Most Primary-Care Physician Practices May Be Too Small To Measure Quality Adequately

Rethinking the approach to performance measurement in ambulatory care may be necessary for Medicare if the United States is to reverse the high and rising costs of healthcare – even as evidence grows that quality is lagging.

Now the wisdom of P4P programs is coming under scrutiny.

Researchers are beginning to realize that individual primary care physicians may not treat enough Medicare patients as those in group practices to reliably measure significant differences in common measures of quality and cost performance. The findings were printed in JAMA.

David Nyweide of CMS and other colleagues examined whether statistically meaningful differences on measures of quality and cost could be measured more reliably for primary care groups than for individual physicians.

The answer was no. "Relatively few primary care physician practices are large enough to reliably measure [the] relative differences in common measures of quality and cost performance among fee-for-service Medicare patients," the study in JAMA found.

The researchers drew their conclusions by looking at the Medicare patient loads of individual physicians in three treatment areas – mammography, diabetes and congestive heart failure (CHF) hospitalization.

"None of the primary care physician practices had sufficient caseloads to detect 10 percent relative differences in preventable [CHF] hospitalization or 30-day readmission after discharge …," the researchers said.

The percentage of primary care physician practices with sufficient caseloads to detect 10 percent relative differences in performance ranged from less than 10 percent of practices with fewer than 11 primary care physicians to 100 percent of practices with more than 50 primary care physicians.

"Novel measurement approaches appear to be needed for the twin purposes of performance assessment and accountability," the authors concluded.

One Doctor’s Response To Quality and Performance Measurements

Dr. Donald Berwick of the Institute for Healthcare Improvement (IHI), in Cambridge, Mass., offeredsuggestions on how to improve the measurement of quality and performance.

"First, the effective sample sizes contract rapidly when the focus is on specific diseases or patient sub-populations. By relying on highly focused quality metrics one at a time, [the researchers] are viewing care through a tiny keyhole. If valid quality metrics could be constructed that cross conditions, more patients could contribute relevant data.

"Second, more could be known if data could be aggregated from all payers, not just Medicare. Creating shared pools of transparent performance information for Medicare, Medicaid and private insurers would be a step toward maturation in the ability to improve U.S. healthcare.

"Third, patients can and should be asked directly about their experiences of care. The uniform use of the Hospital Consumer Assessment of Healthcare Providers and Systems survey measures in Medicare goes in the right direction, but much more should be invested in listening to patients and their families, helping them to describe how well they feel treated.

"And fourth, the ability to measure and track individual patients' health and function over time and place should be expanded. Measuring a mammography rate or the frequency of assessment of glycated hemoglobin is a far cry from measuring true aims: health, function and comfort."

Address: Centers for Medicare and Medicaid Services, 7500 Security Blvd., Baltimore, MD 21244; (877) 267-2323, www.cms.gov.