We will be performing site maintenance on our learning platform at learn.aaos.org on Sunday, February 5th from 12 AM to 5 AM EST. We apologize for the inconvenience.


Published 11/1/2009
Robert H. Haralson III, MD, MBA

No outcomes, no income: The impact of performance measures

The quality enterprise from AQA to QIO

Collecting and reporting quality data is here—and here to stay. Under essentially every version of the proposed healthcare reform legislation, participation in the (currently) voluntary Physicians Quality Reporting Initiative (PQRI) will be mandatory, possibly as soon as 2011. Many payors have also instituted their own versions of pay-for-performance programs.

Quality data is reported by performance measures. This article describes how performance measures are developed and implemented; it also describes the many quality entities, with their myriad of acronyms (Table 1).

It starts with physicians
The main developer of performance measures is the Physicians Consortium for Performance Improvement (PCPI). The PCPI is convened and funded by the American Medical Association (AMA), and its membership includes specialty and state medical societies as voting members, allied health professionals and nonphysician providers as limited voting members, and several foundations and governmental agencies as nonvoting members.

Any medically related organization can develop performance measures and several Quality Improvement Organizations (QIO) have done so. The Centers for Medicare & Medicaid Services (CMS) has also contracted with private consulting companies such as Mathmatica to independently develop performance measures.

The PCPI measure development process is very sophisticated and labor intensive. First, a work group that includes multiple stakeholders (physicians, appropriate nonphysician providers, AMA PCPI staff, and a methodologist) is convened. The work group chair and members are approved by the PCPI executive committee and must be free of any conflicts of interest. The work group meets in a face-to-face meeting and hammers out the measure set based on credible evidence and preferably an evidence-based treatment guideline.

The measures are then edited by AMA PCPI staff and submitted to interested stakeholders for comment. The work group considers the comments and edits the measures as appropriate before approving them. The AMA staff writes the specifications, which includes numerator and denominator definitions, rationale for the measures, and any exclusions that might be appropriate.

The entire document goes back to the work group for approval and is then sent to the full PCPI for discussion and a vote. Often, enough concerns are raised at the full PCPI meeting that the measure goes back to the work group for more clarification.

Once approved by the full PCPI, the measure set is forwarded to the National Quality Forum (NQF) where it is again vetted by a steering group assisted by a technical advisory panel. If approved by the steering committee, the measure then goes to the NQF Consensus Standards Approval Committee (CSAC), and then to the full NQF board. Not until the measure has board approval is it ready for implementation by CMS and other payors.

Until recently, the measure also had to go to the Ambulatory Quality Alliance (AQA) to be approved for “implementation.” The AQA has, however, changed its focus and now is focusing its efforts on encouraging mechanisms to improve quality, including quality measurement.

AAOS involvement
The PCPI has also developed an “independent development process,” which enables a specialty organization such as the AAOS to develop measures independently with assistance from PCPI staff and strictly following PCPI protocol. The specialty society must fund part or all of the expenses associated with this pathway. Because the AMA does not have either the time or the money to develop measures in every area, this allows specialty societies to develop measures to fill gaps in their specialty areas.

In orthopaedics, for example, gaps in performance measures currently exist in pediatrics and hand surgery. Because no NQF-approved, CMS-implemented measures have been developed in these two areas, orthopaedic surgeons who practice these specialties have no way to report quality measures and thereby qualify for bonus payments under various pay-for-performance programs. The AAOS is in the process of developing measures through the independent process, as is the Surgical Quality Alliance (SQA), of which the AAOS is a member.

Several specialty societies have developed measures on their own without the help of the PCPI. Although some are quite good and are being used to improve quality, experience has shown that measures that undergo the rigorous PCPI process are more likely to pass the NQF.

Surgical measures
The SQA is an alliance of 22 surgical specialty societies and anesthesiology that was originally convened by the American College of Surgery to develop a common surgical voice in the quality arena. The SQA generally meets the day before the AQA and has taken on two projects partially related to the quality enterprise.

The SQA has developed a surgical patient experience survey that is undergoing review by the Agency for Healthcare Research and Quality (AHRQ). Once approved, it will be certified as a Consumer Assessment of Healthcare Providers and Systems instrument. This surgical survey will serve as a patient satisfaction assessment. Many payors, including CMS, are beginning to implement patient experience surveys as part of their pay-for-performance programs and many specialty boards that belong to the American Board of Medical Specialties are requiring patient experience surveys as part of their Maintenance of Certification (MOC™) programs.

Given the present healthcare environment, the nonsustainable growth in the cost of health care, and the belief by both policy makers and many members of the medical community that quality health care will be less expensive in the long run, there is little doubt that collecting and public reporting of quality data are here to stay. It is incumbent on the orthopaedic community to learn as much as possible about this expanding trend.

Robert H. Haralson III, MD, MBA, served as the AAOS Medical Director and representative to the PQRI.