Pay for Performance Will Have a Learning Curve

Some initial issues need to be addressed.

BY PRISCILLA P. ARNOLD, M.D.

In order to understand the current reality of "performance measurement," one must have some understanding of past developments. It is useful to look at these developments in terms of initiatives — which have coalesced and moved forward with quite remarkable force. What appears likely is that the performance measurement movement is going to continue to develop in some format, so attempting to ignore the situation does not seem to be a very wise option.

History of P4P

As will be clear below, 1998 to 2001 were somewhat pivotal years for an emerging pay-for-performance (P4P) mandate. In 1998, the National Quality Forum (NQF) was formed by a Presidential Advisory Commission, with the purpose of involving multiple stakeholders in "consensus decision-making" concerning healthcare issues. That organization has grown to include representatives of the healthcare provider, payer and regulatory segments of the United States, and has considerable leverage in decision-making. Also in 1998, the American Medical Association (AMA) formed the Physicians Consortium, which has been charged with developing clinical performance measures for physicians, and involves all specialties.

At this same time, the National Institutes of Medicine published two seminal reports which caught the public's attention and concern. Those publications were "To Err Is Human" (1999) which highlighted medical errors, and "Crossing the Quality Chasm" (2001). I will quote from the latter, "The only way to know whether the quality of care is changing is to measure performance." (italics are mine) If there is a motto for the P4P movement, this is it.

In 2000, the American Board of Medical Specialties issued a requirement that maintenance of certification for all specialties include some method of performance measurement. Large corporate business interests formed the Leapfrog Group in 2000, and the Bridges to Excellence project in 2001 — both aimed at identifying and measuring quality in health care. Lastly, the Centers for Medicare and Medicaid Services (CMS) began special hospital-based demonstration projects over several years to first reward reporting, and then improvement, in certain areas of care.

Recent Events

This brings us to the current situation. In 2006, CMS identified and funded development of physician-reporting measures, including eye care, in preparation for individual physician reporting. These measures were developed through the Physicians Consortium, but also had to be approved by larger consensus-based organizations. As most ophthalmologists know, in 2007 CMS instituted the Physician Quality Reporting Initiative (PQRI) program, which ran for the last 6 months of the year and was entirely voluntary. As the name implies, the purpose was to encourage reporting.

It is instructive to know what the reporting experience from that 2007 program has proven to be — now that we have data from CMS. There were eight potential measures for ophthalmology. To participate, one had to select at least three of those measures, and report on them at least 80% of the time that diagnosis was eligible.

First Reporting Experience

Here's what we have learned from CMS. First, depending on the measure, only 17% to 25% of eligible physicians (M.D., D.O. or O.D.) participated in reporting the eyecare measures. Secondly, depending on the measure, only 50% to 80% of those reporting used their National Provider Identifier (NPI) correctly, so many will not get credit for the project. Lastly, only 45% to 60% reported at least 80% of the time on their chosen measure, so those practices that did not report at least 80% of the time will similarly not get credit — or any bonus. These figures illustrate that we have a long way to go just in the mechanics of measure reporting. This does not even address the question of when the actual bonus for reporting will be paid to those who properly participated.

2008 Program and Beyond

Now we find ourselves in 2008, with a 12-month voluntary program. One big change this year is that there are no cataract measures. That is because the three measures from 2007 did not receive NQF consensus approval. We do have the opportunity to report three additional measures (see accompanying box: "2008 Ophthalmology P4P Measures"). Reporting is still on administrative data claims. Rather than discuss the 2008 program, which is really an extension of 2007, I would like to make some predictions for the future, realizing that we do not know yet whether the PQRI program will continue to exist beyond 2008.

► outcomes measures will be required, rather than just "process" measures. This will raise new problems in the logistics of reporting

► because of these logistical problems, data registries will be utilized for clinical outcome reporting — already this is a reality in a few specialties

► Health Information Technology will be made mandatory and will have to be appropriately certified, interoperational and compliant with privacy regulations. Larger groups and systems will have distinct advantages in this regard over smaller practices.

► cost of care will be measured. Additionally, we will see disease management grouped into "episodes of care" for evaluation of total costs

► public reporting of measures will occur, as it has for the hospital projects

► funding methodology for all of this is really unknown and highly problematic.

No one can be certain what will happen with CMS funding or mandates, but I do not expect this program to go away — though many wish for that. There is simply too much consensus (the operative word) that measurement of performance will allow identification of better quality of care. The physician community certainly understands that whenever the most appropriate care pattern can be defined, that should be the standard utilized. We are the best advocates for the care of our patients, even in a challenging situation such as P4P. OM

Priscilla P. Arnold, M.D., is past president and chair, Government Relations of ASCRS. She is also a delegate, Physicians Consortium, AQA, SQA, NQF, and a member of the Eyecare Measure Development Workshop. Dr. Arnold can be reached at ppa@suddenlink.net