Setting the Bar Before We Measure It

Nov 19 2010 Published by under Uncategorized

Yesterday I attended a session at the Annual Meeting of the American Society of Nephrology regarding changes to reimbursement for nephrology services through the Center for Medicare and Medicaid Services (CMS). Dr. Barry Straube, a nephrologist and Director of CMS, spent 90 minutes discussing the alphabet soup of changes wrought by both CMS and the Affordable Care Act.

One innovation is Quality Incentive Programs (QIP), a move to reward physicians (and the health care team) for meeting or exceeding quality standards. Reimbursement would be lowered for practices delivering sup optimal care. Sounds like a wonderful plan, doesn't it?

Fast-forward to half an hour of Q&A.

"How are we going to set QIP standards?"
Mostly through the use of expert committees.
"Hmmm... That's how we set anemia standards a few years back. Those standards led us to push hemoglobin higher than necessary in patients, levels we now know increase teak of cardiovascular morbidity and mortality. How can we set a bar without data on where to set the bar?"
We have to start somewhere.
"So we may end up penalizing providers for not achieving goals that may not turn out to be the correct goals?"

It's great to say we will reward quality care and outcomes; however, we need to be able to define those outcomes using real data, not opinion and conjecture. We must also recognize that therapeutic goals should be individualized. Attaining blood pressure goals for a large group of patients may prove beneficial for the group, but achieving tight lowering for some patients may cause significant side effects affecting quality of life. Should caregivers be penalized because patients cannot or will not or even should not meet the published guidelines? These exceptions to general goals become especially problematic in smaller practices. If I have 100 patients in my center and 5 fail to meet the goal, 95% are on target if I only care for 6 patients (not an unusual number of children for a dialysis center) and even one doesn't make that target, my success falls to 83%.

We do need to find ways to control healthcare costs and reward thought and quality. Before QIPs can be the answer, we need to know what quality is. This task will take funds and time. We must be careful to avoid over-penalizing before we have defined what we really want.

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