AAOS Now

Published 9/1/2014
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Terry Stanton

How Should Your Performance Be Measured?

Orthopaedic societies want to help shape evaluations

At a time when reimbursement and healthcare delivery systems are undergoing a transformation toward models that measure and reward performance and outcomes, the AAOS and orthopaedic specialty societies are taking steps to ensure that orthopaedic surgeons are leaders in shaping specific performance measures.

“Performance measures” can be seen as an umbrella term for the various quality-based criteria that increasingly will govern how physicians are evaluated and compensated. They are the visible crest of a wave that is moving medicine from a pay-for-reporting to a pay-for-performance model. In this new world, in which quality and value (described as quality divided by cost) are paramount, the ways by which providers are rated—performance measures—are crucial.

In July, the Academy convened a summit of orthopaedic specialty societies, state orthopaedic societies, and external stakeholders to ensure that any orthopaedic measures being used are developed by and with input from orthopaedic surgeons.

Kevin J. Bozic, MD, MBA, chair of the Council on Research and Quality, moderated the summit, along with Warren Dunn, MD, MPH, chair of the recently formed Performance Measures Committee.

“Right now, the primary payment system for healthcare services in the United States is based on fee-for-service (FFS),” said Dr. Bozic. “The physician performs a service and gets paid, regardless of the outcome or the quality or the patient’s experience. As payment systems evolve to reward value, the will promote higher quality care at a reasonable cost. Although most payment systems will have a FFS component, part of the payment will be based on the value of the service.”

The AAOS convened the summit to involve specialty societies from the outset and to get their input in how best to report quality in musculoskeletal care.

It’s a new era
The days of resisting the shift to a performance-based environment have passed, Dr. Bozic said.

“It’s not a matter of whether orthopaedic surgeons want to have measures of accountability and improvement in defining their performance,” he said. “Orthopaedic surgeons are being rated today by a number of different stakeholders. It is a matter of whether orthopaedics as a profession should have input into those measures and whether those measures can become more clinically relevant.”

Input from the orthopaedic community is important because, regardless of the route used to determine performance measures, they will be used by the Centers for Medicare & Medicaid Services (CMS) and private payers to determine compensation. The way in which a performance measure is officially adopted is not standardized, however. Dr. Bozic explained that the “most trusted, most thorough” implementation process is through the National Quality Foundation (NQF). “It is a long and expensive process,” he said, but NQF endorsement “is akin to the gold standard.”

Dr. Bozic outlined the criteria for performance measures that will meet the approval of bodies such as the NQF and CMS. “They need to be relevant and actionable,” he said. They also need a reason for being.

“You have to be able to show that a gap in performance exists,” he continued. “There’s no point in measuring something physicians are already doing well. But if there is variation among providers, you can discriminate among them and determine which providers are delivering a better value.”

American Association of Hip and Knee Surgeons (AAHKS) representative Adolph J. Yates Jr, MD, explained that CMS classifies performance measurement into the following categories:

  1. Public reporting through www.medicare.gov/hospitalcompare/search.html
  2. Public reporting through www.medicare.gov/physiciancompare/search.html
  3. Value-based payment adjustment
  4. Physician Quality Reporting System (PQRS)–based payment adjustment

Orthopaedics has a favorable position with CMS, the NQF, and other stakeholders, due in part to the extent and impact of musculoskeletal conditions.

“Orthopaedics is in a good position and very important to these stakeholders,” said Dr. Bozic. “They are willing to work with us and see what we can develop that will help improve quality and reduce costs.”

Specialty society efforts
Dr. Bozic asked the specialty societies to do the following:

  • Identify three aspirational performance measures (preferably outcome measures, including patient reported outcome measures) for development.
  • Identify three measures that the society would want to be measured on today from data sources readily available to payers and/or public reporting agencies (such as administrative, claims, and registry data).

Several specialty societies have already engaged in performance measures–related activities. AAHKS, for example, has developed a complete set of performance measures for total knee replacement, which gained acceptance from CMS under its value-based purchasing program.

David A. Halsey, MD, Board of Specialty Societies vice chair, is helping to coordinate performance measurement activities. He also oversaw the development of the AAHKS measure sets and explained the steps required.

“We aimed for the baseline,” he said. “Things like, ‘Does the history and physical include whether the patient has pain?’ ‘Were X-rays obtained within the last year?’ ‘Was the implant type included in the dictated operative note?’ Simple things that could actually be measured.”

AAHKS worked through the American Medical Association’s Physician Consortium on Physician Improvement (PCPI); the measure cost approximately $120,000 to develop. It took about 18 months to get the measure set through PCPI, vetted publicly, and approved by a multistakeholder panel. The measures were “tweaked” and submitted to CMS, which accepted them even before the process was complete. AAHKS hopes that participation will pay off in the long run with reimbursements that recognize the work involved.

Dr. Bozic recognized the pioneering efforts of the AAHKS in moving performance measures forward. “When they started out, this concept of physicians being measured on their performance was kind of foreign. Now that they have been through it, it is no longer foreign,” he said.

The next set of measures being developed by AAHKS will focus on hip replacement. Meanwhile, the AAOS Performance Measures Committee voted to develop performance measures for hip fracture and to assume stewardship of an existing NQF measure on function and pain assessment of osteoarthritis.

Moving toward outcomes
“We’ve been doing performance measures in a way for many years,” said Dr. Halsey, “beginning with process measures on issues such as antibiotic administration. But reporting process measures has a ceiling effect; when everybody is doing it, the measure is no longer useful as a distinguisher.”

The trend now, as propelled by CMS and other payers, is toward use of subjective patient-reported outcomes. “This is where the payer community wants to go,” said Dr. Halsey. “They want to know how the interaction with the doctor or surgeon went and how the surgery went.”

“Policy and clinical communities recognize that patient-reported outcomes are an important component of any performance measurement program,” Dr. Bozic said. “We can perform surgery, but if the patient doesn’t feel better, it might not matter. As orthopaedists, we are in the business of improving quality of life function and reducing pain. If we are not measuring that, it is pretty difficult to know whether or not we are doing a good job and what we need to do to improve.”

“The call to action to the physician community was ‘help us do this,’” Dr. Halsey said. “Quite honestly, the physician community has been slow to adopt—because what professional wants their individual work evaluated by a third party?”

He noted that orthopaedics does have several patient-reported outcome measures and clinical assessment tools, but most are proprietary, resulting in no standardized, agreed-upon way to measure a patient-reported outcome after a total knee replacement, for example.

Rather than have individual payers each develop their own measures, the AAOS and specialty societies hope to develop measures that can be used across the board. “Our members want to know that their professional organization is looking out for them, so they don’t have six or seven evaluation tools from every payer,” said Dr. Halsey.

Dr. Bozic urged physicians to take a positive attitude toward performance measures. “We recognize that variations in performance and outcomes exist. As professionals, we spend a good portion of our lives trying to improve the lives of our patients. Presumably, we’d like to have tools to help us figure out how we are doing. Performance measures can help provide the information needed to help us and our teams improve the care we provide.”

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org

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