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Costly physician performance metrics have serious flaws, study finds

Doctors have balked at the increasing burden of implementing metrics, which cost roughly $15.4 billion annually to meet.

Jeff Lagasse, Associate Editor

Researchers are calling for a re-examination of the use of costly performance measures for physicians after finding that less than 40 percent of these metrics are valid.

A study published in the New England Journal of Medicine 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."

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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 and Medicaid Services and private payers have looked for ways to both improve the delivery of healthcare and drive down costs. Doctors have balked at the increasing burden, which costs roughly $15.4 billion annually to meet. That's about $40,000 per physician.

But whether those measures – which come from dozens of organizations – are meaningful remains unclear. The new study could 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 pertinent to general internal medicine. The measures were part of 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. But the agency recently issued a request for proposals for new measures.

Thirty of the measures, or 35 percent, 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 the authors said 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 authors don't 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.

Twitter: @JELagasse
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