“Sometimes people get very good care and have what we all agree is a poor outcome. By the same token, you can have poor care, but a good outcome. We are people, after all.”
muscle behind the need to make sure these are valid measures,” said Dr. Mor- row, medical director of quality for the Rural and Community Health Institute at Texas A&M Health Science Center.
Texas Medical Association leaders say. “The biggest misconception most doc- tors have is that the government, and CMS [Centers for Medicare and Medic- aid Services] specifically, is the one that makes up these measures, and they do not. The measures come from the ex- perts themselves, usually via the spe- cialty societies,” said Ronald S. Walters, MD, a Houston oncologist and member of TMA’s Council on Health Care Quality. “These things applied to physicians, or by which we are measured downstream, are what our individual specialty societ- ies thought were very important to mea- sure. And the message there is: If you don’t like the measures, get involved with your society. That’s where they come from.” Dr. Walters also serves on a measures
review committee of the National Qual- ity Forum (NQF). Federal lawmakers cre- ated that public-private collaborative to endorse and recommend nationally rec- ognized quality measures for Medicare quality reporting and performance-based programs.
NQF also helps oversee the Na- tional Quality Strategy outlined in the Patient Protection and Affordable Care Act (PPACA). A consortium of 52 orga-
60 TEXAS MEDICINE April 2013
nizations, called the National Priorities Partnership, carries it out. It includes the American Medical Association and its measure-development organization, the Physician Consortium for Performance Improvement (PCPI), and the Council of Medical Specialty Societies, in addition to representatives of hospitals, employ- ers, health plans, and patients, among others.
Quality improvement is nothing new to doctors, but the effort thus far is largely voluntary, says Robert B. Mor- row, MD, TMA’s PCPI representative. Over the last decade, and particularly with the passage of PPACA, momentum also shifted from simply improving per- formance to tying it to payment. For example, the health system re-
form law for the first time specifically instructs cancer centers to define and report on quality measures. In 2015, incentives under federal programs like the Physician Quality Reporting System (PQRS) will turn into penalties for non- participation. And come 2017, Medicare will use a value-based modifier to adjust physician payments for the quality and cost of care they provide.
Those kinds of mandates now “turn the carrot into a stick and put some
It starts with the evidence For physicians, that process starts with the medical evidence. Then, organiza- tions like PCPI — composed of physi- cians across specialties — turn that evi- dence into a measure they hope ends with gold star recognition from NQF. To determine whether a measure is needed, “we look at the disease burden: how many patients are affected and how much we are paying as a nation,” said Ghassan F. Salman, MD. The Austin in- ternist was TMA’s representative to PCPI from 2008 to 2012 and is a liaison to TMA’s Council on Health Care Quality. Most of the early measures, for ex- ample, focus on chronic illnesses such as heart disease, obesity, diabetes, and cancer — high-impact and high-cost ar- eas also identified in the national quality strategy.
Once PCPI identifies a need for a measure, the next steps include:
• Reviewing the evidence: What do ex- isting guidelines say? How strong is the evidence? Where are the gaps or variations in care?
• Determining how to measure it: What’s needed to reach an outcome? Which patients should be included or excluded? Are there unintended con- sequences to a measure?
• Deciding where the information for the measure would come from: The chart? The patient?
• Testing the measure on a small scale: Is it reliable? Is it valid? Can it be re- produced?
• Checking for validity: Is the measure accomplishing its intended goal?
After clearing those hurdles, PCPI
reaches out to its physician members to test the measure on a larger scale “to see if it did work in real life and if physi- cians can live with it,” Dr. Salman said. If the answer is yes, the measure
heads to NQF for approval, which may adopt it as a national standard. Roughly
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