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Track dozens of performance measures // Sift through hundreds of patient records // Swallow thousands of dollars in overhead costs—when all they want is to deliver better care.

The Quest for Quality

By Linda Keslar // Fall 2006
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O’tayo Lalude, Bridges to Excellence

Sarah A. Friedman for Proto

Most physicians like to think they’re taking good care of their patients while also running efficient businesses. Louisville family practitioner A. O’tayo Lalude is no exception. Two years ago, when Lalude heard about a project designed to develop “best practices” in diabetes care, he volunteered. The program, sponsored by Center for Studying Health System Change (HSC) in Washington, D.C., reported that physician attitudes about P4P in 12 health-care markets range from skeptical to hostile.

Witness the slow response to the Physician Voluntary Reporting Program, sponsored by the Centers for Medicare & Medicaid Services (CMS). Launched this past spring, the program includes a “starter set” of 16 quality measures—from documenting whether a heart attack patient is given aspirin upon arriving at the treatment site to checking an elderly patient’s history of falls—that are intended to introduce physicians to simple goals while more sophisticated measurements are being developed. Around 2% of physicians who routinely bill Medicare have signed on. And while Nancy Wilson, joint senior adviser to CMS and the Agency for Healthcare Research and Quality in Rockville, Md., expects participation to pick up, she understands why most doctors are holding back. “It isn’t clear that we’ve been able to accurately portray physician performance from a quality or efficiency standpoint,” she says.

Many doctors would put it less delicately. After decades of calls by bureaucrats to standardize medical methods—what critics have termed cookbook medicine—physicians are leery of these latest efforts, which often seem to have more to do with containing costs than with ensuring quality. Many, for example, think the tracking process adds costs without clear benefits to doctors or their patients.

Yet Congress, fearing a future in which Medicare devours an ever larger share of the federal budget, is tired of waiting for consensus. A bill introduced last year could make performance measures permanent and require mandatory compliance. “Once Medicare gets into the game, that will be the game,” says Hoangmai Pham, a physician and senior health researcher at HSC. Pham notes that Medicare influences the entire health system, with virtually every commercial insurer following the government program’s lead. She predicts that if Medicare adopts P4P, choosing not to participate may cease to be an option for most physicians.

As the P4P juggernaut gains momentum, doctors worry about a range of issues. First among those is where quality measures should come from—self-appointed “experts,” employers, the government, physician specialty groups or broader physician organizations. Then there’s the expense and effort of collecting the data, particularly in the solo and small group practices that make up the bulk of medical providers in this country. Should performance information about individual physicians, doctor groups and hospitals be made public, or would such “report cards” only penalize those who take care of older, sicker populations? Should efficiency be part of the P4P equation? And most essentially: Does P4P really accomplish its dual goals of controlling costs and improving the quality of care?

In 1911, Ernest A. Codman, a surgeon at the Massachusetts General Hospital, opened his own private facility, which he called the End Result Hospital. The name reflected Codman’s obsession with knowing the long-range impact of each patient’s care and with learning from mistakes to improve medical quality. During the next five years, Codman tracked 337 patients admitted to his hospital, recording errors in diagnosis and treatment, and following the patients long after discharge to evaluate the ultimate results of their care. In the hospital’s annual reports, Codman tallied mistakes, and he even offered to refund doctors’ professional fees to patients who had an unsatisfactory result. Then he sent the reports to hospitals around the country, encouraging doctors to follow his lead. Now, almost a century after Codman’s earliest efforts, employers, health plans and consumers have taken up his quest, demanding to know what they’re getting for their health-care dollars and forcing the medical profession to get with the program.

At Park Nicollet Health Services in Minneapolis, tracking performance and results has become a daily concern. The group’s 600 doctors are involved with multiple P4P initiatives, including those sponsored by Medicare and BTE, and must report on a whopping 134 patient-care measures related to breast cancer screening, diabetes care, the management of cholesterol, heart attacks, pneumonia, hip and knee replacements and the use of antibiotics, among others.

“It has been a lot of slow, hard work to get the systems in place,” says Nancy Jarvis, director of informatics at Park Nicollet. “Our medical group must look at so many measures, it can be overwhelming.”

previous // next
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Generation Gap

Pay-for-performance could end up penalizing doctors who care for the sickest patients—the elderly.

How P4P Works

The road to being paid for performance is somewhat convoluted.


1.“Early Experience With Pay-for-Performance: From Concept to Practice,” by Meredith Rosenthal et al., Journal of the American Medical Association, Oct. 12, 2005. One of the first published studies on the subject, focusing on lessons to be learned.

2.Performance Measurement: Accelerating Improvement, by the Institute of Medicine, National Academies Press, 2006. Landmark analysis that recommends standardizing performance measures and other strategies for adopting pay for performance nationally.

3.“Large Employers’ New Strategies in Health Care,” by Robert Galvin and Arnold Milstein, New England Journal of Medicine, Sept. 19, 2002. Informative article that explains programs under way at companies with 10,000 or more employees.

4.“The Unintended Consequences of Publicly Reporting Quality Information,” by Rachel M. Werner and David A. Asch, Journal of the American Medical Association, March 9, 2005. A thorough analysis of the potential limitations of health-care report cards for improving quality of medical care.

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