Like it or not, "performance indicators"—measures of
adherence to quality standards developed by public and private payers and
other health care entities—are coming.
And they are coming to primary care physicians and specialists alike, in
what medical leaders say is an across-the-board movement to create greater
accountability for medical quality.
"The movement for performance indicators stems from the demand by
purchasers, payers, and consumers for greater transparency and
accountability," said Kenneth Kizer, M.D., M.P.H., president and chief
executive officer of the National Quality Forum (NQF), in an interview with
"In the last decade we have become aware that the quality of medical
care is not as good as people had assumed, yet we continue to spend more and
more money on it. So there is a desire to know what is going on in this black
box called health care."
The NQF, based in Washington, D.C., is a not-for-profit membership
organization whose goals are to develop and implement a national strategy for
health care quality measurement and reporting. The creation of the NQF was
proposed by the President's Advisory Commission on Consumer Protection and
Quality in the Health Care Industry in 1998 as part of an integrated national
The development of performance indicators is being undertaken by organized
medicine, many private health plans, and the federal government for physicians
involved in the Medicare program; they are also under development by
accrediting agencies such as the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) and the National Commission on Quality
Ideally, performance indicators are founded on evidence-based, clinically
derived guidelines for specific medical conditions; typically, they entail an
instrument for prospective data collection on treatment of individual patients
that can be used to measure physician performance over time.
But whether performance indicators will rise to the ideal—whether
they will be evidence based and clinically appropriate, without imposing
excessive burden on physicians and staff, and whether they will be used to
facilitate physician practice or to penalize doctors—remains to be seen
and will determine how widely they are accepted by physicians.
Kizer acknowledged that, in the meantime, physicians do not generally
welcome the advent of performance indicators with open arms.
"The burden of how this information gets collected is one
issue," Kizer said. "Until we have electronic record collection as
part of a routine process of care, it will have to rely on someone in the
office pulling charts and doing work that doesn't get compensated. There are
also questions about the reliability and validity of the measures—if you
are going to be measured, are you being measured accurately?"
APA is monitoring the development of performance measures and shares the
concerns expressed by physicians generally regarding the application of such
measures to psychiatrists: Will the measures be meaningful to clinicians? Will
they inform and improve care? And will they minimize the burden of information
Psychiatrists knowledgeable about the movement echoed Kizer in saying that
one way or another, performance indicators are the future.
Already, they are being developed by the JCAHO as part of its core measures
for hospital-based psychiatric services, and by NCQA for follow-up treatment
after hospitalization for a psychiatric illness, for antidepressant medication
management, and for substance abuse treatment. Measures for management and
treatment of attention-deficit/hyperactivity disorder are likely in the
"This is a paradigm shift for the entire field of medicine, and it
will likely not go down easily," said John Oldham, M.D., who is chair of
APA's Council on Quality Care and represents APA as a member of the AMA's
Physician Consortium for Performance Improvement. "But as more and more
of these kinds of performance indicators are developed and endorsed, there is
a growing movement to require that physicians demonstrate their use to
Oldham said pediatric and internal medicine boards already require proof of
utilization of benchmark performance measures for specialty
And Oldham noted that mental illness—particularly depression and
substance abuse—is being prominently emphasized in the development of
performance indicators for primary care physicians. In this movement, Oldham
sees enormous benefit for both psychiatrists and their patients, since it
represents an important step in the destigmatization of mental illness within
"It is being recognized by general medicine that mental illness has
real relevance in the treatment of other medical conditions," Oldham
told Psychiatric News.
Oldham said that depression is among six conditions for which the AMA's
Physician Consortium on Performance Improvement has written performance
indicators to be used by primary care doctors. The other five are congestive
heart failure, hypertension, coronary artery disease, diabetes, and
The consortium has also written performance indicators for measuring
primary care physicians' performance in general preventive services.
Taking the lead from the consortium, the federal Centers for Medicare and
Medicaid Services (CMS) is focusing on the same conditions in its
quality-improvement pilot project known as Doctor's Office Quality (DOQ). As
part of its preventive services measure, the DOQ will specifically look at
screening and follow-up for depression and continuation of medication for
depression after initial remission of symptoms.
A companion to the DOQ program is the DOQ Information Technology (DOQ-IT)
pilot. According to the CMS Web site, the program is designed to"
promote the adoption of electronic health record systems and
information technology in small to medium-sized physician offices with a
vision of enhancing access to patient information, decision support, and
reference data, as well as improving patient-clinician
Finally, in June the National Quality Forum convened a workshop on
performance indicators for behavioral health. "There was a consensus
that depression and substance abuse—particularly alcohol abuse—are
the areas most likely to be fruitful and beneficial for the foreseeable
future," Kizer told Psychiatric News.
As inevitable as the advent of performance measures themselves is the
likelihood that physicians will, in time, be paid according to their
performance on those measures—a feature that could prove
Nonetheless, "pay for performance" is coming, said Oldham, and
is already under consideration by the federal government for its DOQ
"If physicians in practice in Medicare and Medicaid demonstrate that
they are using evidence-based performance measures and doing it with
electronic data systems, they will get an enhanced rate," he
Kizer said that more than a hundred "pay for performance"
projects are being piloted in the private sector.
A number of uncertainties remain to be clarified: What is the appropriate
percentage of reward for performance? Does the reward go to the physician or
to the health plan? And, most crucially, will physicians who fall below
performance standards be penalized, so that it is a "zero-sum
game"—as is particularly likely in programs like Medicare and
Medicaid, which work on a fixed budget.
Nonetheless, like performance measures themselves, the use of pay for
performance as an incentive appears to be a fast-moving train. "The
bottom line is that it's here," Kizer said. "It's only a matter of
time before it becomes the norm."
Information about NQF is posted online at<http://www.qualityforum.org/>.
Information about DOQ and DOQ-IT is posted online at<www.cms.hhs.gov/quality/pfqi.asp>.▪