Robert E. Goff
Executive Director & CEO, University Physicians Network (UPN), New York City, New York
Physicians are not equal.
That reality is understood on a certain level by everyone from the public to physicians and regulators. However, one of the great tragedies of our reimbursement systems is that physicians are treated equally in our payment methodology.
Probably the singular frustration of physicians, those that do provide above average quality and compassionate care is that they are treated as merely equal based on a fee-for-service reimbursement requiring an equal payment for an equal Current Procedural Terminology (CPT) code. The reality is that equal is not fair, nor is it financially equitable.
Physicians are not alone in the disdain for equal pay for equal processes. Payers and government have long tried to understand and develop models that would differentiate physicians, to measure "quality," and to then orient these models to recognize quality work with enhanced payments.
With the cost of healthcare in this country along with Social Security outlays on track to bankrupt the country by 2045, every pay source is looking to put the brakes on this relentless upward trend. If healthcare spending is to be curtailed, how do you ensure that you get the best value for those dollars that are spent?
Quite simple. You seek to measure quality and then reward it. Moreover, in the alternative, punish less than minimum levels. But, here is the rub. How do you define and how do you measure quality?
Each payer along with government payers has set up their own measures to gauge quality. If not "quality," as in "I know it when I see it", then the quality of outcomes, proxies for quality and processes that are recognized as known to lead to better clinical outcomes.
The result has been an overly complicated Chinese menu of measures and tasks that are widely and rightly criticized as being a burden on physicians and too numerous and often irrelevant to be of any help to consumers in their decision-making processes.
In an innovative response, government and private payers have teamed up to adopt a common core set of quality measures to replace this patchwork quilt of differing standards among the many payers.
The announcement in February of an agreement by Centers for Medicare & Medicaid Services and the trade group America’s Health Insurance Plans to a common core set of quality measures through a work group called the Core Quality Measures Collaborative. It puts all physicians on notice that they will be measured and their performance reported on against these core measures.
Historically, payment innovation has sought to address utilization, which has often resulted in the criticism that quality has been sacrificed for the cost of delivering care. A set of common measures will allow payment innovation to occur with recognized and common measures of quality in mind. Differing payment experiments will be able to be compared to their impact on quality measures that are common regardless of the payment model.
Theoretically, as payment models change, those that can produce the best "quality" with the greatest impact in cost reduction should find wider spread support and adoption.
A key factor in the selection and measurement methodology agreed to, is to make the outcomes for each physician available publicly. The goal being that in addition to payers having comparable measures for economic purposes, consumers would have available to them relevant and understandable information to aid in their choice of physicians.
Experts have long sought ways to get patients engaged in their healthcare, not just in personal health improvement, but also in understanding that the decisions we make as to whom to go for care have a significant impact on their health and economics.
Outside of healthcare, the United States economy is primarily consumer driven. Consumer choices drive businesses to improve as they compete for customers based on public perceptions and ratings of quality, costs and the experience of doing business with a firm. Information sources abound when it comes to non-medical costs and quality, whether it be from online ratings to the more exacting Consumer Reports magazine.
The potential for the Core Quality Measures Collaborative to drive innovation and change in physician services should not be underestimated. Patients who now are bearing an increasing financial responsibility for the costs of their care in rising copayments and deductibles are choosing care based on costs, and unfortunately with little other measures other than cost and convenience.
Quality has been absent from the equation because most quality measures have largely been inconsistent, irrelevant, or not easily understandable by the patient as a consumer. Now, the patient as a consumer can be armed with information about physicians and the quality of care that they should be able to expect.
While physicians have long held payer ranking programs and other quality measures in disdain, and rightly so, physicians will be well advised to embrace this new opportunity for transparency. And, prepare to take advantage of any positive economics that will come from Core Quality Measures adoption in payment methodologies.
Unlike payer created measures that change from measurement period to measurement period, the Core Quality Measures will prove stable, and can be planned for in advance.
In preparation, practices should reach out to their Electronic Health Record company and find out if (and how) they plan to incorporate the Core Quality Measures into their medical record scheduling and alerts programing. Up to this point, a multitude of payers with differing measurement programs made it impossible for physicians to deploy technology to help as a reminder, or as patient outreach to encourage patient engagement. This will no longer be the case.
The Core Quality Measures announced thus far pertain to performance reporting from Accountable Care Organizations, patient-centered medical homes, primary care, cardiology, gastroenterology, providers of human immunodeficiency virus (HIV) and hepatitis C care, medical oncology, orthopedics, obstetrics, and gynecology. Additional specialty measurements will be adopted and promulgated.
In the continuing ramp up to 2018 when half of Medicare spending outside of managed care is tied to the potential for penalties for less-than-quality outcomes, the creation of the Core Quality Measures is timely. In addition to traditional Medicare, the major commercial plans have agreed to follow Medicare’s lead and have committed to 90 percent of their contracts to be tied to quality measures by 2020.
Fee-for-service payments to physicians continue on a path to extinction. Core Quality Measures support this transition in determining physician compensation.
Doctor, you may need to hear this more than once to get the message: your future compensation will be tied to the utilization of your services, and what services you provide. And, they will be judged and publicized.
A notable criticism of many of the quality measurement programs unresolved by Core Quality Measures is that many require the active engagement of the patient who seeks out a physician. Efforts at increasing immunization rates or breast mammography rates have often fallen short of desired results when patients are unresponsive to pleas by their doctors to come in for care.
The result is that physicians will be held accountable not only for what they do but also for what their patients may choose not to do. This will require significant innovation on the part of the physician to engage their patients and to stimulate them to come in for care so that they will use timely services and tools that will improve their health and outcomes.
Another behavior that consumer advocates, as well as the healthcare industry, will be watching for are signs that patients will use this public comparative information.
Historically turned off by the complexity of what reporting has been available, few patients have relied on the commercial payers ranking of physicians programs, such as Aetna Axxcel, United Premium or Cigna Care Network. The lack of simple (read: user-friendly) information, added to a level of suspicion as to payer created quality ranking programs, have dampened consumer/patient use.
Just perhaps, Core Quality Measures will be the irresistible force that will change consumer use.