Physician Performance Measurement & Reporting Literature Review
PLEASE NOTE THAT THIS REFERENCE DATABASE IS OUTDATED AND DOES NOT REFLECT INFORMATION GATHERED ON VALUE BASED PURCHASING IN 2015.
Performance Measurement and Reporting aims to improve the quality of care delivered to patients by physicians through evaluation and transparency. Improvements in care are typically evaluated over time and standardized using evidence-based measures. Patients and employers can use measurement and reporting as a strategy to develop benefits and network tiers (organizing providers into levels or groups with varying benefit design to steer patients to preferred providers), offer performance incentives, and select physicians. In many instances, physicians utilize their performance achievements to compete for patients and reimbursement for providing high-quality care. Numerous measurement and reporting programs have emerged over the last 20 years, especially within private health plans and government programs; however, the value and usage of physician measurement and reporting remains an area of continued research and evaluation.
Health care measurement can include a variety of focus areas, such as clinical quality, resource use, information technology, patient satisfaction, and more. There are several types of measures—structural, process, and outcome—set forth in the Donabedian model, which is now widely accepted throughout the health care system. A structural measure evaluates physicians’ physical environment, such as physician office and workflow design. A process measure evaluates the actual care provided in diagnosis and treatment, as well as the patient’s activities to seek and carry out the plan of care. An outcome measure reflects upon the results of care as it impacts the population or patient. For more information, see Resources in Getting Started.
Measures are typically considered credible if they have been nationally validated by national organizations such as by organizations such as the National Committee for Quality Assurance (NCQA). NCQA developed HEDIS measures, encompassing eight domains and 71 measures, which are used by 90% of health plans across the country to measure provider performance. For more information, see Additional Resources. Other organizations like the National Quality Forum (NQF) and the National Quality Measures Clearinghouse (NQMC) are resources that provide information about measures which have been endorsed or approved by health services researchers.
Health plans, governmental agencies, and other organizations collect data for each measure to evaluate physician performance. Data can be collected via claims, chart audits, or health plan administrative data. For example, NCQA uses claims data to populate many of the HEDIS measures, while medical chart review typically is the source of data for NCQA's physician recognition programs, such as the Physician Practice Connections®- Patient Centered Medical Home™ (PPC-PCMH) Recognition Program, the Diabetes Recognition Program, and the Heart-Stroke Recognition Program. For more information, see Resources. Claims data has the advantage of being easier to obtain (especially for health plans), but certain clinical data is available only through chart review.
Although many physicians accept the concept of receiving financial incentives for providing high-quality care, some physicians remain skeptical about the measurement component for several reasons. First, physicians believe that performance measurement may lead to adverse patient selection; for instance, physicians may avoid treating sicker or difficult patients in order to perform better on the measures. Second, physicians may develop skewed priorities for performance measurement and focus only on measures that have the greatest impact on their performance status or level. Some physicians are concerned that performance data may lead to medical malpractice lawsuits, but studies suggest that performance information does not impact such suits. Understanding physicians’ perspective about performance measurement and reporting, and participation in such initiatives, remains an area that still requires further research. For more information, see references (9), (10), (11), (13), and (15).
Despite concerns about performance reporting, health plans, purchasers, and various provider organizations, such as the American College of Physicians and the American Medical Association, recognize the need for physician performance measurement and have provided numerous recommendations and guidelines. These recommendations may address the concerns of providers related to risk-selection, measurement priorities, and outcomes. Studies also demonstrate that consumers and employers continue to show interest in the quality and cost of physicians by requesting information from health plans, but consumers and employers do not yet make full use of the information provided. For more information, see references (1), (2), (3), (8), (13,) (14), and Resources.
In many cases, such performance information may be publicly reported to promote transparency and consumer engagement in health care decision-making. As with performance measurement, there are several methods to publicly report physician performance. A health plan website may report performance information about primary care providers and/or specialists so that patients can make informed decisions when seeking care. For example, CIGNA created a performance tool for members to access quality and cost profiles for physicians in twenty-one specialties. Aetna members may search for physician evaluations online through the DocFind tool. Or, a health plan may create networks or tiers of physicians based on performance and recognize high-performing physicians with notations or graphics, for example United Healthcare’s Premium Designation Program. Aetna also developed a program called Aexcel®, launched in January 2004, to evaluate physicians in twelve specialties for clinical performance, efficiency, and total costs. Other websites like Health Grades contain performance information about physicians in a search engine classified by geographic area or specialty. Consumers can access NCQA’s HEDIS measures and performance information through the State Health Care Quality Report. For more information, see reference (6), the Case Studies, and Resources.
Health care purchasing organizations have also begun to measure and report physician performance in communities. For example, the New York Business Group on Health conducted a physician performance measurement and reporting initiative in 2004 through a multi-stakeholder task force. The project is based on HEDIS measures for primary care physicians in the New York area that treat patients with asthma, cardiovascular disease, diabetes, and depression. The program aims to improve quality of care by releasing performance results to each physician practice for quality improvement purposes. For more information, see the Case Studies.
Because physician measurement and reporting complement one another, the same organizations that support physician measurement also support physician reporting. For example, NQMC provides consumers with an opportunity to compare evidence-based quality measures by category. Many health plans, such as Aetna, use the nationally recognized standards of NCQA (the basis for Bridges to Excellence pay-for-performance programs) to design their performance reporting programs.
There are many challenges associated with physician performance measurement and reporting since this area of health care continues to evolve with on-going health care reform efforts. There are technical challenges associated with defining measures and ensuring they provide an accurate portrayal of physician performance. (For this reason, it is appropriate to use measures that have gone through an expert review process, such as the National Quality Forum.)
It can also be difficult to select measures that balance the views of providers, health plans, consumers, and employers, even though each has a common goal of delivering and receiving improved care in a re-engineered health system. Performance data can be difficult and resource intensive to obtain, and the data that is publicly reported is currently not well-utilized by patients and purchasers.
Defining the scope of accountability for patient outcomes remains another question of all health care stakeholders. Outcomes measures are a key focus for purchasers and patients, since improving outcomes is the ultimate purpose of health system improvement. However, physicians argue that outcomes are not within their control, since patient behavior and other external factors may have a greater impact on outcomes than physician performance. As mentioned above, this could lead physicians to avoid sicker or more challenging patients. For this reason, outcomes measures need to be risk-adjusted, which increases their technical complexity. For more information, see references (1), (3), (8), and (13)-(18).
Physician performance measurement and reporting enables consumers to make informed decisions about their health care through performance comparisons for quality and value. Employers also benefit from physician performance measurement and reporting by implementing strategies such as plan design, network tiering, incentives, and employee engagement to improve health outcomes and reduce costs. Health plans can also use this information for strategic planning, contract negotiations, and network management. Physicians ultimately gain valuable performance information through peer comparisons and state/national benchmarks to focus on areas of success and improvement in quality, resource utilization, health information technology, patient satisfaction, and more.
This health care topic links directly to Physician Payment Reform, for measurement and reporting serve as the foundation for payment methodologies. Several value-based purchasing programs align payment with performance (through measurement and reporting) in order to promote transparency and foster quality improvement as needed. Bridges to Excellence serves as an example of a payment reform program which builds upon physician measurement and reporting through a performance assessment organization like NCQA. Based on the physician’s performance achievements, the physician receives an increased bonus per patient to recognize the high-quality of care delivered. For more information, see the discussion and examples set forth in the Physician Payment Reform section.
The literature citations are categorized into the following groups:
 “Types of Quality Measures: Talking Quality.” Agency for Research Healthcare and Quality. https://www.talkingquality.ahrq.gov/content/create/types.aspx.