The long march toward quality

Payers and providers are on the same page when it comes to quality programs that reward physicians for meeting certain benchmarks. The concept of rewarding healthcare quality improvements in order to lower overall healthcare costs is widely embraced, but the implementation is far from perfect.

According to an annual survey of MANAGED HEALTHCARE EXECUTIVE readers, only 12% of the 400 payers and providers surveyed thought quality guidelines were based on good data and should be broadly implemented. Contrast that with the number of payers and providers who responded that the guidelines were either too rigid (about 20% for both groups) or that the data was not good enough (10% of payers and 14% of providers) for broad implementation. Slightly more than half thought the data needed to improve, but quality guidelines should still be implemented.

DECIDING ON DATA

Performance-based programs are based on the idea that better quality, lower-cost healthcare can be achieved by measuring and improving upon key aspects of delivery. But the outcome is only as good as the input, and right now, the input is lacking telling information that would be found in clinical records, such as comorbidities and primary diagnoses.

"The reality is, the only measures that can be rolled out on a large scale are based on claims data," says Bruce Bagley, MD, medical director for quality improvement for the American Academy of Family Physicians (AAFP).

Experts agree that claims data is not designed to measure quality outcomes. However, plans have ready access to claims and can draw some conclusions from it.

"The good thing about measuring quality is it gives you a way to focus on important issues," says Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy, MD. "The question is, do physicians feel that the right measure is being counted, as opposed to focusing on something because it's easier to count?"

For example, it's easy to count the timely administration of antibiotics to patients admitted with pneumonia. However, it's not always immediately clear to physicians whether a patient has pneumonia. Providers are then caught in the middle: administer antibiotics, just in case, or get dinged for not meeting that particular quality guideline. Most assert that in such a case, they treat each patient for optimal outcomes-not for satisfying a checklist of quality measures.

"Most advanced health providers encourage doctors not to comply with a guideline if it doesn't make sense," says Dr. Clancy. "It may be that the measure needs to be fixed. It may also be that something can be learned that would benefit a lot of other patients. No guideline benefits 100% of people 100% of the time, so there's an incredible opportunity to learn from something when it doesn't fit."

As performance-based programs become more ubiquitous, providers are becoming involved in the process to draw up the measures and ensure their implementation. And some conditions are clearly more difficult to treat with standard protocols, such as complex cancers. Such outliers cause concern among physicians.

"You had to start somewhere, and the initial pay-for-performance programs were geared to provide incentives to practices to move toward the outcomes we're trying to get to," says Page Babbit, director of provider engagement, performance and partnerships for Highmark, Inc., based in Pittsburgh.