Quality measurement programs could shortchange physicians caring for at-risk patients

"Physicians have increasingly become the focus of quality measurement, and many health care systems use quality assessment as part of their recredentialing process," explains Clemens Hong, MD, MPH, MGH Division of General Medicine, the paper's lead author. "Pay-for-performance and public reporting programs based on these measures have become widely adopted approaches, but many physicians are concerned about fairness. For example, if a doctor recommends a colonoscopy for a patient who cannot afford the test because he has no insurance coverage, that physician might be ranked lower than one who cares for a higher percentage of insured patients."

The study analyzed data from 2003 through 2005 reflecting more than 125,000 adult patients cared for by 162 primary care physicians at nine MGH-affiliated practices and four community health centers. After initially ranking all physicians based on nine common quality measures -- such as whether eligible patients received mammograms, Pap smears, colonoscopies and standard monitoring for those with diabetes or cardiovascular disease -- they compared patient characteristics between top- and bottom-tier providers. The researchers then accounted for the full range of patient variables and recalculated the rankings to look how they changed based on those characteristics.

The authors found that primary care physicians whose unadjusted quality rankings placed them in the top tier had patients who tended to be older men with many health problems and frequent visits to the doctor. Top-tier physicians were also less likely to practice in community health centers. Patients of bottom-tier physicians were more likely to be minority, non-English speaking, covered by Medicaid or uninsured, and to live in low-income neighborhoods. But for one third of the physicians, adjusting rankings for patient characteristics led to significant changes in their quality rankings, and further analysis revealed that those whose quality rankings improved after adjustment were more likely to work in community health centers and care for patient panels with greater proportions of underinsured, minority and non-English speaking patients.

"Our health system is under intense pressure to both improve quality and contain costs, and to do that we need to address both how we deliver care and how we pay for it," says Hong, an instructor in Medicine at Harvard Medical School. "Incentive programs that do not address patient differences risk directing resources away from providers caring for these vulnerable patients and worsening health care disparities. We do not want to give a pass to doctors who provide poor care, but we want to make sure that those who provide good care to the most vulnerable patients aren't penalized. Much work needs to be done to design incentive schemes that are fair to all doctors while improving care and reducing disparities for our most vulnerable patients."

Co-authors of the JAMA report are Richard Grant, MD, MPH, senior author, and Steven Atlas, MD, MPH, Yuchiao Chang, PhD, Jeffrey Ashburner, MPH, Michael Barry, MD -- all of the MGH Division of General Medicine -- and S.V. Subramanian, PhD, Harvard School of Public Health. The study was supported by grants from the National Institutes of Health and the Agency for Healthcare Research and Quality.