As the practice of medicine becomes more of a metric-ocracy, Austin otolaryngologist Jeffrey Kahn, MD, notes a certain irony in the process that continually spits out measures of so-called quality.
“There’s been an increasing recognition that quality programs need to become higher-quality – that the programs themselves are pretty low-quality in many cases,” said Dr. Kahn, chair of the Texas Medical Association Council on Health Care Quality. “And at the very least, [they] do not hit the primary aims of meaningfulness, fairness, and being actionable.”
TMA is continuously looking to help the architects and administrators of quality programs achieve those aims. With its new membership in the Core Quality Measures Collaborative (CQMC), TMA will work with dozens of other organizations to find common ground on the definition of that Q-word.
Founded by America’s Health Insurance Plans (AHIP) in 2015, CQMC includes representation from medicine, the health insurance world, and consumer groups. (See “Quality Made Easier,” April 2016 Texas Medicine, pages 59–63, www.texmed.org/qualitymadeeasier.) AHIP has since partnered with the Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum, and those three organizations are the driving forces behind the collaborative (www.qualityforum.org/cqmc).
CQMC works to foster agreement on a core set of measures that should form the basis of any quality program, whether it’s a government-payer venture or a commercial-plan setup. Since its founding, it has developed core measure sets for eight different focus areas, such as cardiology, medical oncology, and pediatrics (tma.tips/cqmccoresets).
The collaborative has more than 70 member organizations, including the American Medical Association; the American College of Physicians; the American Academy of Family Physicians; payers including Aetna, the Blue Cross Blue Shield Association, and Cigna; Memorial Hermann Health System; and the National Business Group on Health.
As the first state medical association to join CQMC, TMA will be able to participate in the workgroups that develop the measures for different specialties. TMA will be a nonvoting member of the collaborative; the American Medical Association was already a voting member. AHIP has told TMA that state medical associations that join the collaborative are encouraged to provide their feedback on CQMC votes to the AMA.
Chinwe Nwosu, director of clinical innovations at AHIP, notes that the collaborative doesn’t create new measures itself, but evaluates the usefulness of existing ones.
“We do have some of the measure developers also involved in the workgroups,” she said. “That’s another helpful thing, is that we can use these workgroups to speak directly to the measure developers as to why they might’ve made a certain decision about a measure, and also what they have in development in terms of new measures and what they have planned for any measure updates.”
Yen-Chi Le, PhD, assistant director of health care transformation initiatives at McGovern Medical School at UTHealth, can attest to the abundance and onerousness of today’s quality metrics. Even UT Physicians, UTHealth’s large multi-specialty group with more than 2,000 clinicians, struggles with the demands those measures present.
Dr. Le says UT Physicians manages close to 75 different quality metrics this year, mandated by payers with different emphases. For instance, Medicaid managed care organizations prioritize different metrics than Medicare Advantage plans.
“It’s a real struggle, because in order to meet the quality metrics … we have to employ additional staff and data analytics people,” Dr. Le said.
And UT Physicians doubts the meaningfulness of some of the measures. For instance, Dr. Le says, its physician champion for pediatrics questions the value of a measure for well-child checkups between ages 12 and 21: “In early life, it’s important, but as kids get older, it becomes less important,” she said. Another measure on timeliness of prenatal care is important, she says, but is unreachable as constructed.
“Let’s say a woman delivers in 2020. It looks back to 2019 to see if she had a prenatal visit appointment within her first trimester, or within the first 40 days of when she got Medicaid coverage. That’s really hard, because when we were … first aware of these metrics, we’ve already missed the opportunity to intervene,” Dr. Le said.
Although there's been some improvement on that metric, she says, “the way the measure is written is just impossible to accomplish.”
Consensus: Low-hanging fruit?
During 2020, CQMC plans to update its core sets and create new ones for behavioral health and neurology. The collaborative says on its website that it will perform ongoing maintenance of the core measures to “reflect the changing measurement landscape, including … changes in clinical practice guidelines, data sources, or risk adjustment.”
Saying it’s important for physicians to be at the table, Dr. Kahn is hopeful about the future of CQMC’s work and TMA’s role in it.
“I think they’re looking for buy-in from all three members of the triangle, so to speak: The payer, the physician, and the patient,” he said. “Now, whether you can find that consensus is another thing. But I personally believe that it can be found if you just get these groups in the same room talking about it. Because it’s pretty low-hanging fruit to say, ‘We all should just be using the same metrics.’”
Tex Med. 2020;116(4):40-41
April 2020 Texas Medicine Contents
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