They are looking to quality measurement as a means to accomplish these goals. A study characterizing the use of provider performance measures in private and public programs was published in the August 2013 issue of Health Affairs. The survey participants, 23 health plans with 121 million commercial enrollees, reported using 546 performance measures. Of those used, process measures accounted for 50 percent; outcome measures, 19 percent; utilization measures, 11 percent; patient experience, 6 percent; and cost 3 percent.
Measures tied to payment
Quality measures are increasingly being tied to physician compensation, as seen in the most recent MGMA Physician Compensation and Production Survey, published by the Medical Group Management Association and the American College of Medical Practice Executives (MGMA) in June 2013. Specialists overall reported that 2 percent of their total compensation was based upon quality metrics in the report, which evaluated 2012 data. (The report did not include data by specialty, instead lumping specialists as a group.) They reported that 1 percent of their total compensation was based on patient satisfaction. In comparison, physicians overall reported that 3 percent and 2 percent of their total compensation was based on quality metrics and patient satisfaction, respectively. The national survey included 60,000 physicians. [pagebreak]
MGMA began tracking quality and patient satisfaction in physician compensation plans two years ago, but reported it for the first time this year, noted Todd Evenson, MBA, vice president of consulting services and data solutions at MCMA. “Under a new value-based reimbursement system, we recognize that many organizations, large and small, are now looking to insert these quality measures into their physician compensation,” he said. “This is the front end of a trend moving forward as the reimbursement model changes for private and public payers.”
Why process measures?
“Health plans are looking largely at process measures with cost and utilization at the other end,” said dermatologist Janet “Jessie” Sullivan, MD, chief medical officer at Hudson Health Plan, a Medicaid managed care insurance provider serving six counties in southern New York. However, many agree that the use of process measures for pay-for-performance is driven more by the health plans’ ability to access that type of information from the clinical data than by their desire to measure processes. Tom Valuck, MD, JD, a partner at health care consulting firm Discern and the National Quality Forum’s former senior vice president for strategic partnerships, cited the Hospital Compare website as an example. When it started out, Hospital Compare used only process measures. As it has become more sophisticated, outcome and cost measures have been added over time. Likewise, health plans are using mostly process measures for payment incentives, but the trend is moving toward using more outcome measures provided that they are meaningful and can be appropriately risk adjusted, he said.
Dr. Sullivan agrees that there is a push toward the use of outcome measures. But for now, she is focusing on what she calls “good neighbor” process measures. Both public payers and commercial health plans would like to see the whole delivery system move toward better, more comprehensive primary care as exemplified by the patient-centered medical home (PCMH) approach, Dr. Sullivan explained. “In this model, the primary care provider is the home and the specialists comprise the neighborhood. In order to be more efficient, the primary care doctors need to have good neighbors,” she said. “We are looking for specialists who are good neighbors.” [pagebreak]
Like many specialties, dermatology is small and doesn’t address the high-prevalence and high-cost conditions that concern health plans the most. Being a good neighbor means playing more of a supportive role, Dr. Sullivan noted. “You’re not being directly measured and scrutinized,” she said, “but as a dermatologist you can help primary care providers who are.”
Other ways to demonstrate quality
With regard to costs, dermatologists can demonstrate quality to payers by measuring utilization. Along those lines, the AAD has developed appropriate use criteria for Mohs surgery. (See www.aad.org/mohsauc
to learn more and download the criteria as an app.) By curbing overutilization using evidence-based guidelines, dermatologists can show that they are good stewards of limited health care resources. Dermatologists can also demonstrate that by tracking their use of five commonly performed dermatology-related medical tests and treatments that are not only potentially unnecessary, but could be harmful. Recently identified by the Academy as part of the Choosing Wisely®
campaign, they include:
- the inappropriate use of oral antifungal therapy for suspected, not confirmed, nail fungus;
- sentinel lymph node biopsy or other diagnostic tests for the evaluation of early, thin melanoma;
- Mohs surgery for uncomplicated, non-melanoma skin cancer <1 cm in size on the trunk and extremities;
- oral antibiotics for treating atopic dermatitis without clinical evidence of infection; and
- routine use of topical antibiotics on a surgical wound.
To learn more about Choosing Wisely, visit www.aad.org/choosing-wisely
With patient satisfaction data being collected as part of the Maintenance of Certification (MOC) process and the government’s recent mandate to collect standardized patient satisfaction information as part of the PCMH-Consumer Assessment of Health care Providers and Systems (PCMH-CAHPS) survey, patient satisfaction is another measure that dermatologists can leverage to demonstrate quality to payers. MGMA’s Evenson recommended that dermatologists begin using patient satisfaction surveys, such as the Clinician and Group CAHPS, or CG-CAHPS, survey that is popular among health plans. But he stressed that patient satisfaction is not just about the care provided by the physician — it can also be about access, communication, the doctor’s personality and demeanor, quality of medical care processes, continuity of care, quality of facilities, and office staff. Measuring patient satisfaction can provide practices with information about giving their patients the best possible medical experience, which is information that they would want anyway, noted Steven Feldman, MD, PhD, professor of dermatology, pathology, and public health sciences at Wake Forest University, who is the founder of www.DrScore.com, a physician rating website.
Finally, dermatologists can leverage other quality reporting efforts for MOC, Medicare’s Physician Quality Reporting System (PQRS), and meaningful use criteria for electronic health records to demonstrate quality to payers, said Joshua C. Nyirenda, MPA, PhD, performance measurement manager at the AAD. Dr. Valuck encouraged dermatologists to use available measures that are meaningful to them. Participate in PQRS, CG-CAHPS, and clinical registries as part of MOC, and pay attention to the cost-of-care measures that payers are using, he said.
Dermatologists who engage in quality measurement now can demonstrate their quality to payers today and be prepared for the coming evolution of measurement systems to incorporate more outcome measures — and the use of these measures to determine payment down the road — Evenson said. To that end, he recommended that medical groups, both large and small, begin assessing their compensation mechanisms and figure out how to pay for promoting quality and patient satisfaction using agreed-upon measures. Having a health information technology infrastructure in place to abstract the necessary data is imperative, he added. [pagebreak]
Ultimately, Dr. Valuck said, what payers want to understand as they embark on quality measurement is how a physician’s care is affecting all three parts of the National Quality Strategy that was embraced as part of the Affordable Care Act: better care, healthy people and communities, and affordable care.
Measures that cut across specialties
As a chief medical officer, Dr. Sullivan is looking for measures that cross all specialties and are appropriate for dermatology rather than dermatology-specific measures. “It’s hard for any specialty, including dermatology, to come up with a disease-focused measure that is broadly applicable to catch my attention as a plan medical director,” she said. That is not to suggest that the dermatology-specific measures, some of which she was involved in developing, are without merit. She points out that they engaged the specialty in measurement development, enabled dermatologists to participate in such initiatives as PQRS, and will inform a future in which dermatology outcomes measures play a bigger role in the specialty’s reimbursement.
An example of a multidisciplinary measure that dermatologists can report is one that addresses communication between the referring physician and specialist. The number one complaint she hears from primary care doctors about all specialists is that the latter do not follow-up after seeing a referred patient, Dr. Sullivan noted. Measures that reflect this complaint by offering incentives to specialists who do follow up with primary care doctors, like the PQRS biopsy follow-up measure that tracked the percentage of biopsy results that were communicated to a patient’s primary care provider (as well as the patient) by the providing physician, are the sort of measures that can reflect whether a specialist is a good neighbor.
Another example of a more broadly applicable measure would be one that addresses access to care. In New York and elsewhere, secret shoppers call doctors’ officers to schedule an appointment. It reflects poorly on the health plan when the caller is unable to get an appointment in a timely manner or is incorrectly told that the dermatologist does not accept the plan’s members, she explained. Dermatologists must ensure that they offer timely access to services as well as train their staff to know the health plans in which they participate, Dr. Sullivan said. [pagebreak]
In the future, a patient safety measure for outpatient office surgery and patient-reported outcomes are other examples of measures that dermatologists could report, she said. A measure that looks at “discomfort” defined as either pain or itch could apply to some dermatologic conditions as well as across specialties. Dr. Sullivan suggested that the Academy could play an active role in encouraging the American Medical Association’s Physician Consortium for Performance Improvement® to develop such measures.
The AAD’s measure work
The AAD has already started down that road. The Patient Safety and Quality Committee, Performance Measurement Task Force, and Academy staff are in the initial stages of exploring how Patient Reported Outcomes Measurement Information System (PROMIS) measures being developed by the National Institutes of Health can be applied to dermatology clinical settings. “The patient-reported outcomes will be more cross-cutting and encompass a wider population of dermatologists, if not all,” Nyirenda said.
In addition, to facilitate physician reporting of quality measures, the Academy is drafting measure sets for both psoriasis and non-melanoma skin cancer. These measures will be wider-reaching than the melanoma measures as some dermatologists do not see many melanoma cases, but most treat patients with psoriasis and non-melanoma skin cancers, according to Nyirenda. A dermatopathology measure set is under development as well.
The AAD is also working to double its data collection efforts; the lack of data has been a challenge for the specialty. For example, payers can assess patients’ adherence to treatment with a pill that controls a long-term disease, such as hypertension or cholesterol, but it’s harder for them to know if patients are adhering to treatment using a cream or ointment, noted Dr. Feldman. Dermatology also lacks good clinical tools to measure such conditions as psoriasis or eczema the way primary care doctors can use HgbA1c levels to measure diabetes control, he said. In addition, disease severity is difficult to measure, noted Carl Johnson, MD, chair of the AAD’s Private Sector Advocacy Task Force. Psoriasis can be a couple patches on an elbow or cover 25 percent of a patient’s body surface area; this may be an area where patient-reported outcomes could be helpful. “Eventually, we may need to develop standardized measures of dermatologic conditions that are suitable for use in clinical practice,” Dr. Feldman said. “I think the concern is that if we don’t, someone else will.” Thus, the Academy’s data collection efforts will help the specialty demonstrate its value in the quality measurement arena by being able to show what dermatologists do and how they do it efficiently and effectively, Nyirenda added.