Becker's Clinical Quality & Infection Control

49 QUALITY IMPROVEMENT & MEASUREMENT Viewpoint: Quality measures fail to determine a physician's value By Megan Knowles A lthough insurers and governments have tried to measure physicians' caliber using various metrics, what constitutes a success in medicine — and who's responsible for it — is oen unclear, a physician wrote in e Washington Post. Here are seven insights from the op-ed by Dhruv Khullar, MD, who works at New York-Presbyterian Hospital in New York City: 1. Despite efforts to measure and incentivize the quality of physicians' care, providers oen have less control over outcomes than patients think, Dr. Khullar said. "Patients want longer lives, but they also want healthier lives, care that is more compassion- ate and more convenient, and judicious use of tests and treatments," Dr. Khullar wrote. "Doctors work in teams as just parts of an increasingly complex health system, and they are oen less in control of outcomes than we think, especially when treating patients with challenging social circumstances and coexist- ing medical conditions." 2. "Measurement techniques may grow in- creasingly sophisticated, but doctors are not ballplayers, and healthcare statistics are not as simple as a batting average," Dr. Khullar wrote. Despite this, payers use pay-for-per- formance incentives to improve how physi- cians care for patients. 3. One example of this effort is Medicare's Value-Based Payment Modifier, which measures the quality and cost of care while giving physicians bonuses or imposing pen- alties as necessary. But a recent study suggests the VM program showed no benefit in improving care or cutting costs. "e program's failure adds to a body of evidence finding that financial incentives generally have not been shown to improve patient outcomes," Dr. Khullar wrote. 4. Patients pay a price for these programs as well, Dr. Khullar said. "Financial incentives can encourage doctors to avoid sick or socially disadvantaged patients, who are harder to care for and who may negatively affect their quality ratings," he wrote. Many payment programs, including the VM program, don't adjust for patients' illness severity or socioeconomic status, Dr. Khullar said. "So if I'm trying to pad my stats, it makes sense to gerrymander my patient panel into the richest, healthiest, most-educated panel possible." 5. But having some measurement in place is still critical to ensure physicians are honest and patients are informed, Dr. Khullar said. "One step may be to solicit more physician input into the measures they feel most accurately capture the value of their care," he wrote. "Another is to ensure that all measures are carefully adjusted for patients' medical and social complexity." 6. Although physicians are skeptical of on- line reviews, these sources of feedback could be a big part of the solution, Dr. Khullar wrote. "Already, more than three-quarters of patients use online reviews to find a new doctor, though concerns persist about their accuracy and representativeness," he said. 7. "Despite prolonged and costly attempts, insurers and governments have not been able to accurately measure a doctor's value and won't be able to anytime soon," Dr. Khullar concluded, recalling a "legendary" co-res- ident who made diagnoses others hadn't heard of and rushed patients to lifesaving procedures when they showed the smallest clinical change. "No currently available measures, for exam- ple, would have captured my co-resident's worth as a physician," Dr. Khullar wrote. "And yet, every doctor in our program knew of his worth, and every patient he cared for benefited." n Majority of physicians worried MIPS could harm patient care, study finds By Megan Knowles A lthough most physicians caring for Medicare patients are unaware how Medicare evaluates and pays them, the major- ity of the physicians who do know these standards are concerned this approach could negatively affect patient care, a study published in Health Affairs found. Researchers from Seattle-based UW Medicine and the University of Pennsylvania in Philadelphia looked at Medicare's Merit-based Incentive Payment System, or MIPS, which was implemented in January 2017. "We found a significant number of physicians believed that there could be unintended consequenc- es under these pay-for-perfor- mance incentives," said lead study author Joshua Liao, MD. Through MIPS, Medicare pays phy- sicians based on how they perform in the following areas: reporting and performing on clinical quality measures, controlling how patients use resources, initiating or participat- ing in clinical practice improvements, and using EMRs. To assess how physicians felt about MIPS, the researchers surveyed 700 internal medicine physicians across the U.S. Here are three survey findings: 1. The majority of physicians (69 percent) reported being concerned physicians might "focus on aspects of care being measured to the detriment of other unmeasured aspects of care." 2. Sixty percent of respondents said physicians might "avoid sicker or more medically complex patients to improve performance on quality or utilization measures." 3. More than half of physicians (56 percent) said they wondered if physi- cians would change how they docu- ment care to improve their scores. "These findings indicate there is an immediate and urgent need to contin- ue educating physicians about MIPS requirements," Dr. Liao said. "Medicare should ask doctors what they think because we clearly found many phy- sicians question where MIPS will really improve quality of care." n

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