Confusion exists about the quality movement, an emerging trend to improve the quality of medical care, and to link improvements to physician reimbursement. Using the limited information available, many physicians have difficulty anticipating the direct effect of a pay-for-performance program on practice workflow, productivity, and income. Nonetheless, quality measurement and performance-based payment are approaching realities with implications for both practicing and academic rheumatologists.
The entities with the greatest influence over our healthcare system, including private insurers, the federal government, and academic medicine, have embraced the philosophy of the movement and have begun to support initiatives that will ensure the integration of quality-based programs into every sector of healthcare delivery. TR spoke with four ACR members who have direct experience with quality-based initiatives to get their perspective on the subject.
As articulated in reports from the Institute of Medicine, the quality movement attempts to “close the chasm between what we know to be good quality care and what actually exists in practice,” including the overuse, misuse, and underuse of available treatments—by developing patient-care standards based on the best available scientific evidence.
Those driving the quality movement then propose to implement these standards through enhanced communication and broad-based consensus, and by building monitoring and enforcement elements into the healthcare system. These elements can be as simple as providing a bonus to a physician who ranks highly according to the standards (or, possibly, a penalty for a low ranking physician). This approach of creating and implementing quality standards assumes that everyone has agreed upon what quality is, what the standards are, how we measure quality, and how we measure the delivery of care according to quality standards.
In practice, developing and implementing standards is complicated. Evidence needed to develop and validate standards is not always available. Often, new data must be gathered and analyzed, and abstracting data from medical charts and records can be an arduous task. In addition, getting consensus between payers and providers on the valid measures of quality and performance can be challenging. However, a few pioneering institutions have had success implementing a quality improvement system.
A Pain-Free Quality Experience
Salahuddin Kazi, MD, chief of rheumatology at the Veterans Affairs (VA) Medical Center in Dallas, has considerable experience with practicing in a quality-based environment because the VA has been one of the leaders in implementing these programs. His experience has been a positive one, and he considers himself an advocate for the movement, having written an internal medical grand rounds paper for the University of Texas Southwestern Medical Center entitled “Performance Anxiety,” which is intended to allay physician fear of the issue.