Physicians Are Not All Equal

March 20, 2016 | Featured Articles

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The Potential Impact of the Core Quality Measures Collaborative

All Physicians are not equal. While this is understood on a certain level by everyone from the public to physicians and regulators, the great tragedy of our healthcare payment systems is that physicians are all treated as equal when it comes to payment methodology. Probably the greatest single frustration of physicians who provide quality and compassionate care is that they are treated as equal to those who do not. Fee-for-service reimbursement is built on equal payment for equal CPT code, yet the reality is that equal is neither fair nor equitable.

Physicians are not alone in their distain for equal pay for equal processes. Payers and government have long tried to understand and develop models that would differentiate physicians by measuring “quality” and recognize it with payment.

It is estimated that the rising cost of health care — along with Social Security costs — could bankrupt the country by 2045 so every Payer is looking to put the brakes on that apparent upward trend. If health care spending is to be curtailed, how do you logically get the best value for those dollars? The answer is to measure quality and to reward for it or to penalize those who meet less than minimum standards.

Here is the rub; how do you define and measure quality?

Each Payer (commercial, government, or otherwise) has set up its own measures to gauge quality. It’s not enough to say, “I know quality when I see it,” so we measure the quality of outcomes, or processes that are recognized as leading to better clinical outcomes. The result has been an overly complex and confusing list of measures and tasks that are widely (and rightly) criticized as being a burden on physicians, and too numerous and often irrelevant to be of any help to consumers in their decision-making processes. Imagine participating in multiple insurance company networks and having to report data in different ways on different measures to each one?

In an innovative response, government (Centers for Medicare & Medicaid, aka CMS) and commercial Payers (the major health care insurance companies) have teamed up to adopt a common core set of quality measures to replace this patchwork quilt of varied measures among the multiple Payers. In February 2016, CMS and the trade group America’s Health Insurance Plans (AHIP) announced an agreement to a common core set of quality measures. Through a working group called the Core Quality Measures Collaborative, all physicians are on notice that they will be measured on their performance against the core measures and the results will be reported publicly.

Historically, payment innovation has sought to address utilization, which has often resulted in the criticism that quality has been sacrificed for the cost of care.  A set of common measures will allow payment innovation to occur with recognized and common measures of quality. Payment ‘experiments’ that differ from Payer to Payer will be able to be compared for their impact upon quality measures that are common, regardless of the payment model. Theoretically, as payment models change, those that can produce the best “quality” with the greatest impact in cost reduction should find wider spread support and adoption.

Access to Information

A key factor in the agreed upon selection and measurement methodology between the Payers is to make the outcomes for each physician available publicly. The goal being that, in addition to Payers having comparable measurements for economic purposes, consumers would have access to relevant and understandable information to aid them in their choice of physicians. Experts have long sought ways to engage patients in their healthcare, not just for personal health improvement, but also to understand that the decisions that they make in terms of providers has significant impact on their health and economics. Outside of healthcare, the US economy is largely consumer driven; consumer choice drives businesses to improve. Customers base their decisions on public perceptions and ratings of quality, the experience and costs. Information abounds when it comes to non-medical costs and quality, from online ratings to Consumer Reports magazine. With a common scoring model, we may even see the advent of a Consumer Report on physicians!

From the physician perspective, one common set of measures means compiling data once and complying with a single program, a substantially better alternative than managing multiple programs across Payer networks.

Driving Innovation

The potential for Core Quality Measures to drive innovation and change in physician services should not be underestimated. With rising copayments and deductibles, patients who now bear an increasing financial responsibility for the costs of their care are choosing care based on costs and convenience. Quality hasn’t been a factor for consideration because the measures have largely been inconsistent, irrelevant, or not easily understandable by the patient. With the advent of Core Quality Measures, the patient can be armed with information about physicians and the quality of care, and choose to receive care from practitioners that will help them hold the line on personal out-of-pocket costs.

While physicians have long held Payer ranking programs and other quality measures in distain (and rightly so) physicians should embrace this new opportunity for transparency. Physicians need to be prepared to take advantage of any positive economics that will come from Core Quality Measures adoption in payment methodologies.


Unlike Payer-created measures, which change from measurement period to measurement period, the Core Quality Measures are stable. This stability allows practices to plan in advance of being measured. For example, practices should reach out to their EHR companies and find out if they plan on incorporating the Core Quality Measures into their medical record scheduling and alerts programming.  Until now, a multitude of Payers with different measurement programs made it impossible for physicians to deploy technology to help as a reminder, or as patient outreach to encourage patient engagement.

The Core Quality Measures announced pertain initially to performance reporting from accountable care organizations, patient-centered medical homes, primary care, cardiology, gastroenterology, providers of HIV and hepatitis C care, medical oncology, orthopedics, obstetrics and gynecology. Additional specialty measurements will promulgated.

In 2018, half of Medicare spending outside of managed care will be tied to the potential for rewards or penalties for quality outcomes, making the creation of the Core Quality Measures very timely. In addition to traditional Medicare, the major commercial plans have agreed to follow Medicare’s lead and have committed to 90% of their contracts being tied to quality measures by 2020. Fee-for-service payments to physicians continue on a path to extinction and Core Quality Measures support this transition in physician compensation. Simply put, future compensation will be uncoupled from number of events (visits, procedures) and instead be tied to what services you provide, how well you provide them and the utilization of those services.

Accountability and Patient Engagement

A signifying criticism of many of the quality measurement programs that are unresolved by Core Quality Measures is that many require the active engagement of the patient in seeking out a physician to provide the care. Efforts at increasing immunization rates or breast mammography rates have often fallen short of the desired results when patients are unresponsive to pleas by their physician to come in for care. This means that physician will not only be held accountable for what they do, but also for what their patients may choose not to do. This will require significant innovation on the part of physicians to engage their patients, and to create and use tools to gain their patient’s attention and motivate them to come in for care.

Will patients actually use this information?

That’s the question that quality and consumer advocates will be asking. Historically, patients have been turned off by the complexity of information available, and few seem to have relied on the commercial Payers ranking of physicians programs (such as Aetna Axxcel, United Premium, or Cigna) unless there were cost differentials in choosing ‘inferior’ providers. For example, some benefits are designed such that selecting a Tier 1 provider in United Healthcare’s network was rewarded by a limited cost-sharing by the patient, such as no copay required. Core Quality Measures may be just the innovation that changes how patients as consumers make decisions about their care and providers.