May 20, 2008
12:00 a.m. Eastern Time
Researchers Describe Method For Going Beyond Limitations Of Current Physician Performance Measurement
Study Offers Alternative Approach Designed To Partner With Physicians In Improving Care
Bethesda, MD -- Current pay-for-performance (P4P) strategies for physicians often inappropriately focus on cost reductions by divorcing measures from the specific changes needed to improve care, according to a new study published today as a Health Affairs Web Exclusive. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.4.w250
The study’s authors offer an alternative approach designed to engage physicians as partners in identifying and addressing areas of overuse and misuse. They detail how this approach was used among the roughly 900 primary care physicians and 2,500 specialists at the Rochester Individual Practice Association (RIPA) in New York State to determine better-quality care in treating hypertension and using fiberoptic laryngoscopy to evaluate problems with swallowing.
The trouble with current P4P methodology stems from primarily employing a measure known variously as an “efficiency index” (EI), an efficiency factor, or an observed-expected ratio, the study says. This measure, which compares the costs incurred by a particular physician with the average per physician costs in the relevant specialty, is used in most current physician P4P schemes.
“The EI reflects a judgmental approach that attempts to motivate physicians through blame and fear, making physicians adversaries rather than partners in change. What’s more, the EI focuses on global cost control rather than identifying and then encouraging a reduction in overused procedures and -- equally importantly -- an increase in underused procedures on a condition-by-condition basis,” said coauthor Howard Beckman, medical director at RIPA.
From 1999 through 2006, RIPA used an EI as its efficiency measure in its physician P4P program. “We found that those with higher EIs did not always have higher costs as a result of overuse. Increased costs could be a result of appropriate care, the costs associated with correcting underuse, and/or expenses outside of the control of the physician to whom the costs were attributed,” said lead author Robert Greene, the former associate medical director at RIPA and current vice president for Clinical Analytics at UnitedHealthcare. “At the individual practitioner level, the EI appeared to be susceptible to infrequent events (one or two emergency room visits, for example) that often were not under a physician’s control,” Greene, Beckman, and coauthor Thomas Mahoney, the CEO and executive director of RIPA, write in their article.
Based on that experience, RIPA developed an alternative approach to measuring physician performance. RIPA’s approach was based on analyzing which interventions were the main cost drivers for specific conditions, and determining whether physicians who used these interventions more intensively than others were obtaining better outcomes or simply costing more.
Fiberoptic Laryngoscopy: Reducing Overuse Of A Procedure By Engaging Physicians
In the case of throat disorders, the main cost driver was the performance of fiberoptic laryngoscopies. Physicians in the highest spending quartile performed 3.4 times more procedures than their counterparts in the lowest spending quartile. Greater use of the procedure was not associated with better outcomes or a decrease in costs elsewhere. In fact, physicians who performed more laryngoscopies had relatively higher costs for office visits and pharmaceuticals as well, compared with those performing fewer of them. RIPA designed a project to try to shift the practice pattern among its otorhinolaryngologists. To ensure that quality of care was maintained, the project was conducted under the leadership of the otorhinolaryngology community.
Many heavy users of fiberoptic laryngoscopy were genuinely surprised when RIPA staff showed them that they used the procedure more than other physicians. Some physicians erroneously believed that the procedure was necessary to recheck for resolution in patients treated for gastroesophegeal reflux disease, and some newly trained physicians were more comfortable evaluating patients with laryngoscopies than with older mirror examination techniques.
By respectfully meeting with physicians to share the variation results in late 2005 and January 2006, RIPA was able to reduce the rate of fiberoptic laryngoscopies by 17 percent in 2006 as compared to 2005, a marked reversal of the 18 increase in procedure rates from 2004 to 2005.
Hypertension: Reducing Inappropriate Use Of Brand-Name Drugs
The researchers also examined hypertension care as a proof of their concept, although RIPA did not conduct the same sort of intervention with physicians regarding hypertension care as it did regarding throat disorders. Cost differences among physicians treating hypertension were predominantly due to differences in pharmacy costs. The variation in drug costs was more than five times greater than the variation in costs for laboratory costs and office visits--the only other cost categories that contributed significantly to overall cost variation. Individually expensive but uncommon services such as ER visits, which often increased an individual physician’s EI, had negligible effects on costs per episode of care for the specialty as a whole.
In treating hypertension, higher-spending physicians were more likely to prescribe brand-name drugs, while lower-spending physicians prescribed more generics. Physicians in the highest spending quintile were more than six times as likely than their counterparts in the lowest spending quintile to prescribe drugs known as angiotensin receptor blockers (ARBs), which are only available in brand-name formulations, even though angiotensin-converting enzyme (ACE) inhibitors work just as well for most patients and are available as inexpensive generics.
After the embargo lifts, the article by Greene, Beckman, and Mahoney will be available online athttp://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.4.w250
ABOUT HEALTH AFFAIRS:
Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.
©2008 Project HOPEThe People-to-People Health Foundation, Inc.