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Improving Patient Care |

Performance Measurement in the Small Office Practice: Challenges and Potential Solutions

Bruce E. Landon, MD, MBA; and Sharon-Lise T. Normand, PhD
[+] Article and Author Information

From Harvard Medical School, Beth Israel Deaconess Medical Center, and Harvard School of Public Health, Boston, Massachusetts.


Grant Support: From a contract with the National Quality Forum.

Potential Financial Conflicts of Interest:Consultancies: S.L.T. Normand (Massachusetts Department of Public Health).

Requests for Single Reprints: Bruce E. Landon, MD, MBA, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, Landon@hcp.med.harvard.edu.

Current Author Addresses: Drs. Landon and Normand: Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115.

Author Contributions: Conception and design: B.E. Landon, S.L.T. Normand.

Analysis and interpretation of the data: B.E. Landon.

Drafting of the article: B.E. Landon, S.L.T. Normand.

Critical revision of the article for important intellectual content: B.E. Landon.

Final approval of the article: B.E. Landon.

Statistical expertise: S.L.T. Normand.


Ann Intern Med. 2008;148(5):353-357. doi:10.7326/0003-4819-148-5-200803040-00006
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Efforts to improve quality have shifted from measuring and publicly reporting quality-of-care data to implementing reimbursement systems that reward physicians (1). These programs vary by the number and type of performance measures used, clinical conditions targeted, magnitude and structure of the incentives, and size of the share of the practice's panel of patients; however, they all make use of explicit measures of quality to assess individual physicians or groups of physicians that practice together. To succeed in improving quality, pay-for-performance and public reporting systems must have substantial buy-in from practicing clinicians. This requires valid measures that are evidence-based, clinically important, representative of practice, and statistically robust (2)—and are neither overly cumbersome nor expensive to collect.

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Not convinced about performance measurement
Posted on March 11, 2008
Michael E. Miller
Medical Care AffiliatesUnconvinced
Conflict of Interest: None Declared

I've practiced internal medicine with 3 colleagues for 28 years, and have no desire to impede progress improving patient safety and care quality. However, Landon and Normand evoke more questions than answers, leaving me unconvinced of the value of performance measurements, and unenthusiastic about embracing them.

1) Where is the evidence that public reporting of performance measures and "P4P" programs improve (or worsen) outcomes?

2) Are these programs the right place to invest limited resources towards repairing today's pressing health care problems: the uninsured, ever-rising costs, decreased affordability and access?

3) Do these programs encourage career choices in primary care and address shortages? Do they boost, or likely further sap dwindling physician morale?

4) Health Plan reports to physicians are currently reported in aggregate, de-identified format. Without referencing an identifiable episode of care-are these "generic process recommendations" (prescribe more generic drugs, order more mammograms) useful (evidence?) in changing physician behavior?

5) "Profit Measures." Are these programs ultimately designed to enhance insurer profits/investor returns? Are these "zero-sum" programs; with payment shifted from poorly measured practices to good ones?; the benefit being holding the line on spending. Or, do insurers profit by reducing payments to under-performing practices?

6) Do these programs assuage the nagging suspicion that the major benefit of physician purchased EMR's accrue to insurers via easy access to, acquisition of, and tracking of physician care, process, and prescribing measures? Why should small practices pay to prescribe electronically, when PBM's, pharmacy monitoring programs, and the AMA sell the data for profit?

7) I'm swamped with dreaded requests to complete forms and copy charts for insurers. If patients benefit from these chores, shouldn't they foot part of the cost, perhaps a premium surcharge returned to physicians to recoup costs?

8) Should physicians be "penalized" for patients willingly choosing to be non-compliant?, patients whose care and prescribing are shared by multiple physicians?, and patients enrolled in self-directed/high- deductable plans who deliberately choose not to spend money on proven preventive measures included in performance assessment?

9) The UK experience rewarding physicians complying with performance measures resulted in substantial financial gain for physicians at great government cost. Given the current difficult economic conditions, and negative attitudes towards physician compensation, can a similar program be developed here?

Please convince me!

Conflict of Interest:

None declared

In Response
Posted on April 30, 2008
Bruce, E. Landon
Harvard Medical School
Conflict of Interest: None Declared

To the Editor:

We sympathize with the sentiments expressed in this letter. One of us is a practicing physician and is aware of the extra burden imposed by many performance measurement programs with unclear patient benefits. We note, however, that historical evidence suggests that the proliferation, measurement, and dissemination of quality information have a substantial impact on measured areas of quality. Indeed, one measure (beta blocker use after a myocardial infarction) has been retired because performance has approached perfection.1 It is highly unlikely that performance on this measure and others would be so high if a spotlight had not been aimed at them. Although pay for performance and other programs have been shown to have a generally small impact over short time periods, their cumulative effects over time remain unknown. The hope is that better use of population health management techniques and electronic resources, such as electronic health records and decision support, will improve the capacity of physician organizations to achieve higher quality care.

While space limits prohibit addressing each of the points raised in the letter, we explicitly comment on a few key points. First, given recent evidence that the quality of care produced by the US health care system is suboptimal, we not only believe that limited resources should be directed towards improving care, but in fact that this investment should be much more substantial.2-4 Second, we disagree that these programs are at the root of the current primary care crisis. In fact, the UK has instituted a broad P4P program that includes substantial additional resources directed towards general practitioners in part to stabilize the primary care workforce. We agree with the authors that onerous utilization management tools and requests used by health plans will diminish with time as the interconnectedness of the health care system is improved. Nonetheless, it is unlikely that these programs will disappear while there is still substantial evidence of overuse and variations in use that cannot be explained by clinical need. Some of these other issues have been raised in prior work that we and others have written.5 Despite these problems, we believe that increased measurement and transparency is required for health systems improvement.

Bruce E. Landon, MD, MBA Sharon-Lise T. Normand, PhD Harvard Medical School

References 1. Lee TH. Eulogy for a Quality Measure. N Engl J Med. 2007;357(12):1173-1157. 2. Quality of Health Care in America Committee of the Institute of Medicine. To Err is Human: Building a Safer Health System Washington, DC: National Academy Press; 1999. 3. Quality of Health Care in America Committee of the Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 4. McGlynn EA, Asch SM, Adams J, et al. The Quality of Heath Care Delivered to Adults in the United States. N Engl J Med. 2003;348(26):2635- 45. 5. Landon BE, Normand SL, Blumenthal D, Daley J. Physician clinical performance assessment: prospects and barriers. JAMA. 2003;290:1183-9.

Conflict of Interest:

None declared

Performance measurement: Who will Pay?
Posted on July 17, 2008
Daniel Longo
Virginia Commonwealth University, School of Medicine
Conflict of Interest: None Declared

"Performance Measurement in the Small Office Practice: Challenges and Potential Solutions"(1) provides an excellent overview of the challenges and potential solutions involved. However, in the actual article, the rapid response letter, and the authors' response a critical issue is omitted: How will performance measurement be financed? While this is somewhat alluded to in terms of the various resources required, such as Electronic Medical Records, and the payments promised by a pay-for- performance system, this issue is not directly addressed. It is a priority that must be addressed and solved if performance monitoring is ever to be realized. Performance management has both direct and indirect costs that the current and present reimbursement systems, simply does not adequately take into account.

In a project we are conducting funded by the Agency for Healthcare Research and Quality, "Quality Performance Monitoring and Data Collection and Reporting (QPMDCR) Project", our work clearly highlights this issue. In fact our project's expert panel (national leaders in this field) in a on-line discussion and conference call to consider the barriers to clinical data collection and performance monitoring, were in strong agreement that for performance measurement to occur significant investment of resources by payers, including insurers and government entities, will be required to establish a new measurement paradigm that takes into account the relationships and interactions between patients and providers in the primary care practice encounter. They uniformly agree that such an investment is likely to be worthwhile in improved quality of care and cost efficiencies; but one must still ask --- who will pay for this activity?

While pay-for performance has some promise of providing additional financial incentives for those clinicians who provide "excellent care", these incentives in no way can pay for the costs of the infrastructure and its on-going maintenance necessary to collect relevant data and monitor clinical performance. Primary care physicians can no longer provide services that are not reimbursed no less take on systems such as performance monitoring without such support. Those responsible for health policy at the state and national level, as well as third-party payors and government must wake up to the fact that as they continue to add more and more requirements onto an already broken primary care system, that collapse is inevitable. Hopefully they will meet the challenge in the best interest of quality care for the American public.

(1) Landon, B. E., and S. L. Normand. "Performance Measurement in the Small Office Practice: Challenges and Potential Solutions." Annals of Internal Medicine 148.5 (2008): 353-7.

Conflict of Interest:

This paper was funded under a contract with the Agency for Health Care Research and Quality (Proposal submitted in response to RFP No. AHRQ-06-00029Primary Care-Practice Based Research Networks)

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