Physicians, patient advocates differ over quality measurements

Physician Compare might not seem like the kind of tool that would spark a divisive policy debate. It’s a website, recently launched by Medicare officials, that allows patients to find a cardiologist, a pediatrician, or other Medicare provider in their zip code.

But while it’s just a physician directory now, eventually it will become much more–an online database that includes quality-of-care measurements and patient reviews. And it’s become the subject of a quiet but fierce tussle between consumer advocates and doctors groups, which see the potential for the wesbite in starkly different terms.

“Imagine comparison shopping for a doctor based on patient reviews, a set of easily comprehended measures of quality and other criteria. It’s one of the Holy Grails of a truly patient-centered system!” David Lansky and Steven Findlay, health care consumer advocates, recently wrote in a commentary

for iHealthBeat.

“It’s not in the public’s interest to do this,” said Rodney Hayward, a professor of public health and internal medicine at the University of Michigan. His research focuses on how to measure health care quality and improve patient outcomes. He said this could diminish, not increase, access to high-quality care.

“If you do not measure well the actual quality of the care in detail,” Hayward said, “you will punish the people who take care of sicker, poor, minority, and older patients–all these things we are not able to adjust for completely.”

Over the last decade, health care policymakers have been moving toward public reporting of quality measurements of health care providers, such as nursing homes and hospitals.

Doctors are the newest set of providers to be added into the mix, and federal officials have moved cautiously. In 2007, the Centers for Medicare and Medicaid Services (CMS) launched what’s now called the Physician Quality Reporting System (PQRS). It’s a voluntary program that gives small bonus payments to doctors if they provide some basic benchmark data about the care they deliver.

CMS is now moving to retool the PQRS program, part of an annual process to update the standards. But the stakes are higher this time, because some of the data from PQRS will eventually be fed into the Physician Compare website, providing what proponents hope will be a consumer-friendly database that empowers patients to make more educated choices about their doctors and their overall medical care.

In addition, under the health reform law, instead of getting incentives for participating in PQRS, doctors will be penalized starting in 2015 if they don’t report basic quality-of-care data.

The American Medical Association has urged CMS to focus on the fundamentals as it revamps the current PQRS guidelines and beefs up Physician Compare. In a letter to CMS, the doctors’ advocacy group said the website already has inaccurate information just in its basic listings, which right now includes doctors’ names, office addresses, educational background, and a few other details.

“The AMA urges CMS first to focus substantial resources on ensuring that the Physician Compare Web Site contains correct information for physicians listed on the web site before considering adding any additional information,” the AMA urged in a comment letter to CMS. The physician group warned against including patient reviews.

“Currently, collection methods and data accuracy associated with patient experience lack uniformity and validity,” the AMA letter states, adding that physicians have their own patient survey tools and use them internally to improve patient satisfaction.

But consumer advocates are urging CMS to undertake a quick and dramatic overhaul of PQRS, with a greater emphasis on patient outcomes, rather than physician processes. That will garner better data to put into Physician Compare, they say.

In a Feb. 25 letter to CMS, a coalition of 28 consumer advocacy groups said the program’s current focus is on “minimum standards of competence” that any doctor could meet, rather than “meaningful levels of performance.”

For example, they note, physicians can get a bonus payment for meeting three basic standards, such as whether they ask asthma patients about tobacco use, provide counseling for weight management, and other such measurements. Doctors don’t have to report whether the patient stopped smoking or lost weight–in other words, they generally don’t have to provide data that would indicate whether the care was effective.

“It’s not enough to simply say that a clinician assessed or evaluated a person’s condition,” states the coalition letter, signed by the AARP, the AFL-CIO, and other groups. The results of the care have to reported too. They argue that providing outcomes data will help doctors get a better sense of what works and what doesn’t.

“This is all about collecting information that feeds back to the physician community to improve care, but also allows consumers and patients to use it to base their choices on,” said Findlay. “That’s the ultimate goal here.”

That all sounds good in theory, said Hayward, but it’s not feasible in practice. He agreed that the current PQRS standards are either “weak or inaccurate.”

In the “weak” category, he put items like whether a physician checks patients’ cholesterol levels. What matters, he notes, is whether the doctor treated a patient’s high cholesterol.

But of deeper concern, he said, are measurements that, for example, encourage doctors to get all their high-risk patients’ blood pressure down below 130/80.

“It would great to get everyone’s blood pressure at goal,” Hayward said. But many patients don’t respond to the available medications, even if they’re given 3 or 4 different prescriptions.

“If you add more medicines, you probably hurt people–and there’s reason to think you might kill people,” he said. For the doctor, “they’re following the quality measure they’re judged on, but they’re over-treating the blood pressure.”

He also raised serious concerns about measuring the quality of individual doctors, based on greatly different patient populations, without taking detailed factors into account.

“We want to believe that we can look at a nonrandom sample of one doctor’s 80 patients and another doctor’s 50 patients… and find out whether they’re different on outcomes,” he said. But most individual doctors don’t have enough patients to provide statistically reliable data. And there’s a gamut of variables, from a patient’s socio-economic status to their disease history to whether they take their medications reliably, that doctors have little control over but that greatly impact patient outcomes.

“Everyone wants to try to measure [quality] without the data, but then you either end up measuring it too lightly or too severely,” Hayward said. “People want to believe that with very minimal information, you can somehow determine whether the quality of care is good or bad. Our work has shown that is simply not possible.”

He said inaccurate measurements that carry financial penalties could cause doctors to turn away the kinds of patients that might hurt their quality scores. That will disproportionately affect the most vulnerable patients–the poorest and frailest–who could skew a doctor’s good-outcome rating.

Consumer groups say these concerns have some basis, but are exaggerated, driven in part by doctors’ fear of increased public scrutiny.

“It’s the tension between how good is good enough,” said Jennifer Eames Hoff, of the Pacific Business Group on Health, a consumer advocacy group.

“Do you really want to get to this super-scientific rigor that will take years and years?” she asked. Or can you live with a measurement system that, she argues, is “really, really good” and could usher in dramatic improvements in patient care?

Findlay similarly conceded that measuring quality of care is “not a perfect science.” And he said the standards will have to evolve constantly and quickly, as new medical research contradicts or advances current practices.

“There will never be anything static about this, it will change all the time,” he said. “That’s part of the torture of it–for everybody.”

CMS officials have been gathering up all this input, through the comment letters, a town hall meeting, and other forums.

A CMS spokesman, Joe Kuchler, said proposed new standards for the 2012 PQRS program will likely come out this summer and be finalized in the fall. The health reform law calls on CMS to start putting some of that quality data into the Physician Compare website in 2013, although some information may go online earlier.