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 Psychiatric News.

"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 quality-improvement agenda.

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 Assurance (NCQA).

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 reporting?

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 future.

"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 maintain certification."

Oldham said pediatric and internal medicine boards already require proof of utilization of benchmark performance measures for specialty recertification.

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 general medicine.

"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 osteoarthritis.

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 communications."

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 controversial.

Nonetheless, "pay for performance" is coming, said Oldham, and is already under consideration by the federal government for its DOQ program.

"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 explained.

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>.▪