November 2006

NCQA Releases New Quality Measures for Physician Care

NCQA R eleases N ew Quality Measures for Physician Care

The National Committee for Quality Assurance (NCQA) has released a set of draft measures of ambulatory care quality that will help health plans measure the quality of care at the physician level. These proposed measures will form the foundation of a new Health Plan Employer Data and Information Set ® (HEDIS) designed to assess clinical quality at the physician level.

“By adding physician-level measures to our existing measures, we add another layer of health care quality information to use in health plan comparison,” said NCQA Executive Vice President Greg Pawlson, M.D., M.P.H. “ We hope the public comment will allow stakeholders to weigh in on how to appropriately collect and implement measures for physicians.”

The measures are designed to allow health plans to report physician performance for their network. Not only do the measures provide technical specifications, but they also include implementation methods, such as appropriate sample sizing. NCQA is interested in how well these measures can be implemented in a health plan setting.

The measures contain six prevention measures, such as breast cancer screening and influenza vaccination, as well as coronary artery disease, depression and asthma measures. Measures addressing overuse and misuse are also included.

The draft measures represent a broad-based consensus of what quality care is from several respected organizations. Developed by NCQA, the measures were included in the National Quality Forum-endorsed National Voluntary Consensus Standards for Physician-Focused Ambulatory Care. The Ambulatory Care Quality Alliance (AQA) adopted these measures as part of the Recommended Starter Set of Clinical Performance Measures for Ambulatory Care. Draft measures are available at NCQA’s Web site, www.ncqa.org.

The measures will frame an electronic HEDIS Physician starter set to be released this month as well as a complete HEDIS Physician volume to be released early 2007.

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Quality Forum Finalizing Safe Practices for Preventing Adverse Health Care Events

The National Quality Forum is preparing to issue soon a final updated list of endorsed "safe practices" for preventing adverse health care events.

NQF, a standard-setting organization, issued its latest proposed safe practices for all health care settings on Oct. 16 and is accepting comments through Nov. 14. The organization has not yet set a date for the issuance of the final safe practices.

Medical mistakes and other adverse health care events are a leading cause of death and injury in the United States, even though well-documented methods could prevent the occurrence of many such events, according to NQF.

The forum initially endorsed in 2003 its list of 30 safe practices that are aimed at reducing the risk of harm from processes, systems, or environments of care. NQF recently undertook an effort to update the safe practices to reflect new evidence and innovation.

The proposal included three new practices, 23 practices that have been changed since the original set, and four practices that remained unchanged. For instance, the practices include "create and sustain a healthcare culture of safety," as well as the recommendation to prepare a discharge plan for each patient leaving the hospital, which should be relayed to caregivers with a confirmation of receipt. Another example includes immunizing annually against influenza all at-risk health care workers and patients.

The practices also call for each health care organization to standardize a list of "Do Not Use" abbreviations, acronyms, symbols, and dose designations.

The forum also endorsed recommendations for disseminating, implementing, and updating the list of practices, as well as identifying several areas where additional research should be undertaken.

The proposed safe practices are available on the Web at http://qualityforum.org/pdf/news/txSPReportAppeals10-15-06.pdf.

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Study Finds Over Half of HMOs Offer Pay-for-Performance for Doctors, Hospitals

More than half of health maintenance organizations used pay-for-performance (P4P) programs in 2005 to reward physicians and hospitals for improving the quality of care they offer, according to a federally funded study released Nov. 2.

The study in the Nov. 2 issue of The New England Journal of Medicine found that 52 percent of 252 HMOs in geographic regions with at least 100,000 people enrolled in this type of health plan had P4P programs. The study, "Pay for Performance in Commercial HMOs," was supported by funding from the Agency for Healthcare Research and Quality, part of the Department of Health and Human Services.

Of the health plans with P4P programs, 90 percent operated them for physicians and 38 percent for hospitals.

The sample covered 91 percent of U.S. HMO enrollees and 78 percent of the U.S. metropolitan population, said the survey, conducted by researchers from the Harvard University School of Public Health and Harvard Medical School.

The study found that P4P programs are more often associated with HMOs that use primary care physicians as gatekeepers to specialty care or use capitation payments that give doctors set payments each month.

Clinical Care Measures

Of the 113 HMOs with P4P programs for physicians, just 13 percent focused on individual doctors rather than a medical group for the unit of payment, the study said. Nearly all the P4P programs used clinical care measures to determine P4P payment, including such yardsticks as patient use of diabetes care, mammography, and asthma medication.

About a third of the physician P4P programs were designed only to reward top-rated physicians or groups, the study said. Sixty-two percent offered financial rewards for meeting a predetermined quality threshold, while about 20 percent rewarded improvement toward a goal, it added.

The bonus given to physicians was generally equivalent to 5 percent or more of payments from the HMO, according to the study.

Health plans in the South were less likely to have P4P programs, the study found. The study also said certain characteristics--such as a requirement to designate a primary care provider with or without a gatekeeping role, nonprofit ownership, and capitation payment--were associated with greater use of P4P.

Medicare Advice

The researchers said their findings have relevance for Medicare as it attempts to incorporate P4P programs into its payment systems. HMOs with a large number of enrollees who are not required to select a primary care provider as a gatekeeper--a feature shared by Medicare--were less likely to have P4P programs, the study said.

"This finding may well reflect the challenges of attributing performance to a single doctor or group when many doctors or groups are responsible for a patient's care," the study said. "The development of appropriate strategies to overcome the current lack of a designated [primary care provider] in the Medicare system will be critical to the implementation of a pay-for-performance program."

Private-sector P4P programs also tend to be heavily concentrated in medical groups rather than individual doctors, the study said. Medicare may need to recognize groups as contracting entities to make P4P work, it added.

Health plans apparently have determined that a 5 percent bonus payment for P4P participation "is needed to achieve improvement," the study said. "Given its financial constraints, [Medicare] may not be able to meet this benchmark without reducing base payments to some physicians," it added.

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