Quality metrics: A payer's persepective

While physicians often complain of the burden that tracking and meeting quality metrics places on them, to commercial insurance companies they are an important tool for helping doctors improve the care they provide patients. 

Richard Salmon, MD, PhD, vice president and national medical executive for performance measurement and improvement with Cigna, says metrics serve a dual role. The first is to provide doctors in pay-for-performance models with actual data showing how they are doing in designated areas of care, rather than relying on impressions.

A doctor might genuinely believe, for example, that he or she orders mammograms for all patients who need them according to the latest guidelines. “Then you provide them with the facts, and they see it’s 75%, not 98% like they thought. So it’s taking the time to provide insight into what’s actually happening, which is really important to start with,” says Salmon.

Cigna’s provider network includes 141 accountable care organizations (ACOs).  

The bonuses Cigna makes available to practices operating under this pay-for-performance model can pay for additional resources the group might need to address shortcomings identified by the application of quality metrics, Salmon says “If as a result of measuring a practice sees that it needs to hire an additional staff person to provide patients the right level of preventive care, it’s helpful to have these reward models that offset that additional cost to the group, and ideally result in the best compensation to the highest-performing providers.”

Salmon says about 72% of Cigna’s ACOs meet all the quality goals the company has established. The company does not currently penalize groups that don’t meet its quality goals.

In developing its pay for performance metrics, Cigna looks for measurements that are “clinically relevant and meaningful,” Salmon explains. In practice, that means measurements that have been endorsed by the National Quality Foundation and come from either the Healthcare Effectiveness Data and Information Set or the Physician’s Quality Reporting System.

The company reviews measures internally, using a team that includes clinicians (physicians and nurses), as well as experts in medical analytics. “The latter group helps us understand what we can meaningfully and accurately measure and how to make sure we’re measuring it correctly,” Salmon explains. The internal recommendations then are reviewed by outside physician advisory groups, for importance and relevance.

Salmon says payers are aware of doctors’ complaints over the burgeoning number of quality metrics and the fact that no two payers use the same metrics when evaluating physicians and practices. To try and address that problem, commercial payers-including Cigna-the Centers for Medicare & Medicaid Services and national physician organizations in 2014 formed the Core Quality Measures Collaborative. The organization says its goal is to develop a set of core measure that all payers can use and that will help achieve the goals of “better care, healthier people and command communities, and more affordable care.”