IOM Calls for Standard Performance Measures


While various organizations have made substantial progress developing health care performance measures, it's time for Congress to establish an entity that can standardize these measures across the health care system, according to a report from the Institute of Medicine.

Such a board should be part of the Department of Health and Human Services, according to the report.

In particular, any participating provider should be required to submit performance data to the board, so that Medicare could use the information for quality improvement activities or as a basis for payment incentives and public reporting, the IOM committee wrote. The committee's 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.

A standard nationwide set of measures “would avoid the morass of everyone developing their own, including the government,” Dr. Larry Fields, president of the American Academy of Family Physicians, said in an interview.

But it may not necessarily take a national board to get people to adopt a consensus on measures, he added. The key is to have a set of measures that are accepted as reasonable by these programs. “Other measures can be added as necessary.”

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.

The problem is all of 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. As one of the founding members of the Ambulatory Care Quality Alliance (AQA), the ACP was pleased that the starter set proposed by the IOM comprised the AQA's 26 clinical performance measures for the ambulatory care setting.

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 IOM 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 one-tenth of 1 percent 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 costs of this type of reporting, Dr. Fields said. “The two must go hand in hand, because this type of reporting costs money.” Otherwise, pay for performance is going to be an extreme burden to physicians–primary care physicians in particular–if they don't have technology to do pay for performance, he said.

Questions remain on whether pay for performance can improve quality, Dr. Fields noted. “Some of the private payers don't buy into that. When they talk about quality, what they really mean is saving money.” For certain diseases, this type of reporting has been effective, “but it's not yet been shown to be effective over a wide series of medical problems.”

If a universal system is instituted, it needs to be pilot tested first, to find out if it can improve quality, he said. “There needs to be a gradual shift from reporting aspects [of clinical measures] to actual quality measures.”

Requested by Congress, the report is the first in a series that will focus on the redesign of health insurance to accelerate the pace of quality improvement efforts in the United States. Subsequent reports will evaluate Medicare's Quality Improvement Organization program and analyze payment incentives.

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