Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Medicare Accelerates Program Linking Physician Pay to "Quality"

8/7/2013 8:35:45 PM | 2 comments

A recent article in Kaiser Health News announced that the Centers for Medicare & Medicaid Services (CMS) will accelerate implementation of its Physician Quality Reporting System (PQRS), which links physician payment to the completion of various patient care tasks identified as measures of "quality." According to the article, the American Medical Association (AMA) has been urging Congress to eliminate the program.

I disagree.

As the chief medical officer of a large physician group, I am responsible for developing the system capabilities to collect physician performance data and push that information back to individual physicians. I also work to educate physicians about the metrics under which they will be held accountable and develop processes to help ensure that physicians are performing according to defined standards. Thus, I have some familiarity with the very real issues raised by both critics and supporters of the CMS pay for performance (P4P) programs.

While I concur with the AMA's position that using pay for performance as a cost-cutting measure makes little sense, that doesn't mean that we should eliminate the Medicare P4P programs. Rather, we as physicians need to understand that PQRS is a starting point, and that we need to take an active role in its design and architecture. This will ensure that it eventually becomes a program that furthers our ability to manage physician clinical behavior. This in turn will foster the development of a medical culture in which monitoring, reporting, incentivizing and penalizing certain clinical practices are accepted.

Such a program is good for patient care and good for medicine.

Unfortunately, focusing on the "pay" component of the P4P programs has resulted in our disregarding the "performance" variable. We tend to overlook the fact that PQRS has served as a catalyst for the development of systems and processes that increase our ability to manage physician clinical behavior.

For many years, physicians argued that:

  • Patient care needed to be individualized
  • Each physician, having endured many years of education and training, was the best person to determine that care
  • "Quality" was difficult (if not impossible) to measure because of the uniqueness of each patient.

The above are true for many patients and conditions. However, this view contributed to our not acting — or at least not in a coordinated fashion and certainly not on a large scale — on an equally true position. Namely, for many conditions there are standardized approaches that make sense for all patients based on our existing medical knowledge. Giving aspirin to an acute myocardial infarction patient without contraindications, decreasing time to revascularization, and providing smoking cessation counseling all make sense.

Advances in health information technology are making it increasingly easy to monitor and report physician practice behaviors. To benefit from this technology, we need to develop a medical culture that understands and accepts the profiling of physician practices and rewards appropriate care, driving physicians to a higher level of performance. We need to address roadblocks to this process so that we can:

  • Further the development of accepted best practices
  • Standardize approaches that lead to greater consistency in clinical practice
  • Improve our ability to manage physician clinical behavior

Whether we like to admit it or not, the CMS PQRS program has shown that financial incentives and penalties are a successful mechanism for stimulating physician response to clinical performance metrics. They also create an impetus for physician organizations to develop the structure and systems necessary to monitor and report physician practice behaviors.

PQRS should not only be preserved but also welcomed as a critical advance in our ability to ensure a higher quality of care.

Prentice, couldn't agree with you more. In fact, I just posted a blog in The Fickle Finger that mirrors your conclusions about the value of practice metrics feedback in promoting cost-effective care, tempered by the recognition that we can not expect to completely eliminate variability, given that medicine is as much art as science. In a comment to this post, John Holstein argued that EPs must drive the conversations about patient care practice metrics, rather than allow CMS and others to set them for us. Though CMS does seek input on these metrics, sad to say they don't always listen (i.e. CTs in minor head injured patients on Coumadin). This makes it even more important for groups like CEP America to develop and promote EM practice metrics that make sense to EPs and make a difference for ED patients. Tying these metrics to reimbursement is reasonable as long as it is done thoughtfully and in moderation. <br />Myles Riner
8/14/2013 11:15:22 PM

Physician leadership and nurse collaboration to improve performance and quality will be the key to success for hospitals in the future. It will be less about trying to manage costs and more about managing people to perform. Hospitals which partner with physicians to align across the acute care continuum to improve not only operational performance, but quality and patient outcomes will be the ones that succeed in the future.
8/14/2013 8:35:26 AM