The AAFP has released a new position paper aimed at helping steer the future development and use of quality measures in initiatives related to practice improvement and physician payment.
It's an important step at a critical point in time, said AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan.
"As the move to value-based care delivery continues, quality measurement has stepped to the forefront," Munger told AAFP News. "This position paper will provide the AAFP with the guiding principles with which to advocate for standardized meaningful measures that are relevant for the patient without causing significant disruption of clinical workflows."
The paper, titled "Vision and Principles of a Quality Measurement Strategy for Primary Care," was authored by AAFP staff content experts and reviewed by members of the AAFP Commission on Quality and Practice and three additional AAFP members considered well-versed in the field of quality measurement.
The position paper and the principles it outlines build on existing AAFP policy and were approved by the executive committee of the AAFP Board of Directors in mid-December 2018.
- Late in December, the AAFP released a position paper on quality measurement for primary care that features six guiding principles aimed at helping steer future development and use of measurement in practice improvement and physician payment.
- The AAFP will utilize the principles during discussions with policymakers, payers, health plans and other stakeholders, including CMS.
- The paper makes a clear distinction between quality measures that are used to accelerate internal clinical improvement and performance measures that aim to address high-level patterns and outcomes of care while comparing quality and cost across organizations and geographic areas.
The AAFP intends to utilize information in the paper when interacting with policymakers and others -- including those who develop and endorse such measures, as well as CMS and other entities that fund measure development.
The principles also will come in handy in Academy discussions with payers and health plans, health IT developers, and others. What follows is a brief overview of the six principles outlined in the paper.
Principle One: Quality Versus Performance Measures
Right from the start, the AAFP makes a clear distinction between quality measures and performance measures.
"The main purpose of a quality measure is to accelerate internal clinical improvement," says the paper, while performance measures serve several purposes, including
- providing comparative data useful in value-based payment programs,
- supporting patients in their ability to make decisions about the cost and quality of health care, and
- ensuring appropriate resources are allocated to community and population health needs.
Furthermore, according to this first principle, "Quality measures address the details of patient care, administrative processes and medical decision-making" and aim for benchmarks or goals. Health care organizations use them to "accelerate clinical improvement" and to "gain an understanding of care gaps and the impact interventions have on closing those gaps."
On the other hand, performance measures "address high-level patterns and outcomes of care, comparing various dimensions of quality and cost across organizations and geographic areas."
Performance measures are used for value-based payment, resource allocation and to help patients make informed decisions about their care based on quality and cost.
"Publicly reported measures should meet high standards for validity and reliability because measures that lack these characteristics may disengage clinicians from improvement, unjustly harm the finances and reputation of health care professionals, and misinform patients about the risks and benefits of various treatments," says principle No. 1.
"Many performance measures currently used in value-based payment fail to meet these standards," it continues.
Lastly, performance measures should not instigate financial penalties, but "should lead to investment of resources to improve equity, access, and socioeconomic factors that impact health and health care."
Principle Two: Quality Improvement Integration
The second principle notes that to achieve the primary purpose of accelerating improvement, "quality measures must be integrated into a methodological approach."
Furthermore, "Internal quality improvement efforts require transparency and a safe space to allow honest assessment of care without fear of punishment and without pressure to increase revenue or produce bonus payments," says the AAFP.
As to the members of a quality improvement team, it is imperative that physicians have a leadership role in all improvement efforts and secure the assistance of patients, clinical teams and community partners.
Principle Three: Universal Performance Measures
The AAFP's third principle states the need for a single set of universal performance measures that meet the highest standards of validity and reliability and that are extracted from multiple data sources.
"The measures should focus on outcomes that matter most to patients and that have the greatest overall impact on better health of the population, better health care and lower costs. At the same time, the burden of measurement on practices should be minimized," says the AAFP.
Furthermore, this principle calls for the inclusion of a limited set of measures of quality, cost and population health in performance measures created for value-based payment.
"Giving in to the temptation to measure everything that can be measured drives up cost, adds to administrative burden, contributes to professional dissatisfaction and burnout, encourages siloed care, and undermines professional autonomy."
Importantly, to avoid cherry-picking of patients and improve representativeness of the data, "the same measures should be standardized across payers, programs and systems of care, and universally applied to all eligible patients or populations," says the AAFP.
"Measures currently used in various payment programs lack alignment and are applied inconsistently, which reduces their value and usefulness, limits the ability to aggregate data and determine progress toward a goal, and adds to the burden of data collection and reporting."
Lastly, performance measures should center on the most important strategic priorities -- those conditions, services and factors "that are known to have the greatest impact on health status, outcomes and cost."
Principle Four: Performance Measure Application
This principle urges that performance measures be applied at a system level -- meaning a group practice, integrated health care system, health plan, accountable care organization, or geographic region -- to encourage shared accountability and team-based care.
It also suggests a leveling of the playing field. "Performance measures should be risk-adjusted, when appropriate, for demographics, diseases, severity of illness and social determinants of health," says the AAFP.
Furthermore, "All populations and geographic areas must be attributed to at least one system to promote health equity."
The principle notes that health care professionals, facilities and patients could belong to multiple systems. Entities and health care professionals could find themselves in overlapping systems with a competitor, and this would "encourage cooperation and mutual resource allocation to improve factors that influence health outcomes."
"Holding systems responsible for serving the needs of a geographic population may prevent the closure of clinics, emergency departments, maternity services and other essential services in rural areas," says the fourth principle.
Principle Five: Primary Care Measurement
The fifth principle states that "measures of primary care should focus on the unique features that are most responsible for better outcomes and lower costs and are under reasonable control of the primary care physician."
Those primary care features include access/first contact, comprehensiveness, coordination, patient and caregiver engagement, continuity of care, and care management.
Authors note that current measures of primary care are "generally indistinguishable from measures of other specialties and do not adequately assess the quality of primary care."
"Additional research is needed on how primary care is delivered and how to improve and measure care in the primary care setting," says this principle.
Principle Six: Health IT Redesign
The position paper's final principle addresses the need for a redesign of health information technology to ensure that this important resource facilitates automated data collection and quality measures and eliminates the need for self-reporting.
"Information should be pushed to clinicians and patients at a point in time when it is most useful for decision-making and action."
Authors note that electronic health records (EHRs) "were not designed to support quality measurement and improvement," and that physicians generally report disappointing experiences with their EHRs; unfortunately, the promise of improved efficiency, better care and lower costs have not, for the most part, been realized.
To make matters worse, "physicians have been expected to fill current technology gaps by expending their own time, effort and resources for quality measurement and reporting with little, if any, return on investment."
Still, the AAFP predicts positive change is coming.
"Affordable, advanced technology will alleviate administrative burden, siloed data, incomplete and nonrepresentative data, and lack of timely actionable feedback. Data extracted from claims, EHRs, surveys, labs, pharmacies, public health data, health assessments, administrative data, and other sources will allow computation of measures for virtually any aspect and segment of care," says the sixth principle.
"The redesign of health IT will enable insights into care that are not yet possible with today's information systems."
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