FTC panel explores role of quality measures in a competitive marketplace

Quality information is essential for a competitive marketplace and for consumers to make informed decisions on care. A panel delved into the current state of quality measures and their role in the healthcare market during the Federal Trade Commission’s public workshop, “Examining Health Care Competition” on March 21.

Standardized measures are important so providers can benchmark themselves against others, and to help patients locate high quality medical care and alert them to any safety issues, says Helen Burstin, MD, MPH, senior vice president for performance measurement, National Quality Forum (NQF).

Currently, NQF's focus is on quality measure alignment across care settings and effective communications, she says. “That's where we increasingly are trying to drive where measure development needs to go.”

NQF is looking to combine measures together into a single score “to understand the broader picture of what clinicians are doing rather than slicing and dicing everything down.” Also, the group is focusing on better linkage between process and outcome measures. “If it's a process for process sake, we need to stop it because it's adding burden and not value.”

As things stand now, measures often are inadequate benchmarks with built-in biases, said Larry Casalino, MD, PhD, professor of public health and chief of division of health policy and economics at the Weill Cornell Medical College.

In particular, he noted hurdles in measuring performance of individual physicians or small groups. With Medicare data, providers must be large enough for measures to reliably detect a 10 percent difference in performance between their group and other groups. For measures like congestive heart failure readmissions, ambulatory admissions and mammography, it’s difficult to measure performance for physician groups of ten or less, he said.

“You have to get up to 50 physicians to get any kind of decent traction on these three measures and even for groups of 50 and much more—for readmissions and ambulatory care admissions or preventive admissions--you couldn't do well,” he said. “It’s a real problem too often ignored.”

Casalino also discussed socioeconomic status (SES) differences between providers. A few days before the workshop, NQF had released a draft report that would change its policy to allow SES to be a factor in the risk-adjustment methodology for certain accountability measures. “I think it's easier to have low admission rates or high mammography rates if you take care of affluent people in California rather than if you're taking care of people in the ghetto.”

The issue of adjustments for SES is “something we are still grappling with within the agency,” said Kate Goodrich, MD, director of the Centers for Medicare & Medicaid Services' (CMS) quality measurement and health assessment group in the Center for Clinical Standards and Quality. “So I just want to make clear that it’s not a settled issue yet.”

In other comments, Patrick S. Romano, MD, MPH, professor of medicine and pediatrics, Center for Healthcare Policy and Research, University of California at Davis School of Medicine, argued that “to have a safe and reliable healthcare system, we have to have more measures, not fewer."

He said an efficient marketplace provides transparent information on cost and quality, which requires a comprehensive understanding on accessibility of care, quality of service, safety of service and its reliability over time.

Quality measures will drive competition and improve performance, but he cautioned an underreporting of complications and safety incidents. Romano also expressed concern of consolidation’s impact on quality, and challenges in policing providers’ claims about quality.

CMS is working to build transparency for consumers by providing more accessible quality, performance and pricing information for consumers on its website, Goodrich said.  

Earlier this year, CMS released for the first time performance information on large groups and accountable care organizations on five quality measures around diabetes and coronary artery disease. By the end of 2014, the agency plans to publicly report results of CAHPS clinician and group surveys and a patient experience measure for groups of 100 or more and ACOs. The agency’s goal is reporting performance information down to the individual physician. “This is hard stuff and requires a lot of data validation, thinking through what the right measures are to put on individual clinicians.”

The agency also is working on its future compare sites, which will use a five-star rating system, she said.

However, in the meantime, quality information available on the CMS website often is “extremely difficult to use” and “not relevant to the way that patients make decisions,” said Shoshanna Sofaer, DrPH, professor of healthcare policy, Baruch College City University of New York. “There are limits on how much choice consumers actually have and how much choice they perceive they have and they generally perceive they have less choice than they actually do have."