Trials and Troubles of Real-World Quality Measurement
Accurate and meaningful measurement of quality of care for rheumatic disease patients is an appealing concept, but the complexity of modern clinical practice makes it difficult. Much of the care for rheumatology patients is delivered in settings that are out of their control. Patients are sent to other sites for lab testing or imaging studies, and other providers are often involved in their care. In addition, patient outcomes are affected by patient factors such as compliance and social factors. Health information systems can only partially influence quality, especially when these systems differ across providers and do not communicate with each other. So, rheumatologists have only a limited ability to fully control her or his patients’ quality of care.
Nonetheless, many are calling for individual physician accountability. The Centers for Medicare and Medicaid Services (CMS) has put into place its Physician Quality Reporting Initiative (PQRI), a pay-for-reporting program that is optional now but will likely become mandatory. Private payers have developed many similar programs that require providers to meet minimal reporting requirements in return for preferred placement on tiered provider lists that affect patient access and copayments. Employers have implemented pay-for-performance programs like Bridges to Excellence. All of these programs are based on quality indicators. Quality indicators are only a first step towards quality improvement because they represent minimal standards that convey only the most basic level of care, focusing on the processes of care rather than the outcomes. They do not reflect ideal care or even recommended care.
