Published 4/1/2008
Robert H. Haralson III, MD

The quality initiative alphabet soup

From AQA to P4P—developing quality measures

Pay-for-performance (P4P) programs are being implemented by many payors, including the Centers for Medicare and Medicaid Services. Although P4P programs are changing and may completely disappear, the quality initiative they represent isn’t going away. From now on, physicians will be collecting and reporting quality data—and that can only improve the quality of care that patients receive.

The mainstay of the quality initiative is the performance measure. Several entities—with an alphabet soup of initials—are developing performance measures to be approved and implemented. Here’s a look at the primary players.

The PCPI and the NCQA
The two entities that are primarily responsible for developing performance measures are the American Medical Association’s Physicians Consortium for Performance Improvement (PCPI) and the National Committee for Quality Assurance (NCQA). The PCPI and the NCQA recently agreed to cooperate with each other in developing performance measures.

This coordination will help alleviate the problem of multiple, similar measures. Although some specialty societies and payors have developed their own performance measures, the AAOS believes that all measures should come through the PCPI/NCQA.

The National Quality Forum (NQF) is a not-for-profit membership organization created to develop and implement a national strategy for healthcare quality measurement and reporting. Established as a public-private partnership, the NQF has broad participation from all parts of the healthcare system, including national, state, regional, and local groups representing consumers, public and private purchasers, employers, healthcare professionals, provider organizations, health plans, accrediting bodies, labor unions, supporting industries, and organizations involved in healthcare research or quality improvement. Its goal is to promote a common approach to measuring healthcare quality and fostering system-wide capacity for quality improvement.

A broad-based collaborative venture of physicians, consumers, purchasers, health insurance plans, and others, the AQA (originally the Ambulatory Care Quality Alliance) hopes to “improve health care quality and patient safety through a collaborative process in which key stakeholders agree on a strategy for measuring performance at the physician or group level; collecting and aggregating data in the least burdensome way; and reporting meaningful information to consumers, physicians, and other stakeholders to inform choices and improve outcomes.”

The coalition hopes to reach consensus as soon as possible on the following goals:

  • A set of measures for physician performance that stakeholders can use in private health insurance plan contracts and with government purchasers
  • A multiyear strategy to roll out additional measurement sets and implement measures into the marketplace
  • A model (including framework and governing structure) for aggregating, sharing, and stewarding data
  • Critical steps needed for reporting useful information to providers, consumers, and purchasers

The Surgical Quality Alliance (SQA) is a loose consortium of 20 surgical specialties, including the AAOS, that meets prior to AQA meetings to discuss issues. The SQA helps ensure that the unique issues and distinctive characteristics of surgical care measurement, data collection, and reporting are adequately addressed. It enables surgical specialties to present a united front at the AQA.

The performance measure development process
Measures are developed by the workgroups of the PCPI and/or the NCQA. Once they are voted on and approved by the full PCPI membership, they are sent to the NQF where an extensive review is undertaken by another workgroup. If appropriate, the measures are approved by an NQF steering committee before going to the AQA.

The entire AQA membership must approve measures before they are scheduled for implementation by payors. Thus far, however, payors have been reluctant to implement all of the measures and sometimes prefer to develop their own. The physician members of the AQA are pushing for universal implementation of AQA-approved measures to prevent overlapping of measures.

Although this seems to be a very complicated process, it is better than some of the alternatives, which would allow for measure development by nonprovider groups.

Robert H. Haralson III, MD, is the AAOS medical director. He serves on the executive committee of the PCPI and chairs the health professional council of the NQF. He can be reached at haralson@aaos.org