Take the Reins

Among physicians these days, introducing the subject of quality and the entity known as the quality movement is a bit like talking about U.S. politics: There are a wide range of views. When the subject of quality is raised, there are the “true believers” who think the quality movement is the only option to standardize and improve medical care in the United States while addressing the reality of spiraling healthcare costs, and there are the “hard skeptics” who are convinced that the quality movement is just another scheme to squeeze more out of already embattled clinicians and restrict treatment options to the cheapest alternatives. Many members fall somewhere between the two ends of the spectrum.

A recent poll of ACR members on the quality movement found that these broad views are reflected by our membership. It’s not difficult to see why some physicians would be skeptical. The worthwhile aims of the quality movement may appear at odds with those of its big endorsers such as the Centers for Medicare and Medicaid Services and private insurance—especially from the perspective of a community-based, small-practice clinician. Invariably, among clinicians, the discussion turns to pay-for-performance (P4P) and horror stories of incentive systems that mutated into penalty systems based on arbitrary assessments of “quality of care.”

Expand the Quality Discussion

In a way, it’s unfortunate that discussions of quality are often reduced to discussions of one or two implementation tactics such as P4P and physician rankings because there is great potential to use this movement to promote improvement in care for chronically ill patients. On the other hand, realities such as P4P do make clinicians sit up and take notice of the quality issue that will have a profound influence on how medicine is practiced in the United States in the not too distant future (in fact, it’s already here in some regions).

For some time, the ACR has been monitoring the emergence of the quality movement and planning the College’s representation of the rheumatology community within the quality sphere. We have embarked on a long-term initiative to develop quality performance indicators for rheumatologic disease. This will ensure that our members will be measured on provision of care that is based on judicious review of scientific evidence by rheumatology experts. We have built into this initiative several complementary activities. This will ensure that the interests and positions of rheumatologists are represented when discussions around implementation, adoption, and enforcement of quality programs take place.

We continue to believe that if we engage in the quality movement in the right way and help to steer its adoption appropriately, we will improve the care of rheumatology patients without penalizing rheumatologists financially.

In our member poll, we received some important feedback. First, members wholeheartedly support the ACR’s position that, by virtue of the expertise of its membership in studying and treating rheumatic disease, the College is the entity that should be leading the quality effort on behalf of rheumatology patients and those who care for them.

Draw on the Voice of Experience

The second piece of feedback—perhaps the most important at this juncture—is that our members look to the ACR to inform and educate them on how the quality movement is taking hold and entering into our practices. In this issue of The Rheumatologist, we have provided the perspectives of four rheumatologists who have lived with quality for a while now. (See “Control Quality Anxiety,” page 24). Each of them has had different experiences, which have informed their perspectives and given them a strong appreciation for the benefits and risks associated with quality.

We are lucky to have these rheumatologists among our band of volunteers who are actively participating in the committees and subcommittees that guide our quality-related initiatives. Importantly, these volunteers represent our general ACR membership. They represent the perspectives of community-based rheumatologists (large and small), academic rheumatologists, and those working in hospital-based systems.

As you read their opinions, I’m sure you will appreciate that, while the ACR believes the quality movement will reduce gaps in disparity of care and improve treatment for patients with rheumatologic disease, our committee members are also cognizant of members’ concerns. In addition to developing quality indicators, guidelines, and treatment algorithms, ACR quality activities are designed to provide support to all rheumatologists. ACR is addressing the business issues, such as the price tag of systems, data entry burdens, pressure from payers, and conflicts between cost and quality care.

Ultimately, we know that our members’ primary concern is for their patients and we are determined to promote and defend the ability of rheumatologists to provide quality care to their patients.

We look forward to bringing you more information about the quality movement and the ACR’s involvement in it in future issues of The Rheumatologist, as well as through other ACR communication lines.

Dr. Birnbaum is president-elect of ACR.