Taking a crucial first step in an effort to make pay for performance work for office-based physicians, a coalition of physician groups, insurers, and the federal government has endorsed a set of 26 clinical-performance measures for the ambulatory care setting.

The coalition—the Ambulatory Care Quality Alliance (AQA)—was formed last year by the American Academy of Family Physicians, the American College of Physicians, America's Health Insurance Plans, and the federal Agency for Healthcare Research and Quality.

The starter set of 26 measures focuses on prevention, chronic care, and the overuse and misuse of certain treatments. The set could be implemented as early as next year

“This is a watershed event,” said William E. Golden, M.D., professor of medicine and public health at the University of Arkansas in Little Rock.

The announcement of the 26-measure starter set signals the beginning of an era in which physician performance in the aggregate will be monitored and assessed, he said.

Creating a single set of measures that can be used across health plans is key, Dr. Golden said. It means that physicians won't need to gather different types of data from each patient, he said, and it will allow for increase comparability of patient care.

“The ultimate goal is to improve the quality of care,” said John Tooker, M.D., CEO and executive vice president of the American College of Physicians. AQA's starter set of measures was assembled from existing measures developed by either the Physician Consortium for Performance Improvement or the National Committee for Quality Assurance. Most of the measures are now under review by the National Quality Forum.

AQA compiled the set in part to reduce the administrative burden on physicians, Dr. Tooker said. Most physicians deal with multiple health plans and having a single set of uniform measures used across all plans would lessen the hassle factor for physicians, he said.

In addition to being less of an administrative burden, the measures are evidence-based and were developed with physician input, he said.

But this is just the beginning of the process. The measures still need to be validated in the field, Dr. Tooker said. He expects that the measures will be adopted as they are ready to be implemented, possibly as early as next year.

AQA will also work this year on setting standards for data aggregation and reporting.

And in the future, AQA plans to expand the measure set to include subspecialties outside of primary care.

The measures in the starter set were selected based on their clinical importance and scientific validity, feasibility, and their relevance to consumers, purchasers, and physician performance.

The starter set includes measures of preventive care related to breast cancer screening, colorectal cancer screening, cervical cancer screening, tobacco use and cessation, and vaccination for influenza and pneumonia. Other measures address chronic care of coronary artery disease, heart failure, diabetes, asthma, depression, and prenatal care.

The starter set also contains measures related to appropriate treatment for children with upper respiratory infections and appropriate treatment and testing for children with pharyngitis.

This movement toward performance measures and pay for performance programs is already happening in many parts of the country, said Alan Nelson, M.D., a member of the Medicare Payment Advisory Commission (MedPAC) and a special advisor to Dr. Tooker.

“The pressure is coming from the purchasers of care who are insisting on buying value,” he said. “Medicare is taking the same approach.”

Mark McClellan, M.D., administrator for the Centers for Medicare and Medicaid Services said his agency support the AQA's efforts to implement valid, reliable measures.

In a statement, Dr. McClellan called the initial set of measures a “milestone” in the area of ambulatory care. But Dr. Nelson said he is concerned that most solo and small group practices are not equipped to gather and document the data needed to show compliance with the measures. As this effort moves forward, physicians will need to create patient registries and create some easy and efficient way of collecting the data needed for pay for performance.

MedPAC has acknowledged that difficulty and recommended that under Medicare pay for performance initiatives, only information that can be collected through claims data should be used, he said.

Many of the performance measures that are being pushed by AQA are already in use within the Department of Veterans Affairs, said Rowen Zetterman, M.D., chief of staff at the VA Nebraska-Western Iowa Healthcare System in Omaha.

That bodes well for the success of programs that use the measures going forward since the VA has been able to significantly improve quality through its use of performance measures, Dr. Zetterman said.

The starter-set measures are online at www.ahrq.gov/qual/aqastart.htm

Coalition Defines Set of 26 Clinical Care Measures