Without a single playbook to rely on, pay-for-performance programs are not going to work, according to a just-released report from the Institute of Medicine.
The healthcare industry across the board must be using the same tools and procedures, including a universal set of performance measures, in order for pay-for-performance to gain broad success, argues the report, called Performance Measurement: Accelerating Improvement. The nearly 300-page report was released Dec. 1 in Washington.
In addition to standardizing performance measurements, it also calls on the federal government -- and HHS in particular -- to establish a National Quality Coordination Board that would develop a set of standardized performance measures at an initial cost of $200 million.
The board's members would also monitor and oversee quality improvement across the nation's healthcare community. "The fundamental message of this report ... is that performance measurement needs to focus on public goods and national goals as well as specialized concerns in the healthcare system," said Steven Schroeder, distinguished professor of health and healthcare at the University of California at San Francisco and chair of the IOM committee.
The report states that in order for pay-for-performance projects and quality-improvement initiatives to work, there first must be a "coherent, robust, integrated performance-measurement system" to guide the numerous healthcare stakeholders. To do so, the IOM recommends that Congress free up the $200 million in annual funding for the board, which would come from the Medicare Trust Fund.
Elliott Fisher, professor of medicine at Dartmouth Medical School in Hanover, N.H., and a committee member, said that the current system of performance measurement, where only pockets of healthcare organizations participate, is too fragmented to be sustained over the long haul. "The current approach is not likely to get us where we think we need to go," he said.
What's more, Fisher said that the current system, which is largely reliant on volunteer reporting on a disparate set of measures, does little to promote the "broader national goal. They don't have the leadership to formulate such goals." Peter Plantes, vice president of clinical performance at VHA, a network of some 2,400 not-for-profit healthcare organizations, said he agrees with Fisher and the broader work of the IOM committee. Many VHA members cringe at the number of performance-improvement programs out there, especially at the continuously rising costs.
"Not only is it expensive, but it diffuses and defeats the opportunity to come to a focused result," Plantes said. "That's what we like about the establishment of the (National Quality Coordination Board). It would bring focus on a defined set of measures.
Nevertheless, the list of recommended performance measures so closely mirrors those of other programs -- including the Joint Commission on Accreditation of Healthcare Organizations' Oryx core measures and those outlined by the National Quality Forum -- that hospital quality managers will likely balk at the idea of reporting on yet another group of data sets. And even if Congress approves the IOM's recommendations, those other performance improvement initiatives will likely stay.
Moreover, though the report concedes that other performance-measurement programs have been effective in boosting overall quality, it also says that the patchwork of programs already in existence won't translate to the overall national goals for healthcare improvement.
Government agencies such as the CMS and the Agency for Healthcare Research and Quality, as well as private sector groups such as the NQF and the JCAHO, "have made pioneering efforts to move this field forward and to build upon each other's work," Schroeder said. "These efforts are laudable and noteworthy, but they are insufficient to achieve the vision described in the initial Quality Chasm reports."
When asked if that means that the work of those groups would be rendered moot if Congress adopts the IOM's recommendations, Schroeder was quick to say he doesn't think so. Rather, he said, the IOM's recommendations would strengthen and "accelerate the pace of change."
In essence, the IOM report frames the pay-for-performance movement in very much the same light as David Brailer's Office of the National Coordinator for Health Information Technology frames the government's health IT program. How Brailer decries the current state of electronic record systems -- as piecemeal and counterproductive to a nationally linked network -- is how the IOM views the various performance measurement programs that are found across the country.
The report concludes that the development of a National Quality Coordination Board would go a long way in reducing duplication and inconsistencies among those measures, while sealing gaps in the current patchwork of systems such as the capacity to measure equity and access.
Further, national oversight would put performance reporting in a more transparent light, the report states, adding that "the measures developed by most stakeholders reflect the interests of their constituencies (rather) than those of others."
Fisher said that one of the keys to how effective big government's foray into performance measures will be is based largely on how HHS pulls together the quality board. It's an issue the IOM committee didn' take lightly when it developed its slate of four recommendations, he said.
In the report, the IOM states that the board needs to be structurally independent, protected from any undue influence; have contract and standards-setting authority; and also have control over the purse strings to make such decisions viable."The general construct of having federal leadership on performance is imperative and we've needed it for a long time," said Margaret VanAmringe, vice president for public policy and government relations at the JCAHO.
VanAmringe said that having too many performance-measurement programs create confusion. "Sometimes they (performance measures) are competing and sometimes they are almost the same, but almost the same isn't the same as identical."
Performance Measurement: Accelerating Improvement is the first in a series of three congressionally mandated studies, collectively known as the Pathways to Quality Health Care.
Future reports, expected to be released next year, will focus on payment incentive strategies that play off these measures and offer an evaluation of the quality improvement organizations that work under Medicare.