WASHINGTON, D.C.—With the 2008 presidential election refocusing attention on healthcare reform and purchaser-driven pay-for-performance (P4P) initiatives prominent in the news, speakers at the Rheumatology Quality Stakeholders’ Summit here urged the ACR to accelerate its development of quality indicators in rheumatology.
A Quality Head Start
The ACR already has developed starter sets of quality indicators for RA, osteoporosis, and gout. The ACR also plans to launch a quality-management tool (which will include a central data registry) for rheumatic disease and drug monitoring measures in October 2008 at the ACR Annual Scientific Meeting.
“Your task is to develop a list of validated measures in one year for every disease you treat,” said Robert Brook, MD, ScD, vice president of RAND, a nonprofit research organization, and director of RAND Health in Santa Monica, Calif. “Determine where the holes are, and go to AHRQ [the federal Agency for Healthcare Research and Quality] and get them studied.” The ACR then needs to maintain and implement this comprehensive, clinically detailed set of quality-care indicators. “This is going to be a fundamental change. … I hope you force this agenda in a way that makes consistent sense,” added Dr. Brook.
The timing of the summit, held on Sept. 20, 2007, now seems prescient. On Sept. 28, Health and Human Services Secretary Michael Leavitt announced that the Centers for Medicare and Medicaid Services (CMS) will use Medicare data to generate physician quality performance–measurement results, which will be released at the community level. The quality measures will be consensus-based measures adopted by the AQA Alliance, a national coalition of health quality stakeholders, and endorsed by the National Quality Forum (NQF), a not-for-profit organization that creates strategies for national healthcare quality and reporting. Leavitt said release of the quality information supports CMS’ value-driven healthcare initiative, which seeks to create a system of better care at lower costs.
Rheumatologists can and should develop their own quality indicators—rather than having them superimposed by an outside entity—but the challenge is formidable, said Daniel H. Solomon, MD, MPH, associate professor of medicine and associate chief of Harvard Medical School’s Division of Pharmacoepidemiology and Pharmacoeconomics in Boston, and a member of The Rheumatologist’s editorial board.
“We’ve attempted to be proactive, but the landscape is changing rapidly,” said Dr. Solomon, who chairs the ACR’s Quality Measures Subcommittee. “It’s a tremendous task for a small specialty society. We want to make sure that what we do is practice friendly. The goal is to integrate quality measures into recertification programs.”
I think we have lots of data showing that we have room for improvement….It’s well documented that measurement leads to improvement.
Process Tracking to Outcomes Measures
Dr. Solomon, Dr. Brook, and other speakers noted some unique challenges to developing quality measures within rheumatology. Currently, most rheumatology quality measures are process measures rather than outcomes-based measures, such as whether a diagnosed RA patient is being treated with a disease modifying antirheumatic drug (unless there is a contraindication or inactive disease, or patient refusal is documented). The reason for focusing on process is that many rheumatologic diseases are chronic and require long-term management. Measuring outcome is difficult in the usual time-frame for this type of assessment. Management also involves many fewer procedures than, for example, cardiology. But, noted Dr. Solomon, “We want to move from process measures to outcomes-based measures.”
Healthcare purchasers speaking at the summit stressed that quality measures in medicine are part of a larger movement toward transparency, so that a purchaser can better evaluate what he or she is buying. “We’re trying to transform Medicare from a passive payer to an active purchaser of high-quality, efficient healthcare,” said Thomas B. Valuck, MD, JD, director of the Special Program Office for Value-Based Purchasing at CMS. Dr. Valuck cited CMS’s Physician Quality Reporting Initiative (PQRI), a new, voluntary Medicare program that offers a potential bonus of 1.5% for reporting on quality measures. (See “Medicare Quality Movement Reaches Clinicians,” June TR, p. 1, for more on PQRI.) “Pay-for-reporting is the first step toward P4P,” said Dr. Valuck.
Dr. Valuck noted that the Medicare Payment Advisory Commission (MEDPAC), which reports to Congress, supports the concept of value-based purchasing, and has developed principles to guide the design of a P4P program and select the quality measures that would support it. MEDPAC favors rewarding healthcare providers with financial bonuses, and has recommended that 1% to 2% of Medicare outlays be set aside for these financial rewards.
Dr. Valuck favors the utilization of quality measures that have been submitted by a physician specialty group, and also favors working through the consensus model. As did other speakers at the summit, Dr. Valuck said the electronic health record (EHR) should make the reporting of quality data feasible. “We’re moving from a claims-based to a more clinically based reporting system,” he said. “We need to take a long-term view of what we’re going to be accomplishing and not get discouraged. It’s not going to be perfect coming out of the gate.”
This perspective is important, he said, because the PQRI incentive bonus is too small to make much of a difference in the short-term. “I think the incentive amount didn’t really excite most folks,” said Dr. Valuck. “There’s just one pot of money. What I would encourage you to do is think of this as quality improvement. In the near future, the bonus won’t be a major driver. Over time we might be able to allocate more to the quality-improvement pool.”
We want to make sure that what we do is practice friendly. The goal is to integrate quality measures into recertification programs.
Insurer Perspective
Transparency of data is “very big in the health insurance industry right now,” said Catherine MacLean, MD, PhD, medical director of WellPoint, Inc., in Thousand Oaks, Calif. “Quality of data broadens the dialogue beyond fees to building a foundation of trust,” she added. WellPoint has P4P measures, but does not yet have ones for rheumatologic diseases. “Our P4P programs use nationally endorsed, standardized measures wherever possible. Performance measures should be robust, especially for specialty care,” she said. Asked by Dr. Solomon why rheumatology quality measures are not on the WellPoint list, Dr. MacLean said insurers would like to have quality and transparency data on all physicians, and rheumatology hasn’t yet been a priority.
“I think this is exactly what a specialty group should be doing in 2007–2008,” said Lewis G. Sandy, MD, senior vice president for clinical advancement at UnitedHealth Group in Minnetonka, Minn., of the ACR’s quality initiative. “Purchasers understand that there’s a lot of waste in the system. They’re paying for it. Purchasers are driving this whole movement.…If this is going to work, it’s not something that should be imposed onto physicians,” said Dr. Sandy.
During the summit, the issue of the ACR partnering on quality measures with one or more like-minded groups came up several times. “The ACR can drive this in a meaningful way,” said Dr. Sandy. “We would be more than willing to work with you to help make that happen.”
Dr. MacLean suggested that the ACR consider partnering with an established quality-measurement organization, such as the National Committee for Quality Assurance (NCQA). But Dr. Solomon pointed out that if the ACR does partner, it needs assurance that the quality measures it has set will not be changed or subtly tweaked. “The last thing we want to see is modification by an end user,” he told Thomas Lynn, MD, medical director of Symmetry Products, Ingenix, Eden Prairie, Minn.
Private Sector Wants Rheumatology Input
One approach to a consensus in the private sector on what constitutes P4P quality measures is for employers to link together and use the same quality data. Already about 100 employers have done this in a nonprofit program called Bridges to Excellence (BTE). “The disconnect between cost and quality is really troublesome to employers,” said Edison Machado, Jr., MD, MBA, BTE national accounts manager. “Bridges to Excellence tries to link performance with cost. It’s a part of the value-based purchasing movement.”
Dr. Machado noted that physicians are by nature competitive and they like being recognized by their colleagues, which is fundamentally what P4P does. “Employers are ultimately driving toward an outcomes-based result,” said Dr. Machado. “Our programs are based primarily on patient record data, not claims data.” The BTE programs are rooted in NCQA programs for excellence.
And, Dr. Machado added, “What we hear from employers is that organizations such as yours should establish quality measures and then define what high-quality care would look like as developed by your colleagues. Employers are looking for better outcomes for their employees … and also lower costs.”
Arthritis measures are of great interest to employers because arthritic diseases interfere with functional status. He cited RA as an especially important one for employers because it tends to strike employees in their working prime—ages 25 to 55. He also cited carpal tunnel syndrome, gout, and lupus as of high interest to employers. Dr. Machado said BTE would be receptive to working with the ACR on quality-measurement standards, but cautioned that it takes one to two years to get such a program up and running. He noted that its program on back pain took two years to develop.
A number of meeting attendees said the immediate business case for adopting quality measures is weak, especially for practices that don’t have an EHR. EHRs are a cornerstone of CMS’ value-driven healthcare initiative. “This may be a five- to 10-year time horizon,” noted Dr. Solomon, but he agreed with other speakers that quality is ultimately not about money, but about professionalism and what is best for patients.
This is exactly the position taken by Christine Cassel, MD, president of the American Board of Internal Medicine (ABIM). “The reason to support quality is because it’s a core professional value,” she said. Citing RAND data, she noted that, all over the country, patients can only expect to get the recommended treatment half the time; for Medicare patients, it is one-third of the time. “I think we have lots of data showing that we have room for improvement …” she said. “It’s well documented that measurement leads to improvement.”
