TMA Quality Experts

Council Helps Physicians Be Better Doctors

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Quality Feature – January 2012

Tex Med. 2012;108(1):49-52. 

By Ken Ortolon
Senior Editor

It does not matter what you call it. Performance measurement, value-base purchasing, accountable care, pay for performance, or clinical effectiveness. The fact is commercial health plans and state and federal governments have thrown a plethora of health care quality initiatives – or pseudo-quality initiatives – at physicians in recent years. And, with the ongoing implementation of the Affordable Care Act (ACA), Texas Medical Association officials say pressure will grow on physicians to measure and document the quality of their care.

That is why TMA created a new Council on Health Care Quality to represent physicians and patients in developing new health care quality policy and to educate physicians on the opportunities and challenges these quality initiatives present. Physicians likely will see chances to increase revenue in their practices and provide better care for their patients. Challenges include the complexity of some of these initiatives and the fact that each payer will have its own program.

TMA President C. Bruce Malone, MD, says TMA recognized that under health system reform physicians increasingly would be judged on their performance and their ability to document the care they provide.

"We know that doctors are going to be measured in the future. We know that sometimes payments are going to be tied to those quality measures," said Dr. Malone, an orthopedic surgeon in Austin. "We feel like TMA needs to have a group that has the expertise to evaluate those measures and can advocate for physicians in those programs."

Houston internist Lisa Ehrlich, MD, a member of the new council, says it will help physicians deal with quality reporting and measurement.

"The council is going to have to open a doorway to provide education for physicians to figure out how to navigate through this changing environment," she said.

Getting Started

The TMA House of Delegates approved the council in May 2011 after several months of study that started during the tenure of TMA Immediate Past President Susan Rudd Bailey, MD. She wanted to know how the association could look out for physicians in quality improvement, patient safety, clinical effectiveness, and performance measurement.

Dr. Malone, who appointed the original members of the new panel, says the vision of Dr. Bailey and former TMA President Josie R. Williams, MD, led to the creation of the panel.

"For years, Dr. Williams has been telling us that we need to pay more attention to the measurement of quality and determination of quality outcomes and that if doctors owned that data, we'd be better off," Dr. Malone said.

Health plans try to measure quality, often relying on claims data to rank physicians. Many of those schemes meet vocal opposition from physicians who believe they are more an effort to cut costs than to truly promote quality improvement.

More recently, the government has gotten into the act. Medicare's Physician Quality Reporting System (PQRS) rewards physicians for reporting data on certain quality measures. And new initiatives under ACA include a Physician Compare website on which patients can search for physicians by a number of criteria, including whether they participate in PQRS and Medicare’s electronic prescribing initiatives.

Specialty societies and certification boards have launched their own quality initiatives. For example, Dr. Malone says, the American Academy of Orthopedic Surgeons spent millions of dollars creating best practices profiles. And, some specialty boards now require quality improvement activities for recertification.

Dr. Malone says physicians must realize they are responsible for documenting that they provide high-quality care. That can be difficult and expensive because it requires investment in electronic medical records or time-consuming paper chart review.

With all of that facing physicians, TMA officials felt it was essential to focus more of the association's attention on helping members understand and comply with those initiatives.

In 2010, Dr. Bailey appointed an Ad Hoc Committee on Health Care Quality to evaluate TMA's strategic direction and members' needs in performance measure, patient safety, clinical effectiveness, and quality improvement. That group, chaired by El Paso emergency physician Robert H. Emmick Jr., MD, issued several findings, including the fact that many Texas physicians do not take advantage of financial incentives offered by PQRS, Medicare electronic prescribing initiatives, and others.

The committee also concluded that quality efforts should be linked to increased payments to offset lost productivity, the cost of information technology, and increased staffing required to comply with many of the quality reporting initiatives.

The panel recommended forming the new council to:  

  • Create a physician role in establishing policy on quality improvement, patient safety, and performance measurement;
  • Give physicians education and resources, including continuing medical education (CME);
  • Prepare physicians for the upcoming challenges of value-based payment; and
  • Educate state and federal governments about the obstacles small practices face in implementing quality improvement, patient safety, and performance measurement programs.  

The council expects to achieve those goals by developing web-based information, CME courses, and presentations at TMA meetings, and by lobbying state and federal agencies.

The council also will educate physicians on opportunities to use federal and state incentives to improve patient outcomes and will give them a forum to encourage quality improvement and improved patient safety via evidence-based, transparent, and standardized performance measurement and methodologies. TMA hopes that allows doctors to have full information on how insurers determine their physician rankings and lead to similar sets of rules for each payer's program.

"The thing we're concerned about is that insurance companies have tried to create these measures, and they've tried to use claims data as a basis for measuring quality," Dr. Malone said. "We know that's really not the right way to do it, and it produces information that's not, perhaps, useful. This council is going to be charged with starting the process of creating quality measures that can be done by doctors in their offices."

Setting Priorities

At its initial meeting, the council discussed potential priorities for its work. Number one on its list, says Chair Frank Villamaria, MD, is clinical advocacy on behalf of physicians and patients as health insurers and government roll out new regulations for quality reporting and measurement. Dr. Villamaria is an anesthesiologist at Scott and White in Temple.

He says very few state medical associations attempt to influence policy on health care quality in this way. "TMA is leading the way in this new effort."

Another high priority is helping physicians take advantage of programs like Medicare's PQRS, which provides bonuses for quality reporting, and Bridges to Excellence, a Blue Cross and Blue Shield of Texas program that recognizes physicians who meet certain evidence-based standards in treating chronic illnesses. In Texas, physicians in the Blue Cross network can earn bonuses for meeting those standards in diabetes and cardiac care. (See "A Healthy Bonus," October 2011 Texas Medicine, pages 16-21.)

The third priority, Dr. Villamaria says, is education.

"One of the most important things is to educate the TMA membership on what's happening on the state and national scene with quality. Things are going to change with the new health care law, and we need to help our members prepare."

In fact, ACA includes several quality-related provisions that will impact physician practices. Among them are requiring physicians to develop quality improvement plans to contract with insurers in health exchanges, authorizing the new Center for Medicare and Medicaid Innovation to test new payment models that encourage better quality and lower cost, and requiring the U.S. Department of Health and Human Services to develop the Physician Compare website.

Dr. Villamaria says younger physicians may be better equipped to deal with these changes because medical schools and residency programs put more emphasis on quality improvement tools, patient satisfaction, and best practices than they did a generation ago.

"I'm 56 years old, and that certainly was not on the radar screen when I was a resident or a medical student," he said. "So I've learned that over the course of my career. We need to develop avenues through which physicians who are interested in learning more about quality and quality improvement can do that."

One of the ways the council hopes to deploy this information is via web-based and social media tools.

Dr. Ehrlich says having a group to represent physicians on quality issues is essential because of the impact state, federal, and health plan initiatives can have on health care in the future.

"There is an idea – and I think it's a right one – that we, as physicians, are the best advocates for quality of care for our patients because we are the ones who are not only delivering that care but are also responsible for our patients getting quality care. When you have – as is happening now and has been happening for some time – outside, nonphysician bodies governing or promoting their idea of what quality care is, it may not be patient focused. This council is hopefully going to get physicians more involved in that decision-making process."

Dr. Ehrlich says much of the council's work will involve determining which initiatives are really about quality and which are merely using quality as a front to cut costs. She has participated in both PQRS and Bridges to Excellence and says such programs can achieve both lower costs and better quality. Other programs, such as physician-ranking schemes based on claims data, are more of a sham, she says.

"We do live in the real world," she said. "We know health plans' central focus is probably more of a monetary focus than it is a true quality focus. But there is a place where these initiatives can make monetary sense and improve quality. We want to find that common ground and be able to work with employers, health care systems, and others to achieve common goals."

In the end, Dr. Malone says, patients will benefit from TMA's efforts to impact policy on quality issues.

"We're going to work for physicians, but this council, above all, is going to advocate for the patients' quality care," he said. "We feel the best way we can help doctors when it concerns quality is to know the best practices and best quality measurements that will help our members help patients. In this situation, advocacy for doctors is going to improve the health of Texans."

For more information on TMA's quality improvement resources, visit the TMA website.

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Calendar of Doom Logo

Calendar Helps Avoid Doom, Meet Quality Mandates

TMA has a new Internet-based tool that can help you comply with the increasing number of commercial insurance and federal and state regulations that affect you and your patients. It's called the Calendar of Doom.

The calendar alerts you and your staff to upcoming state and federal compliance timelines and key health policy issues.

When you log on to the calendar,you can click on a compliance date and learn the background of the regulation, what agency enforces it, the consequences of not complying, the next steps you need to take, and how TMA can help you meet the deadline.

Many quality initiatives, including the Physician Quality Reporting System and Physician Compare, are on the Calendar of Doom. TMA will continuously update it as new quality regulations and policies are issued.

"As bad as it sounds, I am quite hopeful that the Calendar of Doom will be a good thing – a very good thing – for you and all Texas physicians," TMA President C. Bruce Malone,

MD, said as he introduced the calendar at the 2011 TMA Fall Conference. "I think it will be good because the demands to comply with growing state and federal regulations are so onerous, and because so few of us are really prepared for it all."

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