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Study Finds Serious Flaws in Physician Performance Metrics

New York, NY—April 19, 2018

Researchers are calling for a "time out" in the use of performance measures for physicians after finding that less than 40 percent of these metrics are valid.

The study, led by Catherine H. MacLean, MD, PhD, a specialist in health care quality and Chief Value Medical Officer for Hospital for Special Surgery in New York City, found that only 37 percent of quality measures the group assessed met a list of criteria for validity devised by the American College of Physicians. Of the rest, 35 percent were deemed invalid while for the remaining 28 percent, the validity was found to be uncertain.  

"The fact that only 37 percent of measures proposed for a national value-based purchasing program were found to be valid using a standardized method has implications for physician-level performance measurement," the authors wrote. "The use of flawed measures is not only frustrating to physicians but potentially harmful to patients. Moreover, such activities introduce inefficiencies and administrative costs into a health system widely regarded as too expensive already."

"What we should be paying for in a value-based system is higher-quality care," Dr. MacLean said. "It’s critically important that we have the right measures. A bad measure is a missed opportunity to inform clinical care."

The researchers reported the findings this week in The New England Journal of Medicine.

Physicians in the United States are now tracked on more than 2,500 performance measures, an explosion of which has occurred during the past 30 years as the Centers for Medicare & Medicaid Services (CMS; the government’s health insurance agency) and private payers have looked for ways to both improve the delivery of health care and drive down costs. Doctors have balked at the increasing burden, which cost roughly $15.4 billion, or about $40,000 per physician, annually to meet.

However, whether those measures – which come from dozens of organizations – are meaningful and robust remains unclear. The new study will reinforce the view among many physicians that the metrics are time and money misspent.

To evaluate the validity of performance measures, a committee for the American College of Physicians developed a five-item checklist: importance, appropriateness, strength of clinical evidence, feasibility of implementation and applicability.

The committee looked at 86 performance measures germane to general internal medicine. The measures were part of the Medicare’s Merit-based Incentive Payment System/Quality Payment Program, a sweeping initiative to link physician performance – and patient outcomes – to reimbursement under the program. CMS has declared that it wants to tie 90 percent of physician payments under Medicare’s fee-for-service system to performance metrics by the end of this year. However, the agency recently issued a request for proposals for new measures.

"We hypothesized that if most of the measures assessed were deemed valid using this process, physicians could have more confidence that adherence to the measures would result in improved patient outcomes," Dr. MacLean and her colleagues wrote.  

Thirty (35 percent) of the measures failed the test. Of those, 19 lacked sufficient clinical evidence to warrant implementation. For example, one measure calls for physicians to screen older patients for signs of elder abuse. But Dr. MacLean, who moderated the panel, and her colleagues note that although elder abuse is a concern, the U.S. Preventive Services Task Force does not recommend routine screening for the problem.

Similarly, the study found that another recommendation, for managing people with high blood pressure using a strict threshold (140/90 mmHg) also failed the validity test because it might do more harm than good in older, sicker patients and those with certain health conditions.

The study also revealed "troubling inconsistencies" in which measures major organizations regard as valid. The authors suggest this may be due to different methods used by different organizations and call for a standard method to grade the validity of these measures.  

"Quality measures only should be based on practices about which we are certain there is a meaningful health benefit. There should be no controversy in quality measures," Dr. MacLean said.

Dr. MacLean and her colleagues do not dismiss the need for performance measures for physicians. But they call for changes to the way the assessments are created. One step, they said, is to avoid an overreliance on administrative data – such as billing claims – which, while easy to obtain, are not particularly informative or nuanced. Another is to try to move away from a system in which physicians are rated long after they deliver care to one in which they receive feedback on their performance in real time.

"The point of the paper isn’t that we don’t support quality measures. We’ve had careers in developing them," Dr. MacLean said. "The problem is that bad quality measures can be harmful. Additionally, they are a waste of time; they’re frustrating, and they’re a waste of money. It’s gotten to the point where it’s almost measures for measurement’s sake."


About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.


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