely challenging to implement successfully. The ACR will continue to remain engaged in national efforts to improve healthcare quality, and we call on each of you to join us in working toward a future where quality improvement is a natural part of clinical practice. We recognize that the path to improve healthcare quality will be difficult and painful. There will be missteps and some failures. Many will question the rationale and long for the time when physicians were more autonomous. However, it is a path that must be taken because it is our professional responsibility to ensure that our patients reap the full benefits of what medical science has to offer.
Dr. Gabriel is president of the ACR. Contact her via e-mail at [email protected].
References
- Welker JA, Huston M, McCue JD. Antibiotic timing and errors in diagnosing pneumonia. Arch Intern Med. 2008; 168:351-356.
- IOM. Learning healthcare system concepts v. 2008. Washington, DC: Institute of Medicine.
- IOM. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: Institute of Medicine.
- Solomon DH, Tyndall A, Gabriel SE, Dougados M. Rheumatology gone global. Arthritis Rheum. 2008;59:1369-1370.
