Since the managed care debacle of the 1990s, billions of dollars have been spent in time and resources to improve and measure the quality of patient care. However, measuring the quality of care in the effort to improve it in a cost-efficient manner is showing evidence of being counter-productive, particularly for small physician practices and practices with complex patient populations.
The goal of these programs is to hold physicians accountable for the care they provide and adjust their payments accordingly. However, many practices that face limited resources and staffing, and a lack of appropriate infrastructure to comply with quality performance requirements, are vulnerable to payment penalties which exacerbate their limitations and create obstacles to improving the quality of patient care.
This paradox is caused by a number of misaligned measures by public and private payers. Medical professionals continually complain about the lack of reliability and relevancy of performance measures and the complexities of quality data management. As a result, the quality chasm is growing wider.
Physicians find it hard to maintain their autonomy and their relationships with their patients as they spend much of their time checking boxes rather than providing and improving actual patient care. As payment becomes more dependent on performance data, what gets lost is that medicine is an art as well as a science which must be tailored to the individual needs of the patient.
Patient engagement in meaningful discussions with the physician about their health care options is actually being discouraged. “If you discuss something with a patient, you lose on the quality measure so it’s antithetical to shared decision-making,” said Andy Lazris, MD, co-chair of Right Care Alliance Primary Care Council. Dr. Lazris spoke at the Doctor-Patient Relationship forum, presented by the Galen Institute and the Doctor-Patient Rights Project last year.
Physicians are often forced to use measures that do not meet the needs of their individual patients, particularly those with complex medical conditions. For example, lowering an elderly person’s blood pressure to meet quality measure specifications may cause side effects such as dizziness and poor balance, increasing the risk of falls and hip fracture, according to Lazris.
“We are burdened for having to adhere to the quality measures and telling us what to do for each individual patient—[but] that quality measure might be invalid”—and sometimes even potentially harmful to patients.
The complexities of measuring quality performance cannot be overstated. The medical profession has been inundated with measures for years, but, so far, evidence of their effectiveness has been mixed at best. Few measures are “viewed as leading to meaningful improvements in quality,” according to a Government Accountability Office report on Health Care Quality.
The lack of meaningful measures also contributes to a perverse incentive in which physicians may try to avoid patients with complex medical conditions to avoid payment penalties. Part of the challenge is factoring in an individual patient’s economic conditions and social risk factors which have an impact on medical conditions and prescribed care. Having to check off specified measure requirements may create a disincentive for physicians to inquire about the patient’s personal goals and concerns.
“Evidence-based medicine is done on a population basis. But when you are with a patient, it’s the doctor-patient relationship that matters,” said Yalda Jabbapour, MD, Georgetown University’s Director of Ambulatory Care and Co-director of Evidence-based Medicine, at the Doctor-Patient Relationship forum.
Further, different payers may use measures with different specifications to address the same health care issue, resulting in different performance levels. “A provider may receive feedback from one payer indicating that the provider performs adequately, while receiving feedback from another payer indicating poor performance,” noted the GAO report. Inconsistent data created by misaligned measures makes it difficult to determine where improvements are needed.
Stakeholders and policymakers agree that measures must be more focused on patient needs and less burdensome to clinicians. The latest effort to preserve what is left of the doctor-patient relationship is CMS’ Meaningful Measures initiative. The purpose of the agency’s initiative—to help promote more focused quality measure development towards outcomes that are meaningful to patients, families, and their providers—appears to represent a larger trend within the health care industry to develop more patient-centered measures.
“There are a lot of great projects in this area …we are all working toward the right goals,” said John Bernot, a Senior Director of the National Quality Forum at an Alliance for Health Policy briefing on Measuring Quality for Person-Centered Accountable Care. “It is an immature field that is growing right now.”
While the “technical” process measures provide a “snippet in time” of the standard process of care, an outcome measure deals with the long-term outcome of the care provided to a patient. “Outcome is that end result and usually a little bit more complicated as to the measure itself,” said Bernot.
An appropriate balance must be struck between process measures and outcome-based measures given that processes are linked to outcomes. “On the provider side of this, it is going to be difficult for some individuals…until this begins to fit within the care we deliver,” said Bernot. “For example, if it becomes yet another box to check while still checking boxes for the technical medicine, this could be something that could add burden.”
In addition, the definition of patient-centeredness as well as quality and value have different meanings to different people. Addressing patient-centered care and a variety of patient-reported outcomes that measure functional status, quality of life, and patient experience “are still very questionable in terms of the work being done to measure them,” said Nelly Ganesan, a Senior Director of Avalere Health at the Alliance for Health Policy briefing. “There still are some optimal challenges to do that.”
The American Medical Association also has noted that “infrastructure challenges may prevent physicians from having the ability to report on outcome measures, such as not having appropriate data elements in the [electronic health record] EHR. Practices may also experience interoperability issues that may interfere with the exchange of information needed to report outcome measures, or may be unable to do longitudinal tracking due to the lack of uniform patient identifiers and patient attrition when tracking outcomes.”
Although conventional wisdom sees moving toward patient-centered outcome measurements as headed in the right direction, it is an open question as to how long it will take to bridge the quality divide without severing the doctor-patient relationship, and how many physician practices will survive the journey.
For example, the merger of physician practices with hospitals and other entities increased last year and appears likely to continue as a result of continued regulatory and technology demands. Whether mergers, consolidation, and acquisitions lead to better quality of care and lower costs is debatable, but certainly, physician practices are losing their independence. Today, fewer than half of physicians own their own practices.
One driving force pushing physician practices over the edge is the Quality Payment Program (QPP) created as part of the Medicare Access and Chip Reauthorization Act (MACRA), which relies heavily on performance measures and data collection. The clinician reporting burden under QPP’s Merit-based Incentive Payment System (MIPS) was estimated at more than a billion dollars in its first year. Under MIPS, a clinician’s payment is adjusted based on performance in quality, improvement activities, advancing care information, and cost.
The Centers for Medicare and Medicaid Services has been looking for clinicians to participate in its “Study on Burdens Associated with Reporting Quality Measures” to assess the clinician burden under QPP. Results will be available in 2019.
Meanwhile, the Medicare Payment Advisory Commission’s March 2018 Report to Congress has called for the repeal of MIPS, contending the payment system will neither improve health care services for Medicare beneficiaries nor move the Medicare program and clinicians toward high-valued care.
Current efforts to capture quality data do not bode well for the physician-patient relationship, potentially leading to a significant deterioration of individualized, quality patient care. Given the number of years it has taken to recognize the burdens that have contributed to burn-out within the medical profession, it does not appear that an effective solution will occur anytime soon.
“The doctor-patient relationship…may get more distant” said Rep. Ami Bera, MD (D-Calif) at the Doctor-Patient Relationship forum. “The doctor of the future may be sitting at a desk with three computer screens doing video visits on one computer screen and having big data sets coming in that they are managing as they are managing their patients.”
Clearly, a change in direction is needed, from centralized decision-making about what constitutes quality to providing more physician autonomy to balance the art and sciences of medicine with the individual needs and challenges of providing the best treatment to individual patients.
* Carol Monaco is an independent writer in the Washington, D.C. area and has covered health care policy and regulatory issues for 25 years.