Transcript Insert text here and fullstop.

Measuring and Reporting
Individual Physician
Performance
SEPTEMBER 2011
Penny Andrew
© Buddle Findlay 2011
Overview
i. What is physician performance measurement?
ii. Why?
iii. What is happening internationally?
 What performance measures are being used?
 How are performance measures being used?
iv. What are the pitfalls?
 Unintended consequences
 Confidentiality
 Public reporting
© Buddle Findlay 2011
What is physician
performance
measurement?
© Buddle Findlay 2011
End Results Idea
Ernest Amory Codman (1869 – 1940)
© Buddle Findlay 2011
Why measure physician
performance?
© Buddle Findlay 2011
A multitude of potential uses...
•
•
•
•
Stimulate improvements in quality / maintain standards
Reduce/eliminate unacceptable variation
Reduce cost – the "business case for quality"
Promote the use of providers that deliver the best
quality for price – "value-based purchasing"
• Promote accountability
– MOPS/certification
– Pay for Performance P4P
– Public reporting
• Engage and empower consumers
© Buddle Findlay 2011
What is most important?
Reflection on clinical practice/quality improvement
“Measures are the only way we can really
know if care is safe, efficient, effective, and
patient-centered. Performance measures also
help us improve faster” TIM FERRIS MD MPH
© Buddle Findlay 2011
What is happening
internationally?
© Buddle Findlay 2011
USA
© Buddle Findlay 2011
© Buddle Findlay 2011
Background: Physician Performance Measurement Initiatives
Measures Development
•AHRQ – CAHPS standardised patient experience
surveys
•NCQA – HEDIS clinical quality measures
•NQF - > 500 endorsed performance measures
•AMA – Physician Consortium for Performance
Improvement (PCPI) 266 clinical performance measures
(structure, process, outcome)
Roski , Kim M. Current efforts of regional and national
performance measurement initiatives around the United
States. Am J Med Qual. 2010;25(4):249-54
Measurement and Reporting
Federal
•CMS – Physician Quality Reporting System
State
•Cardiac Surgery Reporting Systems
Employers & Health Plans
•Leapfrog Group & Bridges to Excellence
State & Regional Collaboratives
•Massachusetts MHQP
•California Pay for Performance (P4P) initiative
Medical/Speciality Societies
•See RAND working paper: Providing Performance
Feedback to Individual Physicians: Current Practice and
Emerging Lessons July 2006
© Buddle Findlay 2011
US public reporting
•Pay for performance
(P4P) initiatives
 CMS Physician
Quality Reporting
System (PQRS)
•
State reporting
cardiothoracic
surgeons
•
Consumer reporting
© Buddle Findlay 2011
US public reporting – CMS PQRI
• CMS – Physician
Quality Reporting
System
P4P
 +2%
 + 0.5%maintenance
of certification
incentive
Names of eligible
practices and
individual physicians
but not results...yet
© Buddle Findlay 2011
US – state reporting on cardiothoracic surgery
© Buddle Findlay 2011
US – state reporting on cardiothoracic surgery
© Buddle Findlay 2011
US Variation Reporting - Dartmouth Atlas
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
© Buddle Findlay 2011
UK
© Buddle Findlay 2011
UK physician performance measurement and reporting
•Slower to start...but
catching up fast
•NHS surveys (patient
experience reporting) Picker
Europe
•2004 >
 Quality Outcome
Framework (QOF)
© Buddle Findlay 2011
UK
• 2005 >
Quality
Outcomes
Framework
(P4P primary
care)
GP practicelevel
performance
reporting
© Buddle Findlay 2011
UK
•2005 >
Quality
Outcomes
Framework
(P4P primary
care)
GP practicelevel
performance
reporting
© Buddle Findlay 2011
UK NHS Choices
•2010 >
NHS Choices
Consumer
Comments
GP practice
performance
Quality
Accounts
© Buddle Findlay 2011
UK NHS Choices
•2010 >
NHS Choices
Consumer
Comments
GP practice
performance
© Buddle Findlay 2011
UK Quality Accounts
•Quality
Accounts
All providers
of NHS services
(Primary Care
QAs from June
2012)
Mandatory
indicator
reporting +
local priorities
© Buddle Findlay 2011
UK
•Quality
Accounts
All providers
of NHS services
(Primary Care
QAs from June
2012)
Mandatory
indicator
reporting +
local priorities
© Buddle Findlay 2011
UK Primary Care Variation Measurement and Reporting
Dr Foster
Primary care
variation
measurement
and reporting
© Buddle Findlay 2011
AUSTRALIA
© Buddle Findlay 2011
Australian Commission on Safety and Quality in Health Care
• ACSQHC
55 National Safety and
Quality Indicators
13 Primary Care
Indicators
2 main purposes:
 priorities and system-level
strategies for safety and
quality improvement
 inform quality
improvement activities of
service providers
http://www.safetyandquality.gov.au/internet/safety/pu
blishing.nsf/Content/217E5A28E94590E0CA2577C9
00111538/$File/TNI-Sep2009.PDF
© Buddle Findlay 2011
Australia RACGP
http://www.rac
gp.org.au/
© Buddle Findlay 2011
Australia RACGP Clinical Audit Tool
http://www.clinical
audit.com.au/
© Buddle Findlay 2011
NZ
© Buddle Findlay 2011
NZ
Lots of data, lacking in
intelligence!
Ministry of Health
NMDS
Health Independence
Reports (14 quality &
effectiveness indicators
Health Targets
© Buddle Findlay 2011
NZ PHO Performance Management Programme
• DHBNZ
P4P
PHO
performance –
individual
PHOs
© Buddle Findlay 2011
NZ PHO Performance Management Programme
Funded Indicators
Chronic conditions indicators
Cervical cancer
Total Population
screening coverage
High Needs
3%
Breast cancer
screening coverage
High Needs
6%
6%
Ischemic
Cardiovascular disease
detection
Cardiovascular disease
risk assessment
Total Population
High Needs
3%
6%
Information only indicators
Total Population
8%
Current smoker status
High Needs
Total Population
12%
3%
High Needs
Total Population
6%
3%
High Needs
Prevention of infectious disease indicators
65+ flu vaccine
Total Population
coverage
High Needs
Age appropriate
Total Population
vaccinations for 2 year
High Needs
olds
6%
Breast cancer screening
3%
Utilisation by high need enrolees – doctor consultations
6%
3%
Simultaneous testing of acute phase response
6%
Inhaled corticosteroids
Diabetes detection
Diabetes follow-up
after detection
Financial indicators
GP referred laboratory
expenditure
GP referred
pharmaceutical
expenditure
TOTAL
Total Population
10%
Total Population
10%
Smoking status recorded
Metformin : Sulphonylureas ratio
Measurement of the acute phase response
Investigation of thyroid function
Utilisation by high need enrolees – nurse consultations
Utilisation by high need enrolees – doctor and nurse
consultations
% of current smokers who have been given brief advice in
the last 12 months
% of current smokers who have been given or referred to
cessation support services in the past 12 months
100%
© Buddle Findlay 2011
NZ
•Private
Organisations
Healthstat
Best Practice
Advocacy
Center (BPAC)
© Buddle Findlay 2011
NZ Public Reporting
• Health
Quality and
Safety
Commission
Serious and
Sentinel Event
Reporting
In the
future...
Variation
reporting (NZ
Atlas)
Quality
Accounts
© Buddle Findlay 2011
NZ Maintenance of Professional Standards
• Medical Council of NZ Recertification and CPD
Continuing professional development is involvement in clinical
audit, peer review and CME, aimed at ensuring that a doctor is
competent to practise medicine
Clinical audit is a process used to assess, evaluate and improve
the care of patients in a systematic...by objectively measuring your
performance against standards... It involves a cycle of continuous
improvement of care, based on explicit and measurable indicators
of quality. It has a statistical basis
Regular practice review is informed by a portfolio of information
provided by the doctor, which may include
audit outcomes and logbooks
© Buddle Findlay 2011
NZ RNZCGP Aiming for Excellence
•Aiming for Excellence 2011
—The Standard for New Zealand General
Practice
APPENDIX: Develop practice-based
activities to improve clinical outcomes
for patients
https://rnzcgp.org.nz/assets/documents/C
ORNERSTONE/Aiming-for-Excellence2011.pdf
© Buddle Findlay 2011
NZ Quality Measures Library
http://202.89.42.8/dev/library/index.php
© Buddle Findlay 2011
What are the pitfalls?
© Buddle Findlay 2011
Unintended consequences of measuring and reporting
Possible dysfunctional consequences – organisations or
individuals may:
concentrate on the clinical areas being measured to the
detriment of other important areas ('tunnel vision')
pursue narrow organisational objectives at the expense of
strategic coordination (‘sub-optimisation’)
concentrate on short-term issues and neglect long-term
criteria (‘myopia’)
place greater emphasis on not being exposed as an outlier
rather than on a desire to be outstanding (‘convergence’)
be disinclined to experiment with new and innovative
approaches for fear of appearing to perform poorly
(‘ossification’)
alter their behaviour to gain strategic advantage (‘gaming’)
indulge in selective and creative data gathering, classification
and coding, perhaps extending to outright misreporting and
fraud (‘misrepresentation’)
• Huw Davies
Measuring and
reporting the
quality of health
care: issues and
evidence from
the international
research
literature. NHS
Quality
Improvement
Scotland, 2006
© Buddle Findlay 2011
Pitfalls
• Methodological robustness of measures
– Sample size
– Incomplete patient list
– Risk adjustment
– Attribution
– Bias
– Limitations of type of measure
(structure/process/outcome)
© Buddle Findlay 2011
Focus on the Vital Few!
There are many things in life that are interesting
to know.
It is far more important, however, to work on
those things that are essential to quality
rather than spend time working on what is merely
interesting!
The challenge is to be disciplined enough to
focus on the essential
(or vital few) things
© Buddle Findlay 2011
42
© 2009 Institute for Healthcare Improvement, R. Lloyd
Measurement Guidelines
• Report and study a few key
measures monthly
• Don’t overdo process indicators
• Use available data bases to develop
measures
• Integrate data collection into daily
routines
• Plot data on key measures each
month
© Buddle Findlay 2011
43
Pitfalls
• Confidentiality of performance information?
© Buddle Findlay 2011
When must information be disclosed?
• Entities with powers to require disclosure of information
• HDC
• s62 Health and Disability Commissioner Act
• Coroners
• Commissions of Inquiry
• Courts
• Tribunals
• Mortality Review Committees
© Buddle Findlay 2011
When must information be disclosed?
• Rights to information
• NZ Bill of Rights
 Section 14 Freedom of expression
Everyone has the right to freedom of expression, including the
freedom to seek, receive, and impart information and opinions of
any kind in any form
• Consumers' Code of Rights
 Right 6 Right to be Fully Informed including:
 information that a reasonable consumer, in that consumers'
circumstances, would expect to receive
 the identity and qualifications of the provider
© Buddle Findlay 2011
When must information be disclosed?
• Official Information Act 1982
• Applies to government officials/bodies e.g.
MOH/Crown Entities/DHBs
• Starting point of the Act is the "principle of
availability"
• Good reason for withholding includes protecting
personal privacy
• Public interest balancing test – reason for
withholding must outweigh public interest in
disclosure
© Buddle Findlay 2011
How can information be protected?
Official Information Act and
Privacy Act
• Personal privacy
Mortality Review Committees
• Schedule 5 NZ Public Health
and Disability Act
Protected Quality Assurance
Activities (PQAAs)
• Sections 54-63 Health
Practitioners Competence
Assurance Act
© Buddle Findlay 2011
Protected Quality Assurance Activities
• Section 53 of the HPCAA defines a QAA as:
an activity that is undertaken to improve the practices or
competence of one or more health practitioners by assessing
the health services performed by those health practitioners…
• Gazetted PQAA Notice required
© Buddle Findlay 2011
Effect of the Protected Status of a QAA
• Subject to certain exceptions, a protected QAA means
that:
• any information that becomes known solely as a result of the activity
is confidential; and
• any documents brought into existence solely for the purposes of the
activity are confidential; and
• no civil or disciplinary proceedings lie against any person in respect of
conduct engaged in good faith in connection with a protected QAA
© Buddle Findlay 2011
US Litigation: is physician performance information personal
information?
• Wall Street Journal and Center for
Public Integrity
•
2009 investigation of potential Medicare billing waste,
fraud and abuse
•
FOIA request seeking data on individual physician
reimbursements
•
2010 publication of "Secrets of the System" series
•
2011 Florida Medical Association, Inc., et al., v. Dept
of Health, Education and Welfare & Dow Jones &
Company, Inc. – motion to vacate Florida injunction
© Buddle Findlay 2011
US - legislation
• April
2011 Bill introduced by Sen.
Grassley and Wyden to make
Medicare claim data transparent
• Medicare Data Access for
Transparency and Accountability Act
(Medicare DATA Act)
• Publicly available searchable
Medicare payment data base
• Data on Medicare payments to
physicians and suppliers do not fall
under the FOIA personal information
exemption
© Buddle Findlay 2011
© Buddle Findlay 2011