The demand for accountability for health care provider performance has increased dramatically in an environment of consumer-driven health care, a growing interest in aligning payment and quality, and in value-based purchasing by Medicare and other purchasers of health care services. Increased “transparency” in providing health care consumers with helpful information about the quality, safety and pricing of health care has been a 2006 call to action by President Bush, the Centers for Medicare and Medicaid Services, the American Hospital Association and Federal Legislation – the Deficit Reduction Act of 2005.
In this arena, performance data that is credible and reliable takes on an expanded and important role as the basis for performance-based payment systems. The following provides a summary of the major performance measurement initiatives focus on physician and hospital performance:
Physician-focused initiatives
The ACS National Surgical Quality Improvement Program (ACS NSQIP) is a nationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. The program employs a prospective, peer controlled, validated database to quantify 30-day risk-adjusted surgical outcomes, which allows valid comparison of outcomes among all hospitals in the program. Medical centers and their surgical staff are able to use the data to make informed decisions regarding their continuous quality improvement efforts.
The ACS NSQIP collects data on 133 variables, including preoperative risk factors, intraoperative variables, and 30-day postoperative mortality and morbidity outcomes for patients undergoing major surgical procedures in both the inpatient and outpatient setting.
ACS NSQIP provides feedback and information to participants through annual IRR site visits, SCNR and surgeon champion conference calls, and the ACS NSQIP Annual Meeting. In addition, the ACS NSQIP Advisory Committee monitors the development of the program and encourages participants, surgical specialty groups, and other quality improvement organizations to share their experience and expertise with the program.
CMS continues to sponsor measurement initiatives to help physicians improve patient care. These include the Doctor’s Office Quality (DOQ) Project and the Doctor’s Office Quality Information Technology (DOQ-IT) Project.
The Doctor’s Office Quality Project is designed to measure quality of care for chronic and preventive services in Medicare populations that are provided in the doctor’s office. The DOQ measurement set has three components: clinical performance measurement set, the Physician Practice Connections tool, and a patient experience of care survey.
Doctor’s Office Quality information Technology (DOQ-IT) encourages the expanded use of information technology in the doctor’s office.
New NQF projects include identifying consensus standards (measures) for the reporting of health care-associated infection data, standardizing quality measures for cancer care, achieving national consensus on evidence-based practices for the management of substance abuse disorders, and identifying a minimum set of preferred practices for hospice and palliative care. The latter were just approved by the NQF Board in May. Ongoing projects include the endorsement of ambulatory care quality measures, specifically focused on physician practice. To date, NQF has endorsed 36 “physician-focused” voluntary consensus standards (measures) through an expedited review of ambulatory measures drawn from the American Medical Association’s Physician Consortium for Performance Improvement, CMS, National Committee on Quality Assurance, and the Agency for Healthcare Research and Quality.
The Physician Consortium for Performance Improvement is an American Medical Association-led initiative to identify evidence-based clinical performance measures and tools for physicians. The Consortium has thus far endorsed 93 performance measures on 16 clinical topics. A number of these measures have been endorsed through the NQF project on ambulatory care measures. The Joint Commission participates in the Physician Consortium for Performance Improvement, as well on as several specific measure workgroups.
The Ambulatory Care Quality Alliance (AQA) was formed in September 2004 by the American Academy of Family Physicians, the American College of Physicians, America’s Health Insurance Plans, and the Agency for Healthcare Research and Quality. The mission of the AQA is to improve performance measurement, data aggregation, and reporting in ambulatory care settings. The AQA has now become a broad-based national coalition of more than 125 organizations that is led by a steering committee of 11 organizations. The AQA has first sought to achieve consensus on a starter set of ambulatory care measures. Stakeholders began using the first 26 endorsed consensus measures in January 2006. These measures address prevention (e.g., colorectal screening, tobacco use), coronary artery disease, heart failure, diabetes, asthma, depression, prenatal care, and overuse or misuse of services. The next goal involves pursuit of a multi-year strategy to roll-out additional measurement sets and implement measures in the market place. AQA also envisions the establishment of a Data Stewardship Board that would reach consensus on uniform rules and standards for the aggregating and sharing of quality data. To address its goals, the AQA has formed a series of workgroups – on performance measurement; data aggregation and sharing; and reporting. During 2006, a pilot project supported by funding from CMS and AHRQ will take place at six sites across the country to evaluate the combining of public and private sector reporting on physician practice.
The National Committee for Quality Assurance (NCQA) will review 48 health plans, including five preferred provider organizations, against NCQA’s new Physician and Hospital Quality standards beginning this summer and continuing through 2006. Health plans seeking distinction in Physician and Hospital Quality must show that they measure the quality and cost of network providers through the use of clinical measures of physician quality endorsed by the National Quality Forum (NQF) and the Ambulatory Quality Alliance, as well as hospital quality measures endorsed by NQF and the Hospital Quality Alliance. Plans must use results respecting both cost and quality, whenever possible, to improve the quality of services delivered, and share the data with their customers.
Hospital-focused Initiatives
The new CAHPS Hospital Survey (H-CAPHS) was developed through a partnership between AHRQ and CMS, and consists of a standardized questionnaire that produces reliable information about consumer care experiences in various hospital settings. The first public reporting of the H-CAPHS data will begin late 2007 on the Hospital Compare website and, hopefully, on Quality Check as well.
Under the 8th Scope of Work (SOW), Quality Improvement Organizations (QIOs) are charged to continue to operate in a number of settings, including hospitals, to improve care to Medicare beneficiaries. The current CMS quality agenda includes public reporting of quality measures, known as National Quality Initiatives, to assist Medicare beneficiaries in making informed decisions in accessing local health care services. Measures currently in use by hospitals under the QIO 8th SOW contract cycle (August 2005 – July 2008) address acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and surgical infection prevention (SIP). These measures are aligned with and common to corresponding Joint Commission measures. For the past three years, the QIOs have been working with hospitals to improve performance on the starter set of ten hospital measures drawn from three of these sets (five AMI, two HF and three PN measures), and, during this period, performance on these measures has improved.
The Surgical Care Improvement Project (SCIP) is a national quality partnership of organizations committed to improving the safety of surgical care through reduction of postoperative complications. Initiated in 2003 by CMS and the Centers for Disease Control and Prevention, the SCIP partnership is coordinated through a Steering Committee of 10 national organizations, including the Joint Commission. This year, SCIP is launching a multi-year national campaign focused on the prevention of surgical site infections, peri-operative cardiac events, deep vein thrombosis and postoperative ventilator-associated pneumonia.
As part of the effort to assure alignment of common measures, the SCIP infection module (to be folded into the existing SIP measure set) and the acute myocardial infarction and venous thromboembolism modules will be implemented by CMS and the Joint Commission over the next two years. Meanwhile, CMS and the Joint Commission continue to work on aligning the ventilator-associated pneumonia measures from the SCIP and (Joint Commission) ICU measure sets.
The Medicare Modernization Act of 2003 provides a financial incentive for eligible hospitals to submit data for the Hospital Quality Alliance’s “starter set” of 10 measures. The legislation stipulates that eligible hospitals paid under the Prospective Payment System (PPS) that do not submit data for the 10 measures are to receive a 0.4% lower update to their Medicare payments for fiscal years 2005, 2006 and 2007.
The Deficit Reduction Act of 2005 (DRA) was signed by President Bush in February 2006 and stipulates implementation of a value-based purchasing program for hospitals in 2009 and therein contemplates incremental, broader-ranging measurement efforts than currently exist. The DRA provides that a hospital that does not submit data for an expanded list of designated quality measures will receive a 2% lower update than a hospital that does not submit performance data. The DRA supersedes the Annual Payment Update (APU) for Fiscal Year 2007. The DRA stipulates that the starter set of measures be progressively expanded to adopt the set of measures identified in the December 2005 report on performance measurement issued by the Institute of Medicine (IOM). The IOM measures include the Hospital Quality Alliance measures, the H-CAPHS survey, and the three structural measures promoted by the Leapfrog Group (computerized physician order entry systems, use of intensivists and volume-related referrals).
The Premier Hospital Quality Incentive Demonstration Project – the federal government’s most visible pay-for-performance initiative – provides financial rewards to top-performing Premier hospitals through increased reimbursement for services provided to Medicare patients. Under the demonstration, about 270 hospitals are voluntarily providing data on 34 quality measures related to 5 clinical conditions: acute myocardial infarction, heart failure, pneumonia, coronary artery bypass graft, and hip and knee replacement. Using the quality measures, CMS is identifying hospitals with the highest quality performance in each of the five clinical areas. Hospitals scoring in the top 10% in each clinical area receive a 2% bonus payment in addition to the regular Medicare DRG payment for the measured condition. Hospitals in the second highest 10 % receive a 1% bonus payment. Following the first year of the demonstration (FY 2004), CMS awarded a total of $8.9 million to participating hospitals in the top two deciles for each clinical area.
The Hospital Quality Alliance (HQA) is a public/private sector collaboration to improve the quality of care provided by the nation’s hospitals through measuring and publicly reporting on that care. This collaboration is led by the American Hospital Association, the Federation of American Hospitals, and the Association of American Medical Colleges, and is supported by the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, the Joint Commission, the National Quality Forum, and an expanding array of other professional, business, and consumer organizations. The HQA is currently supporting the reporting of twenty measures on Hospital Compare. These include the currently- required DRA measures. Measure sets currently under active HQA consideration include the SCIP set, pediatric asthma measures developed by the Joint Commission, the critical care (ICU) measures developed by the Joint Commission, and the nursing sensitive care measures developed by the Joint Commission and NQF. In addition, HQA and CMS plan to implement the CAHPS® Hospital Survey and 30-day mortality measures for acute myocardial infarction and heart failure in 2007.
The Leapfrog Group launched its first rewards program for hospitals in 2005. The Leapfrog Hospital Rewards Program (LHRP) portrays hospital performance in relation to coronary artery bypass surgery, percutaneous coronary intervention, acute myocardial infarction, community-acquired pneumonia, and deliveries/neonatal care. Within each of the five clinical areas, Leapfrog has identified several measures of quality endorsed by NQF that are being collected either through the Leapfrog Hospital Quality and Safety Survey or through the Joint Commission ORYX initiative. In addition, the program includes a measure of the efficiency of resource use. This latter measure calculates resource efficiency as severity-adjusted average length of stay, broken down by routine care days and specialty care days, and adjusted for short-term readmission rate to the same facility.