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.
However, no one has figured out how to measure the system to fairly and accurately hold all parts accountable. Current approaches that evaluate individual providers, like a blind man feeling only one part of the elephant, can provide misleading information. Successful quality improvement must involve a comprehensive examination of the entire system. Although such an approach is a long way off, we must keep it in our sights, because it affords the best chance to have a major impact on health outcomes.
What Can the ACR Do?
As this movement evolves, the ACR must ensure its members are informed and have an opportunity to engage in the discussion. The ACR provides a forum for discussion through many avenues, including the list serves, where the dialogue may be informative, lively, and often controversial. The ACR also attempts to influence national decisions. We assert publicly that providers should be accountable for only one set of provider-approved measures. Although providers must recognize their responsibility to provide the best care at the lowest possible cost, their first responsibility is to their patients. Therefore, we consistently argue for measures that focus on processes and outcomes, rather than efficiency.4 Finally, we argue that any performance-reporting program from payers should compensate providers in exchange for their participation. This compensation could be in the form of additional payments for meeting quality requirements or reduced administrative burden (e.g., decreased prior authorization requirements), or both.