The results of a survey of physicians practices "can be seen as a referendum not just on the current state of quality measurements of physicians, but also of electronic medical records," says the lead study author.
This article was originally published on March 9, 2016.
Physician practices spend more than $15.4 billion each year reporting quality measures that nearly three out of four physicians believe do not reflect the best measures of quality, according to a study this week in Health Affairs.
Researchers from Weill Cornell Medical College and the Medical Group Management Association surveyed 394 physician practices from across the nation found that physicians and their staff averaged 15.1 hours per physician per week processing quality metrics, which is the equivalent of 785.2 hours per physician per year, at an average cost of $40,069 per physician per year.
The survey, funded in large part by The Physicians Foundation, found that physicians spent 2.6 hours per week dealing with quality measures, time that could have been used to provide care for an additional nine patients. The times spent processing data varied greatly depending upon the practice specialty.
Specialists spent considerably less time and money on reporting data when compared with primary care physicians. For example, primary care doctors averaged 3.9 hours per week dealing with quality measures, compared with 1.1 hours for orthopedists, with an average annual cost of $50,468 for PCPs, compared with $31,471 for orthopedists.
"To some extent our survey can be seen as a referendum not just on the current state of quality measurements of physicians, but also of electronic medical records," says study lead author Lawrence Casalino, MD, with the Department of Healthcare Policy and Research at Weill Cornell Medical College. "We are talking about substantial amounts of time—$40,000 per physician per year, almost three hours a week, and a lot more time from staff. That's not trivial."
Casalino spoke with HealthLeaders Media about the survey findings. The following is an edited transcript.
HLM: Why did you do this study?
Casalino: I do a lot of research involving physicians. Having to deal with [quality measures] is one of their chief complaints. There have been a lot of anecdotes, but not much evidence over the years about how much time this is really taking from them. We thought we would take a look at that.
HLM: What are physicians telling you?
Casalino: We had a free text area in the survey where anyone could write what they wanted. Here's one person: 'You get so focused on making sure that you are clicking the right fields in the (electronic medical record) that you lose touch and connection with the patients. It is very sad what medicine has come to.' That's a family practice physician. An orthopedic surgeon wrote: 'The current system for measuring 'quality' is simply a reporting mechanism for documenting check boxes, not really an indication of a person's health.'
HLM: Your survey found that only one-in-four physicians believe that the quality measures moderately or strongly represent quality of care. Please explain that disconnect.
Casalino: The physicians' view is that some of the quality measures record things that are real, but maybe not as important as things that aren't measured. It's like looking for the keys under the lamppost because that's where the light is better. For example, diagnosis, how well a physician does diagnosis is not measured by any quality measure, but that may be the most important single thing a physician does.
Physicians understand that and they respect other physicians who are good diagnosticians. They don't necessarily respect other physicians who remember to check all the right boxes in the EMR.
I don't mean to imply that these quality measures are useless. Diabetics should get annual retinal exams. They should get A1Cs checked regularly. Women should get mammograms. Those things are measured by quality.
But the general physician perception is that only 27% of practices thought the measures were moderately or highly representative of their quality of care. The percentage that actually used the measures to improve quality in their practice was similar.
In the long run, the idea of using systematic processes to improve the health of your entire population of patients in your practice is the right idea. Simply doing the best you can for whatever patient is in front of you while they are in front of you isn't enough anymore. But from the individual physician's point of view they see it as more hassles interfering with their ability to spend time with their patients and an unfunded mandate.
HLM: How do you strike a balance between reporting quality measures and reducing hassles for physician practices?
Casalino: We need better measures and there is a lot of work going on in that area. We need more measures for specialists, because right now the burden is very heavy on the primary care physicians. The measures for specific specialties, there are very few of them.
It'd be nice if these measures evolve so that they better measure quality. Some of the things that might count, such as avoidable readmissions, you can't really measure that at the level of an individual physician.
The numbers of patients aren't large enough to get statistically reliable results. The more meaningful the measure is, the harder it is to do for all but the very largest and really large organizations. That is a real problem. Therefore, the measures tend to be things that you can measure and get statistical reliability. So the measure isn't 5% one year and 80% the next year and 30% the next year for the same physician, which is what can happen if you only have measures for seven patients.
That is a particularly big problem because the [Sustainable Growth Rate] fix mandates value-based payments going down to the level of the individual physician. [The Centers for Medicare & Medicaid Services] is grappling right now with the Congressional mandate to do that, and how they are going to carry that out.
The two biggest things that would help are first of all, standardization of the measures. We didn't go into too much detail in the study, but it just drives practices crazy when you have lots and lots of different measures for diabetes that are almost the same, but not quite coming from different health plans. There is no excuse for that. It just kind of happened, and once it happened there is a cost for everyone to make a change, particularly payers.
The Core Quality Measures Collaborative goal of standardizing measures would be a big help. The other thing that would be a big help is that if EMR are better designed so that quality data could be either sucked out of them by external entities, or easily generated by the practices themselves and easily sent to the external entity.
The more that things can be measured without anyone having to do extra work, the better this will be. But we are a long way from that right now.
HLM: How do you see this playing out over the next five or 10 years?
Casalino: It's hard to predict a timeframe, but eventually we will get to a place where the measures are fairly standardized. And the measures ought to keep getting better and more meaningful, and where it is possible, to get them out of the EMR when it's possible. That is the direction we're moving. The frustration is that there hasn't been a lot of rapid progress with EMRs and measures not being standardized.
In the meantime, if you wanted to dramatize it, a whole generation of physicians is being sacrificed. It's great to measure things. It's great to have EMRs. The reorganization of the healthcare system is by and large a good thing. But for the hundreds of thousands of physicians who have to live through it this is very tough.
For them, it's all burden and no benefit as far as they can see. It's a lot of work that they don't get rewarded for, and they're not convinced that it is making care better for their patients. It's been that way for a while, and it doesn't look like it is going to change soon.
John Commins is a content specialist and online news editor for HealthLeaders, a Simplify Compliance brand.