Published 10/1/2015
William T. Brox, MD, Joseph P. DeAngelis, MD; Jill E. Larson, MD

Measuring Performance, Post-SGR

The why, the what, and the how

Now that the sustainable growth rate (SGR) is no more, orthopaedic surgeons are facing a new value-based environment. In this post-SGR healthcare world, quality and performance measurement are of critical importance. In particular, the orthopaedic community must have a common understanding of these terms.

Global payments, bundled payments, and shared-risk contracts are all tied to various measurement processes, which are generically referred to as “performance measures.” Although performance measures are not new, they will become ubiquitous over the next 4 to 8 years.

This article describes the relationships among clinical practice guidelines (CPGs), appropriate use criteria (AUC), and performance measures (PMs) in the assessment of quality for orthopaedic surgery. It also explains the development process for performance measures and outlines the requirements for performance measurement reporting in the immediate future and beyond.

Why performance measures?
As orthopaedic surgeons, we are working in an increasingly cost-conscious environment, in which the payers (insurance companies, government, patients, and employers) are demanding greater value from providers. We all understand the value equation: quality (clinical outcomes plus service) divided by cost. But although cost may be easily measured, the quality of orthopaedic surgery is harder to define. In general, quality is a function of the service provided combined with the quality of the patient’s outcome.

The next question is: who should determine “quality”? When patients were asked that question, they overwhelmingly responded that physician societies should be responsible. The SGR Repeal and Medicare Provider Payment Modernization Act of 2015 requires development of quality measures and ensures close collaboration with physicians and other stakeholders regarding the measures used in the performance program.

What’s behind PMs?
The current focus on assessment and improving quality is unprecedented. To understand quality measurement, orthopaedic surgeons must understand three central tools: evidence-based CPGs, AUC, and PMs.

CPGs define what healthcare providers should do—as well as what they should not do. Evidence-based CPGs are based on an exhaustive review of all available evidence to determine the best practices for management of a specific disease, diagnosis, or condition. Evidence-based CPGs include a series of recommendations on clinical care, supported by the best available evidence in the clinical literature. They tell us if a procedure or service works.

AUC define what is “reasonable to do.” They are specific to a given condition and indicate that an “appropriate” procedure’s expected health benefits exceed the expected risks by a wide margin. The Academy’s AUC are developed using evidence-based information in conjunction with the clinical expertise of physicians from multiple medical specialties.

AUC are intended to improve patient care and obtain the best outcomes while considering the subtleties and distinctions necessary in clinical decision making. AUC specify when it’s appropriate to perform a specific procedure or service and on whom it should be done.

PMs are the “must-do’s” of health care. A performance measure is a quantitative tool (such as a rate, ratio, index, or percentage) that provides an indication of performance in relation to a specified process or outcome. PMs are selective, focused, measureable, and actionable. They are based on guidelines that indicate proven ways to improve patient outcomes. Broadly, the three types of performance measures are as follow:

Process measures—These are commonly used; an example is recording whether a patient gets prophylactic antibiotics before a procedure. Another example of a process measure is the “percentage of patients aged 60 years and older with fracture of the hip, spine or distal radius who had a DXA measurement performed or pharmacologic therapy prescribed.”

Structural measures—These measures seek to improve care coordination, resource utilization, and efficiency or patient safety. For example, a structural measure might assess whether a healthcare organization uses Computerized Physician Order Entry (CPOE) (based on evidence that the presence of CPOE is associated with better performance and lower rates of medication error).

Outcome measures—These have the most impact in terms of quality improvement. They measure the results of health care. An example would be the hip fracture mortality rate. A patient-reported outcome measure captures the patients’ assessment of their health status. An example would be the percentage of patients with more than 20 points difference in pre- and postoperative Hip disability and Osteoarthritis Outcome Score (HOOS).

How are PMs selected and developed?
The National Quality Forum (NQF) recommends that topics slated for performance measure development be evaluated for their suitability based on the following standardized criteria:

  • importance to measure and report
  • scientific acceptability of measure properties
  • feasibility
  • usability and use
  • related and competing measures

The most important considerations in designing a meaningful PM are clinical relevancy and impact on the clinical work flow. Ideally a PM should place the lowest possible burden on both physicians and patients.

Feasibility of a measure is determined by data availability and specifications. For example, administrative databases, medical records (including electronic health records), and survey data are commonly available sources of data. Administrative data are usually readily available in electronic form and relatively inexpensive to use whereas medical records data, though richer in detail, are expensive to obtain and require personnel and time-intensive data abstraction methods.

Usability and use refer to the application of the data being collected. Data must contribute to improvements in health care delivery or processes; data collection must not be so difficult as to prevent the applications of a measure in a healthcare setting.

When possible, it is best to use existing, validated performance measures because developing new measures is costly in terms of both time and money. Specific considerations in orthopaedic surgery focus on comparing nonsurgical and surgical management. Frequently, the same PM may not apply to both scenarios.

Using outcome measures is preferred over using process measures. Finally, a PM is not valuable unless it has broad consensus and its use leads to meaningful quality improvement.

What’s the role of the NQF?
The NQF is a not-for-profit organization that has developed the gold standard for endorsing performance measures in the United States. The NQF does not develop or fund the development of measures. More than 85 organizations—including national associations (like AAOS), universities, public agencies, medical groups, health plans, local alliances and others—have developed measures that NQF has endorsed.

Of the 629 NQF-endorsed measures, 42 are musculoskeletal measures. Unfortunately, fewer than 10 of these measures pertain to orthopaedic-specific procedures or conditions.

The Outcome Ratio is an example of an NQF measure for orthopaedic surgery. It is calculated using morbidity (as defined by the American College of Surgeons), mortality, or return to the operating room as the numerator and all of a surgeon’s patients undergoing a specific procedure who are 65 years or older. For example, if a surgeon performs a specific procedure on 250 patients age 65 or older, and 5 of those patients must return to the operating room, that surgeon’s outcome ratio is 5/250, or 2 percent.

Due to the paucity of orthopaedic-specific PMs in the ambulatory care, office, and clinic settings, the AAOS has begun to develop them. The AAOS Performance Measures Committee has instituted criteria for PM development. Performance measures will originate from CPGs because they are rooted in strong evidence. Workgroups will include a broad representation of relevant stakeholders. The measures will be developed according the NQF measure evaluation criteria. PM sets will be reviewed by the committee on an ongoing basis, with a goal of developing two new orthopaedic PM sets every year.

Recording and reporting PMs
Reports of physician performance can be accessed using existing commercial websites like Health Grades® and Yelp®. Although these consumer-facing options provide one perspective, a sanctioned reporting service that ensures the quality and consistency of the data is needed.

In addition, the federal government, under the Affordable Care Act (ACA), mandates quality reporting. The Centers for Medicare and Medicaid Services (CMS) and the National Quality Strategy (NQS) have recognized specialty and subspecialty societies as one of the most effective ways to monitor quality. The American College of Surgeons’ National Surgical Quality Improvement Program® database and the American Joint Replacement Registry (AJRR) offer two successful examples of this approach.

The NQS was published in March 2011 as part of the ACA. It aims to improve healthcare quality and reduce cost in six domains (Table 1). The CMS quality reporting system—the Physician Quality Reporting System (PQRS)—uses negative payment adjustments to promote reporting of quality information by individual eligible professionals (EPs) and group practices. Those who do not satisfactorily report data on quality measures for covered Medicare Physician Fee Schedule services furnished to Medicare Part B beneficiaries (as defined in the law) will be subject to a negative payment adjustment. To avoid reduced reimbursement in 2017, EPs must report on at least nine individual measures covering at least three of the NQS domains this year (2015).

What’s next?
Now, instead of the SGR, we are faced with the Merit-Based Incentive Payment System (MIPS), in which an individual physician will be scored based on input from four categories (quality, resource use, meaningful use, and clinical practice improvement activities).

Quality measures will represent 30 percent of the composite score, using the PQRS system. The value-based modifier (resource use) is determined based on the quality of care furnished compared to the cost of care during a performance period and is physician–group-specific. Meaningful use contains a series of requirements and broadly refers to the use of an electronic health record.

Beginning in 2019, the payment system will depend on a threshold value of the composite score. Providers scoring above the threshold will receive proportionately larger bonus payments, with up to $500 million being paid each year. Providers scoring below the threshold will be subject to payment reductions, which will be capped at 9 percent by 2022.

We individually as orthopaedic surgeons or collectively through our societies such as the AAOS can affect the MIPS composite score through the quality arena—by identifying and developing performance measures to include in the MIPS quality equation.

If you are interested, you can get involved through AAOS and the Performance Measures Committee, which, in addition to developing two orthopaedic measure sets per year, is working to establish a generalizable risk adjustment strategy for practices that take on higher risk patients. The specifics of performance measurement development and implementation are evolving. It will continue to mature as the practice of orthopaedic surgery changes. Performance measures will be used to monitor and improve quality and value for our patients.

William T. Brox, MD, is a member of the AAOS Performance Measures Committee. He can be reached at tim@drbrox.com. Jill E. Larson, MD, is the resident member of the AAOS Performance Measures Committee. She can be reached at jill-larson@northwestern.edu

Bottom Line

  • PMs are essential to maximizing quality within a value-driven healthcare environment.
  • PMs are designed based on evidence-based CPGs, have multiple stakeholder contributors, and have payment and policy implications.
  • Basic CMS PQRS requirements for 2015 include the reporting on at least nine individual measures across at least three of the NQS domains.
  • The AAOS Performance Measures Committee, as well as orthopaedic specialty societies, are actively developing and managing PMs to be used by the orthopaedic community.

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