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Allison Inserro
The majority of quality measures for ambulatory internal medicine in Medicare's Merit-based Incentive Payment System (MIPS) program are not valid based on criteria developed by the American College of Physicians (ACP), which called for a "time out" to assess and revise the approach to assessment of physician performance.
The majority of quality measures for ambulatory internal medicine in Medicare's Merit-based Incentive Payment System (MIPS) program are not valid based on criteria developed by the American College of Physicians (ACP), which called for a "time out" to assess and revise the approach to assessment of physician performance.

ACP performed an analysis, published in Wednesday’s New England Journal of Medicine, in response to physician concerns that current measures—now numbering more than 2500—aren’t meaningful in improving patient outcomes. And ACP said the fact that a minority of measures proposed for a value-based purchasing program were found to be valid has implications for physician-level measurement.

To perform the analysis, the ACP’s Performance Measurement Committee developed criteria to assess the validity of performance measures. Using a modified version of the method developed at the RAND Corporation and UCLA for evaluating the benefits and harms of a medical intervention, it applied the ACP criteria to the MIPS/Quality Payment Program (QPP) measures and hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, doctors could have more confidence that adherence to the measured practices would result in improved patient outcomes.

ACP analyzed 86 performance measures out of 271 included in Medicare's MIPS and QPP and found that 32 were valid (37%), 30 (35%) were not valid, and 24 (28%) were of uncertain validity. Of the 30 measures rated as not valid, 19 were judged to have insufficient evidence to support them.

A characteristic of measures rated as not valid was inadequately specified exclusions, "resulting in a requirement that a process or outcome occur across broad groups of patients, including patients who might not benefit," the authors wrote.

Examples of measures rated as “not valid” included CMS’ “Elder Maltreatment Screen and Follow-Up.” The authors wrote that although elder abuse is a serious problem, the US Preventive Services Task Force has found insufficient evidence for routine screening. The resources required would be better directed elsewhere, they said.

"ACP has long supported and advocated improving performance measures so they help physicians provide the best possible care to their patients without creating unintended adverse consequences," ACP President Jack Ende, MD, MACP, said in a statement.

The organization identified performance measures that had poor specifications that might misclassify high-quality care as low-quality care. For example, the paper cited a performance measure having to do with antidepressant management, which assesses whether patients who started taking an antidepressant medication continued taking 1 at 3 and 6 months after starting. The authors said the measure does not take into account patient preference to switch to evidence-based alternatives if they experience side effects.

The paper noted that using flawed measures is not only frustrating to physicians but potentially harmful to patients. Physician practices spend $15.4 billion per year, or about $40,000 per physician, to report on performance. In a recent survey, nearly two-thirds of physicians said that current measures do not capture the quality of the care they provide.

In an email to The American Journal of Managed Care®, Catherine H. MacLean, MD, PhD, chief value medical officer at the Hospital for Special Surgery and the study's lead suthor, described the time out as a "time to take a step back and thoughtfully consider the quality measures that we're using."

ACP also identified inconsistencies among organizations in judgments of the validity of physician quality measures. ACP suggests that a single set of standards, such as those developed by the National Academy of Medicine for clinical practice guidelines, would allow others to evaluate the trustworthiness of performance measures before they are launched.

"A possible solution is to have physicians with expertise in clinical medicine and research develop measures using clinically relevant methodology," Ende said. "Performance measures should be fully integrated into care delivery so they can help to address the most pressing performance gaps and direct quality improvement."

"ACP is asking for the next generation of performance measures to be based on high quality methodological rigor, follow uniform standards of measure development integrated into care delivery, and move away from easy-to-obtain data designed for billing and not user friendly when it comes to improving care or filling performance gaps," said MacLean.


MacLean CH, Kerr EA, Qaseem A. Time out—charting a path for improving performance measurement. [published online April 18, 2018]. N Engl J Med. doi: 10.1056/NEJMp1802595.

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