How Physician Quality Measures Are Developed
If physicians measure the care they deliver, the improvements will come. So goes the thinking when it comes to reforming the health care system. But who actually builds those doctor quality measures, and how? As it turns out, practicing physicians themselves largely drive the metrics they are accountable for as health care inches toward a value-based payment system that factors in both costs and care improvement. Keeping a seat at the quality table will be even more important as measures become more sophisticated and less voluntary, Texas Medical Association leaders say.
The definition of quality can be complex and controversial because of the different views of people with a stake in good health care.
Physicians tend to view quality in a technical sense – accuracy of diagnosis, appropriateness of therapy, resulting health outcome. Physicians want to provide the best service using the most accurate tests and treatments (which at times, may be the most expensive). Physicians also want to provide preventative care which the insurance company (payer) may not cover.
Payers generally focus on cost-effectiveness. Payers want providers to follow a clear, documented, evidence based, diagnostic plan and reach an accurate diagnosis and treatment plan with the fewest visits and least number of tests.
Patients want compassion as well as skill with clear communication. Patients expect an employer to offer a wide variety of options for health coverage that can be customized to their specific needs. They also look for the employer to fund the majority of the cost of health insurance.
Employers want to maintain or lower their cost contribution. They want the patient/employee to seek only needed care, follow providers’ instructions, and recover quickly to full utility.
Complexity of disease process. Many health care issues are very complex. The disease process may be chronic or acute. As intended consequences may be difficult to measure, a measurable process in place of one that is tougher to get at (a proxy measure) or an evaluation of a process, rather than an outcome may be used.
Complexity of data. For example, physicians may be interested in how effective the practice is in counseling for smoking cessation. Since details of that are embedded in free text in medical records, to enable a practice to make use of computer records, a practice may choose instead to look at:
Complexity of attribution. Correctly and systematically attributing patients and certain aspects of care to individual physicians when increasingly complex patients and conditions require teams of care is difficult. Yet, answering this question is critical for improving individual physician performance, as well as ensuring a fair credentialing process.
Complexity of systems. Quality of care may not be high due to medical, patient or system reasons. Oftentimes, this is difficult to indicate within quality implementation programs.
TMA staff has prepared the following report, which captures those parts of the Affordable Care Act that impact quality measurement and performance.
The survey also found that the vast majority of physicians do not see that federal or commercial initiatives to measure quality lead to improvements in their patient care, and prevention of "never events" and medication errors have the highest physician participation.
TMA Past President Josie Williams, MD said the survey results indicate that it is time for physicians "to think about how you are going to implement electronic health records, when are you going to implement them, and how they will help you improve care. This also will give you the information you need to compare your data with what you're going to be getting from hospitals, from Centers for Medicare and Medicaid Services (CMS), and from insurance companies so you can either disagree, prove wrong, or agree."
Among the survey's key findings:
TMA again surveyed physician stakeholders and thought leaders to assess the needs of physicians regarding quality improvement. The latest report, in 2011, captured the following trends:
Interviews with Texas physician leaders revealed these keys to creating and sustaining a successful culture of safety and quality:
Commitment to quality
Philosophy of teamwork
Attitude of change
Tracking, measuring, and reporting
Since long before then, Texas physicians have had the desire to provide the best possible care. This evolution is not new, but has been building steadily over the last decade or more. Physicians must prepare themselves and their practices for the increased accountability that surely will be demanded of them in the days ahead by those in both private and public sectors. Physicians generally have been unhappy with government and private health plan attempts to measure the quality of their care, but former TMA President Josie R. Williams, MD, says performance measurement is here to stay. TMA Trustee Carlos Cárdenas, MD, adds that measuring quality data not only will help physicians improve the quality of their care, but also will be their best defense against economic credentialing and pay-for-performance schemes.
Texas physicians have a professional responsibility to provide evidence-based health care consistently while asking, "How can we do things better?"
Now is the time to evaluate the daily practice of medicine and begin to implement those changes that will yield higher levels of patient safety and more effective, efficient care. Continuous quality improvement depends on physician leaders to nurture and drive teams sharing a common vision - one that is ultimately realized through the care provided every day, every time, and for every patient.
As part of a case studies report to better understand this new arena of healthcare, TMA Clinical Advocacy Department staff interviewed a dozen Texas physicians in a variety of clinical settings about their efforts to improve quality in their practice or hospital. The settings ranged from solo practitioners in rural Texas to large multispecialty groups to physician-owned hospitals to large hospital systems. While the report found that larger organizations may have the economic infrastructure and necessary resources to effect big change, the presence of those factors alone is not enough to ensure a true culture of quality and patient safety. "Through our case studies and interviews, it became very apparent that adopting a personal philosophy and professional commitment to always provide the highest level of effective and efficient care is only the first step," the report stated. "To make it work, quality must be driven from the top down, no matter the size or complexity of the organization. And, it is essential for physicians to understand that they must objectively revisit and redefine their traditional authoritarian positions to allow all members of the team to be seen as valuable and vital to success."
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