Quality Measures: How to Get Them Right


The way we deliver and pay for health care in the United States has changed significantly in the last 50 years. The current emphasis on value-based care over traditional fee for service has led to the development of more than 2,500 quality measures1 used to incentivize physicians and health care organizations to improve quality of care and reduce cost. The latest and most comprehensive effort to tie quality measurement to payment is the Quality Payment Program, which resulted from the Medicare Access and CHIP Reauthorization Act (MACRA). (See “Pay for performance and cost control: a brief history.”)


  • The proliferation of health care quality measures and pay-for- performance programs has not led to significant improvements in patient outcomes but has contributed to greater administrative burdens for physicians.

  • Some groups are working to consolidate the number of quality measures, especially measures with unclear benefits or a lack of evidentiary support.

  • Quality measures should emphasize outcomes important to patients, provide them with a net benefit, and preserve their autonomy.

  • Quality measures should also encourage behavior that leads to improved health, offer benefits that outweigh the resource expenditure, discourage “gaming,” be specific, focus on outcomes the physician can influence, and consider social determinants of health.

Despite the proliferation of quality measures and the pay-for-performance (P4P) systems that use them, there is little evidence of resulting positive changes in physician behavior or patient outcomes.24 Instead, most P4P systems have led to significant administrative burdens5 and unintended consequences.6 Quality measures tied to financial incentives often crowd out the intrinsic motivation of physicians, particularly for complex cognitive tasks,7 devaluing the patient-physician relationship and contributing to clinician burnout.


Medicare – 1965

Medicare was established to provide health insurance to those 65 years of age and older, covering both inpatient and outpatient services. As access increased and technology advanced, costs soared. Between 1967 and 1983, Medicare reimbursements to physicians and hospitals increased tenfold,1 inspiring a priority shift in the 1980s from access to cost containment.

Diagnosis Related Groups (DRGs) and Relative Value Units (RVUs) – 1983

DRGs were introduced to replace fee-for-service with a prospective payment system based on the average cost to deliver care for a specific “case.” The complex formula was primarily designed to encourage inefficient hospitals to improve. In 1983, Medicare also introduced the Resource-Based Relative Value Scale, which pays physicians based on the number of RVUs assigned to services. RVUs are based on time spent, required skill and training of the physician, practice expenses, and malpractice expense. Over time, this system came to overvalue procedural services at


Dr. Adler is an associate professor of family medicine and community health at the University of Massachusetts School of Medicine in Worcester, Mass., and co-founder of Care That Matters, a physician advocacy group. Sami Hamdan is a fourth-year medical student at Tufts University School of Medicine, Boston. Dr. Scanlon is a second-year resident at the Tufts Family Medicine Residency at Cambridge Health Alliance in Cambridge, Mass. Dr. Altman is a professor and the Jaharis Family Chair of Family Medicine at Tufts University School of Medicine. He is also a co-founder of Care That Matters.

The authors wish to thank their collaborators from DynaMed Plus in the development of the 10 criteria: Brian Alper, founder; Alan Drabkin, family medicine section editor; and Alan Ehrlich, executive editor.

Author disclosures: no relevant financial affiliations disclosed.


show all references

1. National Quality Measures Clearinghouse. Agency for Healthcare Research and Quality. https://qualitymeasures.ahrq.gov/browse/setting. Accessed June 20, 2018....

2. Eijkenaar F, Emmert M, Scheppach M, Schöffski O. Effects of pay for performance in health care: a systematic review of systematic reviews. Health Policy. 2013;110(2–3):115–130.

3. Mendelson A, Kondo K, Damberg C, et al. The effects of pay-for-performance programs on health, health care use, and processes of care: a systematic review. Ann Intern Med. 2017;166(5):341–353.

4. Levine DM, Linder JA, Landon BE. The quality of outpatient care delivered to adults in the United States, 2002 to 2013. JAMA Intern Med. 2016;176(12):1778–1790.

5. Casalino LP, Gans D, Weber R, et al. U.S. physician practices spend more than $15.4 billion annually to report quality measures. Health Aff (Millwood). 2016;35(3):401–406.

6. Saver BG, Martin SA, Adler RN, et al. Care That Matters: quality measurement and health care. PLoS Med. 2015;12(11):e1001902.

7. Himmelstein DU, Ariely D, Woolhandler S. Pay-for-performance: toxic to quality? Insights from behavioral economics. Int J Health Serv. 2014;44(2):203–214.

8. Blumenthal D, Malphrus E, McGinnis JM, eds. Committee on Core Metrics for Better Health at Lower Cost, Institute of Medicine. Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: National Academies Press, 2015.

9. MacLean CH, Kerr EA, Qaseem A. Time out – charting a path for improving performance measurement. N Engl J Med. 2018;378(19):1757–1761.

10. Drabkin A, Scanlon C, Adler R. Checking the check-boxes – an evidence based review of quality performance measures. Poster session presented at: 5th Annual Lown Institute Conference - Research Symposium. May 5–7, 2017; Boston.

11. Yudkin JS, Lipska KJ, Montori VM. The idolatry of the surrogate. BMJ. 2011;343:d7995.

12. Frosch DL. Patient-reported outcomes as a measure of healthcare quality. J Gen Intern Med. 2015;30(10):1383–1384.

13. Wolfson D, Santa J, Slass L. Engaging physicians and consumers in conversations about treatment overuse and waste: a short history of the choosing wisely campaign. Acad Med. 2014;89(7):990–995.

14. Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870–2874.

15. Cassel CK, Jain SH. Assessing individual physician performance: does measurement suppress motivation? JAMA. 2012;307(24):2595–2596.

16. Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA. 2004;291(19):2359–2366.

17. Woolhandler S, Ariely D, Himmelstein DU. Why pay for performance may be incompatible with quality improvement. BMJ. 2012;345:e5015.

18. Roberts ET, Zaslavsky AM, McWilliams JM. The value-based payment modifier: program outcomes and implications for disparities. Ann Intern Med. 2018;168(4):255–265.

19. Daniel H, Bornstein SS, Kane GC. Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168(8):577–578.


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