IOM Calls for Standards on Pay for Performance


Congress needs to establish an entity within the Department of Health and Human Services that can standardize health care performance measures across the health care system, according to a report from the Institute of Medicine.

Participating providers should be required to submit performance data to the board, so that Medicare can use the information for quality improvement activities or as a basis for payment incentives and public reporting, wrote the IOM committee, whose efforts were mandated by Congress and sponsored by the HHS.

In a statement, Dr. C. Anderson Hedberg, president of the American College of Physicians, praised the IOM's intention to establish a centralized organizing structure.

“This may be one way to set clear quality goals, coordinate performance measurement efforts, support fair comparisons of cost and quality, and ensure stable funding for organizations involved in performance measurement,” Dr. Hedberg said.

Performance measures are benchmarks by which health care providers and organizations can determine their success in delivering care. Examples include regular blood and urine tests for diabetic patients, a facility's 30-day survival rate among cardiac bypass patients, or perceptions of care collected from patient surveys.

Yet these independent initiatives have led to duplication in some areas and neglect in others that are important to national health goals, the committee noted. Individual stakeholders understandably focus on certain features of care that they consider to be the highest priority for improvement. “But they frequently overlook areas of national interest that are difficult to quantify, such as whether care is equitable, efficient, and well coordinated.”

As an initial step toward achieving a universally accepted set of measures, the report recommended the adoption of an evidence-based “starter set” of existing measures that would cover care delivered in ambulatory, acute care, and long-term care settings and in dialysis centers.

The board should also guide development in areas that are currently lacking in performance measures, such as efficiency, equity, and patient-centered care, the committee noted.

“One of the biggest obstacles to overcoming shortfalls in the quality of health care is the absence of a coherent, national system for assessing and reporting on the performance of providers and organizations,” said the IOM's committee chair Steven Schroeder, Ph.D., professor of health and health care, University of California, San Francisco. Leadership at the federal level is needed to ensure that performance measures achieve national goals for health care improvement, he said.

The committee recommended that Congress should authorize $100 million to $200 million in annual funding for the national board from the Medicare Trust Fund.

This amounts to less than 1/10 of 1% of annual Medicare expenditures.

What's lacking in the report is a recommendation for Congress and the private payers to put money into the system to help defray the costs of reporting, especially with regard to technology needed to do pay for performance.

Further, “quality” translates to “saving money” for some private payers. Also, pay for performance has not yet been shown to be effective over a wide range of disorders.

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