Performance measurement

In 2005, the Centers for Medicare and Medicaid Services (CMS) approached several medical specialty societies to begin sponsoring quality measure development for inclusion in Medicare's Physician Quality Reporting System (PQRS), formerly known as the Physician Quality Reporting Initiative (PQRI).

The CMS Physician Quality Reporting System is currently a voluntary program that began in 2007 as a part of the pay-for-performance movement. This program offers an incentive bonus to physicians who perform and report quality measures; however, bonuses will decrease over the next several years. Penalties for non-participation will begin in 2015.

The National Quality Forum (NQF) is a voluntary consensus standards body that reviews and endorses quality measures. Although CMS recommends NQF-endorsed measures, the PQRS is not limited only to NQF-endorsed measures.

Measure-development process

The American Academy of Dermatology is committed to ensuring dermatologists are able to participate in performance-measurement programs such as the PQRS. As such, the AAD is active in the process to develop and secure approval of measures relevant to the practice of dermatology. The measure-development process is as follows:

Performance measurement graphic

Expand the menu items below to learn more about the measure-development process.

I. Selection of topics:

A periodic needs assessment is conducted to prioritize which measure topics should be chosen for development. The frequency of this assessment is flexible and dependent on the measurement needs of the specialty. 

A needs assessment consists of select members of the Performance Measurement Task Force (PMTF), Patient Safety and Quality of Care Committee (PSQC), Clinical Guidelines Committee (CGC), Needs Assessment and Outcomes Committee, the American Board of Dermatology (ABD), and Private Sector Advocacy Task Force. 

Selection of topics for measure development is always responsive to member needs and the advocacy, policy, and educational concerns of the Academy. The needs assessment evaluates the criteria listed below, while considering timeliness/urgency and availability of supporting evidence.

Criteria to facilitate topic selection include, but are not limited to:

  • Degree of public health importance (high prevalence, significant morbidity).
  • Perceived or documented variation in practice patterns (affect on quality of care and patient safety).
  • Potential for Maintenance of Certification (MOC) module development.
  • Timeliness of the topic for informing and improving provider decision-making.
  • Availability and strength/quality of evidence to produce measures.
  • The area addresses multiple aspects of dermatology practice scope.
  • Area where increased dermatologic attention and involvement would be helpful for the specialty.
  • Relevant to Medicare and Medicaid programs (e.g., Physician Quality Reporting System (PQRS), Meaningful Use Incentive Program).
  • Relevant to managed care programs.
  • Availability of interventions with high societal or economic cost.
  • Identified as priority topics for clinical effectiveness research.

Once the needs assessment is completed, the PMTF proposes the clinical topics for quality measure development, as well as a development schedule, to the PSQC, Council on Science and Research (CoSR), and then the Board of Directors for approval. 

Both the Council on Government Affairs, Health Policy, and Practice (GAHPP) and the Council on Education and Maintenance of Certification are given the opportunity to review and provide comments on the proposal prior to Board approval; however, neither GAHPP nor Education/MOC are able to entirely veto a measurement initiative.

II. Work group appointment and activity

Once the topics for measure development have been selected and approved by the Board of Directors, a Work Group (WG) for a related group or single measure is appointed by the chair of PMTF and tasked with developing measure descriptions and specifications (e.g., numerator instructions, denominator instructions, exclusion instructions) for the Board-approved measure topics. 

The work group chair is considered a clinical content expert and thought leader in the respective Board-approved measure topic. The work group members are comprised of about 49 percent clinical content experts for that respective measure topic and at least 15 percent of the members are considered “measure methodologists.” A measure methodologist has experience in at least one of the following areas:

  • National Quality Forum’s (NQF) measurement framework.
  • American Medical Association-Physician Consortium for Performance Improvement’s (AMA-PCPI) measurement framework.
  • Survey development and validation.
  • Independent measure development (e.g., within an academic center, for a private payer).

III. Review process

Expert review

The work group produces a draft measure or set of measures that is submitted to the PMTF for their approval, or if requested, further revision.  

Patient Safety and Quality of Care Committee Review

Following the incorporation of modifications to the draft measure, the measure is presented to the Patient Safety and Quality of Care Committee (PSQC) for review and approval. Once approved by the PSQC, the draft measure is released to the membership for review and comment. 

Membership review

After the PSQC review, the draft measure document is then posted on the Academy website, and is only accessible to members via member login. Members are given 10 business days to comment on the draft measure, and are required to have a current COI disclosure statement with the Academy. The submitted comments are compiled and sent to the work group chair for review and response.

Members who make comment submissions are informed, in writing, about receipt and any subsequent action regarding their comments. Following the member comment period, the draft measure is sent to the Council on Science and Research for approval. 

Council on Science and Research review

Following the member comment period and incorporation of modifications to the draft measure, the measure is presented to the Council on Science and Research (CoSR) for review and approval, along with the member comments that were received. Once approved by the Council, the draft measure is sent to the Board of Directors for final approval. 

IV. Final approval and publication

A final draft is approved by the Council on Science and Research and submitted for approval to the Board of Directors. Upon approval by the Board of Directors, the measure is posted on the Academy's website.

Board-approved measures are submitted to the NQMC to support professional and public access.

V. Review and revision of quality measures

Board-approved quality measures are considered for reaffirmation, update, or sunset at least every three years based on a review of published literature since measure publication. The three-year interval is consistent with the review cycle of the NQF. The PMTF determines if the revisions are substantial enough to require a review by the entire membership. Final Board approval is required for measure modifications that are deemed substantive enough to prompt member review.

VI. Testing

Testing of the measure is done at the discretion of the PMTF.

Physician Quality Reporting Systems (PQRS)

Currently, five dermatology-specific measures are included in PQRS. These include:

Melanoma: Continuity of Care: This measure measures the percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered at least once within a 12-month period into a recall system that includes: A target date for the next complete physical skin exam, and a process to follow up with patients who either did not make an appointment within the specified time frame or who missed a scheduled appointment.  

Melanoma: Coordination of Care: This measure gauges the percentage of patient visits, regardless of patient age, with a new occurrence of melanoma. They must have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Melanoma: Overutilization of Imaging Studies: This measure measures the percentage of patients with melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.

Biopsy Follow-Up: This measure measures the percentage of patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician. To satisfy this measure, the biopsying physician must review the biopsy results with the patient, communicate those results to the primary care/referring physician, track communication in a log, and document the tracking process in the patient’s medical record. This measure applies to all patients who undergo a biopsy, regardless of diagnosis.

Psoriasis: Tuberculosis Prevention for Psoriasis and Psoriatic Arthritis Patients on a Biological Immune Response Modifier :

In this at-risk patient group, this measure evaluates whether providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test.

NQF-endorsed quality measures

Current NQF-endorsed measures are:

  • Melanoma: Overutilization of Imaging Studies: Percentage of patients with stage 0 or IA melanoma, without signs or symptoms, for whom no diagnostic imaging studies were ordered.
  • Melanoma: Continuity of Care — Recall System: Patients entered into a recall system with the target date for the next complete physical skin exam specified, at least once within the 12-month reporting period.

The PMTF is working to develop more measures to increase the measure inventory for dermatologists in PQRS.

Current measure development projects

  • Psoriasis and psoriatic arthritis
  • Non-Melanoma Skin Cancer
  • Atopic Dermatitis (with AMA, PCPI, and AAAAI)

Co-developed measures

There are cases in which a sister organization or an external organization may approach the AAD to co-develop measure(s) based on a predetermined timeline and topic that is of interest to the AAD. In such cases, the outside organization is considered to be the "measure steward" and is the entity recognized to have the final approval by other external stakeholders (e.g., NQF, CMS). 

The Performance Measurement Task Force (PMTF) chair assesses such measure development opportunities, using the needs-assessment criteria, to determine if the AAD should participate. If a need for participation in an externally initiated measure-development project is established, a number of AAD representatives (the number is usually set by the convening organization) are appointed to the measure-development project team. The PMTF coordinates the identification and approval of these representatives, although the appointments also require approvals by the PSQC chair, CoSR chair, and the executive committee of the board of directors.

Review of externally developed quality measures 

The PMTF sometimes serves as measure reviewer when it is approached by a dermatology subspecialty or related organization with a draft measure or set of measures for which they request review and feedback. When such a request arises, the PMTF seeks approvals from the PSQC and the executive committee to serve as a measure-review board. If approved to serve as a review board, all consequent formal comments by the PMTF are vetted through these respective bodies as well. 

Performance Measurement Task Force members

  • Oliver J. Wisco, DO, FAAD, chair
  • Milan J. Anadkat, MD, FAAD, member
  • Daniel J. Hogan, MD, FAAD, member
  • Abrar A. Qureshi, MD, MPH, FAAD, member
  • Thomas M. Beachkofsky, MD, resident member
  • Sylvia L. Parra, MD, FAAD, member
  • Nneka I. Comfere, MD, FAAD, member
  • Junko Takeshita, MD, PhD, FAAD, member
  • Sylvia L. Parra, MD, FAAD, member
  • An-Wen Chan, MD, PhD, FAAD, member
  • Howard Wooding Rogers, MD, FAAD, incoming member
  • David M. Adelson, MD, FAAD, adviser