Panel sets primary care standards for Medicare pay-for-performance

The new quality measures could make it easier for physicians to report performance to multiple health plans.

By Kevin B. O’Reilly — Posted Sept. 5, 2005

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

The group charged by Congress with endorsing the performance measures upon which Medicare payments will be based recently adopted 36 quality standards for physician-focused outpatient care of conditions such as asthma, hypertension, heart failure and depression.

The Washington, D.C.-based National Quality Forum drew two-thirds of those measures from the AMA's Physician Consortium for Performance Improvement. The other 12 measures were drawn from the National Committee for Quality Assurance, an employer- and pharmaceutical company-supported group known for rating health insurance plans.

Both of the pay-for-performance bills circulating in Congress task NQF, a collection of 200 stakeholder groups including the AMA, with endorsing the quality measures Medicare will use in determining physicians' pay.

"It's a major advancement that NQF has endorsed consortium measures," said Nancy H. Nielsen, MD, PhD, speaker of the AMA House of Delegates. "These are measures decided by the profession as the ones that matter. They measure what matters in terms of outcomes for patients."

Although the AMA and other physician groups don't have much objection to the NQF-endorsed standards, they still are unhappy with legislation in Congress that would penalize doctors for failing to report quality data and reward top-performing doctors by taking from the existing pool of funds rather than adding to the pot.

While private-sector programs such as the NCQA's Bridges to Excellence and California's Integrated Healthcare Assn. provide financial incentives to physician practices to help them offset the burden of adopting costly electronic health record systems, the bills circulating in Congress place that burden squarely on doctors' shoulders.

A Senate bill sponsored by Senate Finance Committee Chair Charles Grassley (R, Iowa) and ranking member Max Baucus (D, Mont.), the Medicare Value Purchasing Act of 2005, would reduce doctors' reimbursements by 2% if they fail to report quality data by 2007. By 2008, the Dept. of Health and Human Services would redistribute 1% of reporting physicians' payments to doctors who scored the best on NQF's quality measures, with the amount increasing by 0.25% each year until it hits 2%.

A competing bill sponsored by House Ways and Means health subcommittee Chair Nancy Johnson (R, Conn.), the Medicare Value-Based Purchasing for Physicians' Services Act of 2005, would cut doctors' payments by 1% in 2007 and 2008 for failing to report quality data. Under that bill, physicians could see an additional 1% cut for not meeting performance thresholds or failing to sufficiently improve quality of care.

The quality measures, endorsed by NQF under an expedited review process after pressure from employer groups frustrated by annual medical cost increases of up to 15%, previously have been used by the Centers for Medicare & Medicaid Services in its Doctor's Office Quality and Doctor's Office Quality Information Technology test projects.

Aside from pending legislation, the measures are timed for use in insurance contracts beginning January 2006, and are intended to reduce the redundancy of differing performance measures used by various health plans. They cover the areas of asthma and respiratory illness, behavioral health and depression, bone conditions, heart disease, hypertension, prenatal care, preventive care, immunization and screening.

No subspecialty standards yet

"I think these are good measures for the most part, because they've been tried and tested and seem to be valid," said Bruce Bagley, MD, medical director for quality improvement at the American Academy of Family Physicians. Dr. Bagley also sat on the steering committee for the NQF's outpatient measures project.

"The shortcoming is the variety," he said. "There are not enough measures for all the different specialties and conditions, but it's a place to start."

The push for quality-of-care measures is driven in part by cost concerns, but research also has shown that patients get recommended care slightly more than half of the time.

A widely cited study in the June 26, 2003, New England Journal of Medicine found that on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care, patients received recommended care only 54.9% of the time.

The recently adopted measures are only the second phase of a three-stage process. For phase three, NQF already has identified more than 800 potential additional performance measures, and the group has received 167 other potential measures for comment. NQF's voluntary consensus standards process could take from as little as nine months to as long as four years, according to various sources.

"How we're going to adhere to that time frame when we've got bills in Congress demanding that we start collecting data in 2006 and subspecialty groups wanting to line up measures immediately, I'm not sure," said NCQA Executive Vice President Greg Pawlson, MD, MPH.

NQF is composed of four stakeholder councils representing physicians, nurses, hospitals and health plans, quality researchers, purchasers and consumers. All four councils voted in favor of the adopted measures, which can be appealed until Sept. 2 by any interested stakeholder that might be materially or adversely affected.

That kind of unanimity will be difficult to achieve when it comes to endorsing a set of efficiency and utilization standards. Though NQF does not have a funded project to develop efficiency measures, a spokesman for the group confirms it is "extremely interested" in tackling the issue.

"That's where the rubber's going to meet the road, because the rest is science," Dr. Nielsen said. "There's not a good evidence-based way for most conditions to measure what is exactly the right thing to do -- no less, no more. And that's where our profession really needs to be involved, because if we're not then, frankly, the bean counters are going to decide what these issues and measures are."

Making data public

Another question is how and when the collected quality data would be made public. NQF-developed standards for hospital, nursing home and home care have been used for comparative purposes via the HHS Web site.

"That's where we'd like to go, eventually," said Trent Haywood, MD, deputy chief medical officer at CMS. "At the individual practitioner level, we have a ways to go before we get there."

Health care consumers also favor such a move. "That definitely would respond to a need within the consumer community," said Reva Winkler, MD, MPH, the clinical consultant who shepherded the NQF ambulatory project through phase two and is working on phase three. "Whether that need is going to be met and in what way remains to be seen."

Dr. Nielsen objected to the idea on the grounds that for small group practices and solo physicians, tiny sample sizes would render the data statistically invalid.

Back to top



The National Quality Forum endorsed 36 measures for outpatient primary care, covering asthma, behavioral health, bone conditions, hypertension, prenatal care and preventive care. Each measure was evaluated for importance, scientific soundness, feasibility and usability. For example:


Assessment: Percentage of patients who were evaluated during at least one office visit for the frequency of daytime and nocturnal asthma symptoms.

Pharmacologic therapy: Percentage of all patients with mild, moderate, or severe persistent asthma who were prescribed inhaled corticosteroid or an acceptable alternative treatment.


Plan of care: Percentage of patient visits during which systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg was met with a documented plan of care for hypertension.

Controlling high blood pressure: Percentage of hypertension patients with a last blood pressure reading lower than 140/90.

Sources: AMA Physician Consortium on Performance Improvement, National Committee for Quality Assurance

Back to top

AMA's standards for P4P programs

The AMA House of Delegates in June adopted a set of five principles to which any fair and ethical physician pay-for-performance program must adhere. Delegates said such programs should:

Ensure quality of care: Programs must focus on improving health outcomes, not reducing utilization.

Foster the patient-physician relationship: Programs must allow doctors to exercise sound clinical judgment, not restrict patient access to needed care.

Offer voluntary participation: Programs must allow doctors to opt out without affecting reimbursement levels or other contractual obligations of payers.

Use accurate data and fair reporting: Programs must use scientifically sound measures and allow physician input. Results must not be used capriciously in physician credentialing.

Provide fair and equitable incentives: Programs must offer new funds for positive incentives for physicians, not penalties.

Source: AMA

Back to top

External links

Physician Consortium for Performance Improvement's primary outpatient care quality measures (link)

National Committee for Quality Assurance's primary outpatient care quality measures, in pdf (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn