Quality FAQ

General

What is the quality movement?

The QM seeks to improve patient outcomes by identifying and promoting best practices ranging from use of diagnostics, medications and procedures to physician practices and hospital operations. Determining best practices includes analyzing the effectiveness of products and services; finding flaws in care-delivery systems that lead to medical errors; and measuring how physicians treat their patients – doctor by doctor, patient by patient. Once best practices are determined, professional organizations can use this information to produce treatment guidelines, and various organizations may use the practices as the foundation for pay-for-performance programs, physician rankings and other initiatives. 

What is the upside?

The QM promises to raise the quality of patient care overall. Establishing best practices for each rheumatic disease physicians treat will help provide the right care at the right time to each patient. Payor incentive programs, when implemented appropriately, can serve as a bar that physicians can strive to reach, to the benefit of patients. High-quality care should consistently result in more efficient care, saving costs to the health system and physician practices – over the long term. 

What is the downside?

If quality is not pursued with adequate expert input, a one size-fits-all system of care could be created based on 1) an oversimplification of appropriate rheumatologic treatment, and 2) short-term cost-savings. Perverse incentive programs that adhere blindly to specific medical practices could punish physicians for providing appropriate care to some patients – an untenable conflict that would damage patients’ trust. That is why the ACR is actively leading the effort to define quality care for patients with rheumatic diseases. 

How will the QM affect my practice?

Patient care: Physicians will be expected to know and follow valid best practices, to reduce inappropriate variability in treatment and to provide patients proven quality care. However, quality programs must include the flexibility to treat outside of best practices when they do not apply to an individual patient, according to the physician’s clinical judgment. 

Record-keeping and reimbursement: Many public and private payors are planning to base reimbursement on performance measures. The Medicare Modernization Act of 2003, for example, includes pay-for-performance provisions that will affect future Medicare reimbursement. Other programs may include physician report cards, physician rankings and preferred doctor lists. Physicians will need to track and report to payors how they treat patients and/or their patients’ outcomes, which may be linked to reimbursement. 

Technology: At some point, physicians will probably need to acquire technology for electronic medical records and possibly software to track patient treatment and outcomes or contribute to consortium databases. Other technologies, such as electronic prescribing (another provision of the Medicare Modernization Act), may also become part of physician practices. Once Congress defines a pay-for-performance implementation plan and timeline, the ACR will examine currently available electronic medical record systems and make recommendations on systems that will support the type of reporting that will be required. 

Who is driving QM?

In 1999, the Institute of Medicine released a startling report revealing that between 44,000-98,000 lives were lost every year to medical errors, followed by its 2001 publication, “Crossing the Quality Chasm,” a guide for creating an evidence-based, patient-centered health system. These two reports galvanized national quality organizations, such as the Institute for Healthcare Improvement, which in June 2006 reported more than 100,000 lives saved through a hospital-based campaign it initiated less than two years ago. For many years, patient organizations have advocated measuring and increasing quality of care for patients. The U.S. Congress has held hearings on quality of care. Most recently, to contain exploding healthcare costs, employers, insurance companies and state and federal governments have been leading the charge to make healthcare more effective and efficient – making physicians wary that the focus on cost may overshadow patient care. It is the responsibility of the ACR as well as the individual rheumatologist to take a front-line role in shaping policies that will directly affect rheumatology patients’ lives.

How do physicians know the QM is not just another phase that will quickly pass?

It is unlikely that the QM will disappear with so many diverse and leading organizations acting as proponents for its implementation. In fact, the ACR believes the momentum for the QM will only strengthen over time. It is real, it is here to stay and it has the potential to truly improve patient outcomes if conducted the right way. The ACR is dedicated to leading development of the measures that will be used to define appropriate patient care and determine physician reimbursement for rheumatologists.

Quality Performance Indicators

What is a quality performance indicator?

A quality performance indicator – or QPI – is a process or measure used to assess quality of care. QPIs are based on the best available scientific information and expert opinion that will benefit patients (outcomes), physicians (efficiency) and consequently the health system (safety and productivity). QPIs may be used by payors to create pay-for-performance and other reimbursement programs.

How will the ACR ensure that QPIs for rheumatologists are valid (based on patient benefit, not primarily on cost) and realistic?

Through its members, the ACR will not only lead the creation of rheumatology-related QPIs, but will strongly advocate for adoption of the ACR-endorsed QPIs by the health system and payors nationwide as the best practices for rheumatologic care. The ACR’s Quality Measures Committee is developing classification/response criteria, treatment guidelines and performance measures for rheumatic diseases that are both valid and practical for the practitioner.

Has the ACR created QPIs?

The ACR released a “starter set” of 16 evidence-based QPIs in February 2006 that address rheumatoid arthritis, osteoporosis, gout and drug safety . T here are plans to develop additional rheumatology-related QPIs in the future. Due to the time required and the enormous expense of conducting these comprehensive scientific analyses, the ACR will collaborate with partners when appropriate and is exploring alternative funding sources, in an effort to develop QPIs in the most efficient way possible.

How will the ACR ensure that appropriate QPIs are adopted by the health system?

With both specialized scientific knowledge and clinical experience, rheumatologists are the most qualified professionals to develop effective measures of treatment of patients with often-complex and challenging rheumatic illnesses. Because national quality organizations, medical societies and government organizations must assess QPIs before their adoption as established national standards, the ACR is proactively collaborating with these stakeholders to develop and review performance measures for rheumatologic care, which will provide the foundation for quality-based reimbursement models.

Pediatric Rheumatology

The pediatric rheumatology community is represented on the major ACR committees conducting this work: Quality Measures Committee; Quality of Care Subcommittee; and the Criteria Subcommittee. In addition, a pediatric rheumatologist sits on the working group looking at implementation of quality measures in the practice setting.

The first full set of quality performance indicators that the Quality Measures Committee hopes to develop “from scratch” will be on juvenile idiopathic arthritis. Pending ACR Board of Directors consideration and approval in February 2007, the Quality of Care Subcommittee anticipates starting work on these indicators in 2007 in collaboration with the Arthritis Foundation and possibly the American Academy of Pediatrics. Discussions with these groups about such a collaboration have begun. To date, the focus of quality indicator development projects has been on adult rheumatology primarily because some indicators had already been developed in that area, and these were modified for use in the ACR Starter Set. The QMC looks forward to beginning its work on pediatric indicators next year.

The Policies and Procedures for ACR Quality Measures allow for ACR endorsement of documents developed by other organizations. In 2006, the ACR reviewed and endorsed a definition of improvement for JA, which was submitted to the ACR by PRINTO and published in Arthritis Care & Research as a PRINTO/ACR document.

The ACR issued an RFA for organ-specific lupus response criteria in spring 2005. A proposal to develop pediatric lupus nephritis criteria was chosen, and the project is underway.

Practice Issues

What will the Practitioner be required to do?

At this stage, it is not known exactly what insurers will require, and it is expected that the requirements may vary from payor to payor. This is why the ACR is working to develop relationships with all insurers around quality issues and, in fact, had several insurers represented at the ACR convened Stakeholders Summit in August 2006 – both to influence the requirements and also to learn what they will expect as soon as possible.
Meanwhile, it is anticipated insurers may ask physicians to review patients’ medical charts and report such elements as symptoms, diagnosis, diagnostics requested, treatment prescribed (and rationale if not within established best practices), follow-up and patient outcomes. Payors will use the reported information to determine if the physician has provided quality treatment. These factors may influence physician reimbursement level, ranking or status within the payor’s system.

How do I know that payors will evaluate physician perform ance in a valid and fair way? What if each payor uses a different benchmark?

This is why it is important for the ACR to work swiftly with organizations to establish a common set of evidence-based QPIs for musculoskeletal diseases, developed by or under the auspices of the ACR, so that all payors measure physician performance using the same “ruler.”

What should physicians do when an insurance carrier requires a report on performance or outcome measures?

Understand what the payor is asking and why, as well as specifically how they want the physician to perform the task. The ACR is hopeful that the ACR’s QPIs will become a national standard for rheumatologists. The ACR would appreciate if physicians would inform the ACR practice advocacy department regarding their experiences with requests and requirements of insurance quality programs. This will allow the ACR to ensure that insurance companies are following the ACR’s QPIs or hopefully encourage the insurance company to follow the ACR standards.

What will happen if physicians do not supply the information to the payor?

No specific penalties for noncompliance are known at this time. It is anticipated, however, that eventually reimbursement will be tied to reporting on quality measures. Therefore, those physicians who do not supply the requested information may receive a lower reimbursement rate, be ineligible for certain bonuses or incur some other penalty (such as a lower “ranking” on public records).

Will physicians be penalized for taking care of riskier, sicker patients or patients who do not follow their physician’s advice?

It is anticipated that pay-for-performance systems will include a mechanism to adjust for physicians who treat sicker or noncompliant patients. The ACR will be working with payors to ensure they evaluate rheumatologists fairly and appropriately.

What if payors impose such stringent guidelines or narrow formularies that physicians cannot provide appropriate treatment to some patients?

The ACR will work diligently with private and public payors to educate them about the critical importance of evidence-based, patient-centered, physician-directed care. This means it is critical for physicians to follow scientifically based best practices. It also means that when best practices do not apply to individual patients, by virtue of their unique biology, capabilities, health status or other personal circumstances, physicians must have the flexibility to treat them according to their needs. It is important to remember that when payor policies are based upon the ACR’s accepted QPIs, the policies will be well-aligned with good medical practice.

Does quality require that physicians purchase electronic medical records?

EMR technology is fast becoming the standard in medical care. Aside from enabling physicians to track and report quality measures, experts agree that EMRs increase the safety and effectiveness of patient care by enabling instantaneous sharing of a patient’s complete medical history among treating physicians. Medicare may require EMRs in the future, as part of its reimbursement model. The transfer to electronic records can be challenging. But those who have made the switch generally report that EMRs create far greater efficiency in the office, and most physicians say they would never want to go back to paper.

ACR Organization

How is the ACR organized internally to be effective in the quality arena?

Several ACR committees are involved in quality-related work. The ACR recently established a Quality Leadership Council, which will help define the overall strategy of the ACR’s quality initiatives and integrate the quality-related work of the ACR Committees on Quality Measures, Rheumatologic Care, Education, Training and Workforce and Government Affairs. It will also monitor the external environment and coordinate ACR responses to quality-related issues, as necessary.

Government Affairs

Is the ACR prepared to advocate on federal quality-related legislation?

The ACR’s Government Affairs Committee is working with both Congress and CMS during the development and implementation of QPIs. The Government Affairs Committee is also actively engaging with other organizations that have a vested interest in the quality movement, including the AMA, American College of Physicians and the Arthritis Foundation, to monitor and respond to quality-related legislation. The ACR is prepared to act aggressively to influence proposed quality and pay-for-performance legislation that affects rheumatologists and their patients.

Profession Education/ Re-Certification

What is a PIM?

A PIM is Web-based self-evaluation tool that walks users through a Quality Improvement Cycle for a specific condition, procedure or preventive service. Linked to educational materials, a PIM guides practice-based learning and improvement. No prior knowledge about measurement or improvement is needed. Completing a PIM requires the following four steps:

1. Collecting Patient Data: The PIM will guide a medical chart abstractor (usually office personnel) through medical chart abstraction. Only data without patient identifiers are collected.

2. Examining Practice Systems: The physician completes a questionnaire about practice systems to evaluate both human process and information technology that affect the reliability of care.

3. Identifying Goals and Redesigning Processes: The PIM summarizes the data collected in steps one and two and provides the user with a summary report of the practice in order to identify goals for improvement. The user then redesigns one or more relevant practice processes to achieve the desired goals.

4. Performing Focused Re-measurement: Through re-measurement, the user assesses the impact of change on the practice. The results of the re-measurement and lessons learned are reported to the ABIM as a final step to completing the PIM.

If I have a lifetime certificate and am not required to recertify, are there any benefits to participating in the ABIM Maintenance of Certification process?

Most physicians who complete a PIM learn something by seeing their practice as a population of patients with a common condition. They realize that their practice performance depends not only on what they know, but also on the systems that support the delivery of care. It is also anticipated that performance reports generated by the PIM will become a tool to meet the quality reporting requirements of patients, purchasers and payors.

Is the ACR addressing the evolving needs of its members who need to recertify?

Yes. In 2006 the ACR will offer two Self-Evaluation Process Learning Sessions for Recertification, introduce a new Web - based self-assessment program and begin to release a series of rheumatology specific PIMs. The ACR’s first PIM topic will be rheumatoid arthritis. Enrollment for the RA PIM will begin in November 2006. In addition, the ACR will offer a Recertification Exam Preparation Course in March 2007. Like the ABIM MOC Exam questions, the course will be case-based and will focus on disease management problems and key advances in practice over the past 10 years. All of the above programs are based on quality measures and practice guidelines. For more information contact Donna Hoyne , vice president of education at dhoyne@rheumatology.org , Amy Beith, senior specialist of continuous professional development at abeith@rheumatology.org or visit the ACR’s Website at www.rheumatology.org/educ/recertification/index.asp.

Will I be able to use the ACR PIM to determine if the quality of care I am currently providing is comparable to other rheumatologists?

Physicians who complete a PIM will be able to use the performance report data to demonstrate their competency with regard to patient care. Moving forward, as more physicians complete PIMs, quality of care benchmarks will also be available. All data will be collected in a de-identified format and reported in aggregate.

Rheumatology Training

How is the ACR preparing future generations of rheumatologists for the important role that evaluating and reporting quality of medical care will play in their practices?

The ACR wants to prepare rheumatology fellows for work in an environment where evaluating and reporting on quality of medical care is an integral part of their practices. The ACR Board of Directors recently approved the new ACR Rheumatology Fellowship Core Curriculum Outline, which is a substantial and comprehensive revision of the previous ACR Core Curriculum Outline for Program Directors. The revised Outline was developed in response to changes from the Accreditation Council for Graduate Medical Education. The new curriculum outline adds practice-based learning, systems-based practice, interpersonal and communications skills and professionalism to the traditional competencies of medical knowledge and patient care – new areas that address quality of care in a way that no previous curriculum outline has done. The ACR Core Curriculum Outline will likely be used as a model by other subspecialties as they develop their own curriculum outlines.