Education called key to acceptance of performance ratings

Leaders of national health care organizations are saying that performance measures for primary care physicians are inevitable and will be included in the wave of the future that will overtake and transform health care in the United States.

Although attitudes are changing, many experts believe more education on the issue -- for both physicians and the general public -- would make for a smoother transition. A smooth transition also will require easing physician concerns about unfair rating systems or being judged for things beyond their control.

Above all, physicians need some guarantees that the record of their actions will not be used against them in court before they are willing to input their actions into a performance measurement system.

"Physicians don't have any confidence in the tort system," said Yank D. Coble Jr., MD, AMA immediate past president, explaining the resistance to performance measures. "In fact, they have extraordinary dread."

Stephen H. Miller, MD, the executive vice president of the American Board of Medical Specialties, said "society as a whole" would need to decide whether it does, in fact, want health care improved. If it does, he said, it must be willing to remove doctors from an adversarial environment where they can be punished for participating in the improvement process.

Eliminating the fear of legal action will be a major step forward, said Bruce Bagley, medical director of quality improvement for the American Academy of Family Physicians. "I really think that's a major issue," he said. "Because it's such an easy reason for people to duck behind and say, 'I don't want to do this.' "

Some physicians also contend that the measures themselves might not be accurate or reliable, or they fear that they will be assessed as part of the system in which they operate, and that system might include many factors out of their control.

For example, doctors might not mind that they will be measured for ordering certain tests on certain patients, but they do not want to be held accountable for those test results being lost or misfiled. "They say, 'I don't want to be responsible for the system I work in,' " Dr. Bagley said.

Lastly, they feel as if they haven't been asked for their input on this issue. Using a poker analogy, Dr Miller said, not only have physicians not been dealt any cards, they still haven't even been asked to sit in.

Kenneth Kizer, MD, president of the National Quality Forum, is encouraging doctors who feel this way to get involved in the process of improving quality in general and, specifically, in creating performance measures.

The "missing link"

"We have to stop trying to stop this train but, instead, get on board and try to steer it in the right direction," he said. "Physicians have an established history of standing in front of the train, trying to stop it and then getting run over.

"A lot of physicians are beginning to realize not only the inevitability of performance measures, but that using them is the right thing to do, so let's make it happen as painlessly as possible," he added.

At a recent Commonwealth Fund-sponsored program on improving health care quality, the subject of performance measures came up. Dr. Kizer said that physicians might not like them, but they'd better get used to them.

On the same program, Dennis O'Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations, said the physician community was the "missing link" and suggested that one way to get more doctors on board would be to weave performance measures into the recertification process.

"We would not characterize it as opposition," Dr. O'Leary said in an e-mail to American Medical News. "Rather, it is conservatism in physician groups who would prefer to use measurement as a vehicle for quality improvement as opposed to public reporting."

Dr. Coble said he was not necessarily opposed to public reporting of performance measures. But in their current form, he does not feel they "are ready for prime time." Refinements are needed to boil them down to something that gives an accurate assessment of how well a physician is doing.

"And, often when this is communicated to the public, it comes across as American physicians are opposed to performance measures," he said.

Using performance measures to rank physicians with individual profiles or report cards is unfair, Dr. Coble said, because that's not what the measures were designed for because most physicians do not have enough different types of patients for meaningful statistical comparisons.

Instead of rankings, Dr. Miller suggested, standards could be set, and then individual doctors could be measured by how they compare with these standards.

Although he admits that the process is coming along too slowly for some, Dr. Coble said care must be taken to make sure performance measures evolve into the use for which they are intended: quality improvement. Otherwise, they can mislead patients, unjustly damage physician reputations or become so unreliable that no one pays attention to them.

"For physicians, the critical thing to be identified is that these are scientifically based," he said. "Also, they are tools, not rules. They are guidebooks, not cookbooks."

For Robert Brook, MD, a professor of medicine and public health at the University of California, Los Angeles, physician education is the key ingredient in the recipe for performance measure acceptance.

Although Dr. Brook said he had "not seen any data suggesting that physicians are the missing link," he added that, if he were to become the "czar of continuing medical education," he would dedicate a few days of CME to the science behind performance measures.

"I really do believe that the basic knowledge of practicing physicians about the science of measuring the quality of health care is close to zero," said Dr. Brook, who also serves as a vice president of the Rand Corp. and the director of Rand Health. "If it's going to be an integral part of their life, that's a shame."

As barriers are knocked down, financial incentives for using performance measures will crystallize, making widespread use of these quality improvement tools more enticing.

"The main carrot in the future will be pay for performance," Dr. Kizer said. "That's going to be the elixir that makes it all happen."

Noting that "when someone says 'performance measures,' in the same breath they should say 'public reporting,' " Dr. Kizer said this is all part of the transparency in health care that the public is demanding.

Dr. Brook said such transparency eventually would make patients more comfortable with their doctors and vice versa.

"It will eventually make people appreciate what doctors are doing," he said. "We have to get over our short-term paranoia."