IOM: New agency needed to simplify pay-for-performance measures

The Institute of Medicine says consolidation of quality benchmarks under one roof will be necessary for value-based purchasing and would be easier on doctors.

By David Glendinning — Posted Dec. 19, 2005

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Washington -- The physicians and researchers tasked by lawmakers to help get pay-for-performance off the ground worry that it's already carrying too much weight for liftoff.

The Institute of Medicine released a report earlier this month detailing a plan to adopt and develop performance measures, the building blocks for any program that bases payments for services on quality of care. While researchers concluded that several good sets of measures already exist, they noted that they are too numerous and spread out to be effective.

"Currently, it's a little bit like the Tower of Babel. There's a set of uncoordinated requests to measure and capture different things in different formats," said Steven Schroeder, MD, a health professor at the University of California in San Francisco and chair of the IOM committee that produced the report. "If they were streamlined and coordinated, it actually might ease the regulatory burden on overworked physicians."

The group's proposed solution to this roadblock is to establish a new federal office within the Dept. of Health and Human Services that would coordinate and fund the development of quality measures needed for pay-for-performance, public reporting, accreditation or any other quality improvement effort.

The National Quality Coordination Board would set the benchmarks that government initiatives -- and potentially private-sector ones as well -- would utilize.

Placing all of these efforts under one roof would minimize the burden on physicians and others to keep track of multiple lists of quality measures that have little to do with one another, said Alan Nelson, MD, a member of the IOM committee. A more cogent set of reporting guidelines shared by Medicare, Medicaid, private insurers and review boards would make doctors' lives a lot easier as more payers start to link reimbursements to quality, he said.

"Setting up some central coordinating board so that doctors don't have to deal with 15 different performance measurement systems is essential," Dr. Nelson said.

"Then we can make sure that you don't have to collect one set of quality data to be recertified in internal medicine, another set of quality data to be paid by Aetna and another set of quality data to be paid by Medicare," he said.

How physicians would be judged

To get the ball rolling for the proposed HHS board, which would require approval by Congress, the IOM panel endorsed a starter set of quality measures that could be used by multiple payers to assess doctors and others. Rather than construct yet another new list of ways in which the quality of health services would be judged, the group culled what it considered the best measures from existing proposals.

For physician outpatient care, IOM deferred to the Ambulatory Care Quality Alliance, a coalition of physician, insurance and government groups. The institute said the 26 measures for preventive care, chronic disease treatment and efficiency of care adopted by the alliance earlier this year are ready for incorporation into a pay-for-performance or other reporting system.

Dr. Nelson predicted that physicians would accept the starter set and would be able to report the data with minimal administrative burden because doctors helped develop the measures in the first place. The AQA used as its starting point the work of the AMA's Physician Consortium for Performance Improvement.

But the IOM said doctors also should be evaluated on how patients rate the care they receive. This information would be collected through the CAHPS Clinician and Group Survey, which aims to determine how well practitioners provide quick, needed care while maintaining good communication with patients.

Eventual linking of the survey results to physician reimbursements might come as a surprise to many doctors, Dr. Nelson said.

"If doctors know that one of the things that will influence what their payments are is whether their patients felt good about the encounter -- as a patient, I like that condition," he said. "But oftentimes physicians aren't aware of the fact that patient-centeredness is one of our quality aims, and in order to get that, it probably will involve some direct interviews of patients."

The next steps

The Institute of Medicine now must try to sell the concept of the National Quality Coordination Board to Congress. In doing so, it will need to convince lawmakers that another federal entity is necessary to bring together the work of such groups as the Agency for Healthcare Research and Quality, the National Quality Forum, the National Committee for Quality Assurance, the Joint Commission on Accreditation of Healthcare Organizations and others.

But the IOM also wants to impart a large measure of independence to the office so that it doesn't function as a government-run operation from the top down. Although the board would report to the HHS secretary and Congress, it would have a guaranteed annual funding stream of $100 million to $200 million from the Medicare trust fund, lessening the potential for policymakers to exert pressure by withholding appropriations. Terms of the office's leaders also would be staggered so that no one administration could dominate appointments to the board.

Dr. Nelson said the institute envisions the entity functioning independently, much in the same way as the Federal Reserve Board or the Federal Accounting Standards Board.

The architects of the performance measurement plan are confident that lawmakers will respond to the plan, said Elliot Fisher, MD, MPH, a professor of medicine at Dartmouth Medical School and one of the IOM panel members. One of the biggest reasons Capitol Hill might pay attention to the proposal is that Congress itself mandated the institute's report, he said. This release is the first in a series of studies that also will include a plan to link performance measurement specifically to pay-for-performance.

"We think Congress will listen," he said. "This solves a lot of the problems that we see out there."

And even if Congress takes a pass on the HHS board or the starter set of measures, the White House could act on its own to use some of the IOM's ideas, said Centers for Medicare & Medicaid Services Acting Chief Medical Officer Barry Straube, MD.

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A first step

The Institute of Medicine has endorsed a starter set of quality measures to be used in pay-for-performance or other reporting initiatives. Some of the 26 measures that apply to outpatient care are the percentage of:

  • Women who had a mammogram during the year.
  • Patients age 50 to 64 who received an influenza vaccination during the year.
  • Patients with coronary artery disease who were prescribed a lipid-lowering therapy.
  • Adults diagnosed with a new episode of depression who remained on an antidepressant drug for at least six months.
  • Pregnant women who were screened for HIV infection during the first or second prenatal visit.

Source: Institute of Medicine

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A new authority

The Institute of Medicine wants Congress to establish a National Quality Coordination Board, within the Dept. of Health and Human Services, to help implement more universal performance measurement systems. The board would:

  • Specify the purpose and aims for American health care.
  • Establish short- and long-term national goals for improving the health care system.
  • Designate, or if necessary develop, standardized performance measures for physicians and others, and monitor the nation's progress toward these goals.
  • Ensure the creation of data collection, validation and aggregation processes.
  • Establish public reporting methods responsive to the needs of all stakeholders.
  • Identify and fund a research agenda for the development of new measures to address gaps in performance measurement.
  • Evaluate the impact of performance measurement on pay-for-performance, quality improvement, public reporting and other programs.

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