Quality movement is "here to stay": AMNews interviews Robert Haralson III, MD

For years, health plans have ranked physicians' quality using measures that many doctors find suspect. Hundreds of pay-for-performance programs are now up and running, with more than half of HMOs including such incentives in their physician contracts.

The latest to join is the Centers for Medicare & Medicaid Services, which this month began offering physicians a 1.5% bonus on Medicare reimbursements for reporting on at least three quality measures for 80% of their patients in that category.

Fifty-nine of the 74 Medicare-reportable measures were developed by the Physician Consortium for Performance Improvement, a body convened by the AMA and composed of more than 100 national specialty and state medical societies; federal agencies, medical boards, disease groups and health plans also are members.

Robert Haralson III, MD, is a member of the consortium's executive committee. Dr. Haralson recently met with AMNews to talk about the consortium's work, clinical quality improvement and pay-for-performance.

AMNews: Briefly describe how the consortium works.

Dr. Haralson: There are a number of medical specialty societies that suggest performance measures to the consortium, and we insist they be based on the best evidence available. Various work groups within the consortium develop the measures and then submit them to the National Quality Forum for endorsement and then they are moved over to the AQA Alliance for implementation.

AMNews: What is the biggest misunderstanding physicians might have about the quality measurement development work the consortium is doing?

Dr. Haralson: Many physicians don't really know a whole lot about the quality effort yet, and those who know a little bit are very suspicious that this is really a mechanism to cut costs. Now, once you educate physicians and they understand that the quality movement is not only about cost but also about quality, then that view changes. One of the things that the physician community, including the consortium, is very insistent about is that this movement actually include quality and not just cost-cutting.

AMNews: Some payers are members of the consortium. What is their role in developing quality measures?

Dr. Haralson: The NQF and the AQA require, and we agree, that the payer and the consumer need to be involved in developing the measures. They have to be vetted amongst the payer and the customer community.

The payer needs to know this data can be collected and is meaningful. One of the problems we're having is that payers would rather have data that's collected from administrative claims because if it's not already in the computer, it requires data abstraction from the charts, which is extremely time-consuming and costly. That limits us significantly because there's only so much data available and we'd like to be measured more on outcomes than on process. ...

We're going to need both. Outcome measures will tell you if you have a problem, and process measures identify where it is. But right now we're stuck on processes. ... We're going to need to learn how to do outcomes and that's going to take some time.

AMNews: As much interest as there is in pay-for-performance as a way to drive quality improvement, the evidence that it actually works is pretty modest. Will pay-for-performance improve health care quality?

Dr. Haralson: What CMS is doing, the 1.5%, probably isn't enough to make physicians want to do this, so [doctors] are not doing it for the money but to learn how to do it. We think it will be mandatory eventually. It doesn't really matter what CMS does, because all the other payers are doing this and are hell-bent for leather. ...

I frankly think that pay-for-performance will eventually go away. I think what's going to be here forever is the necessity that we assess and report quality. The quality movement is here to stay -- I'm convinced of that. And I frankly think it will be better for medicine. I'm a little embarrassed that they had to attach money to it before we physicians started assessing quality. But once that is ingrained in everybody's culture, then they are going to quit paying for it because they won't have to. ...

There is tons of evidence that if you just show physicians where they are not up to the standard they will improve. You don't have to pay them or penalize them. Just show them the data and they will improve.

AMNews: What about the concern that pay-for-performance or pay-for-reporting could actually worsen racial and ethnic health disparities?

Dr. Haralson: The answer there is risk adjustment. There are ways to risk adjust, but unfortunately they are not very good. ... The consortium has not addressed risk adjustment, but we'll need to get into that eventually because I think that's extremely important to prevent the cherry- picking of patients.

AMNews: What about cost, then? Health plans certainly view it as part of physician performance as evidenced by plans' widespread use of ill-defined efficiency measures.

Dr. Haralson: We need to define efficiency. The way I like to define it is cost divided by quality. I can take care of patients very cheaply if I don't give them good quality care. I think it's extremely dangerous for anybody to assess cost without looking at quality. ...

If an insurance company or anybody else is tracking my quality and my cost, if how they do that is not transparent to me then I don't know how to get better. If they want physicians to improve on quality and expenditures, we need to know how you're measuring us beforehand. So, I think the "black boxes" are probably going to go away. ...

The consortium is not developing efficiency measures yet, but in the strategic planning session we had [in March] that's one of the things we addressed. We definitely will look into efficiency measures.