Lauren Silver HPM564: Health Outcomes 10-22-2009

Miller TP, Brennan TA, Milstein A. How can we make more progress in measuring physicians'
performance to improve the value of care? Health Affairs. !!" #ep$%ct&'()*+,-"$./.
0n1erstan1ing of the pro2lem+ 3hy measure in1ivi1ual physicians4 performance? As health care
spending continues to rise in the U.S.far outranking all other member countries in the OECD in per capita
spending and in terms of the share of total GDParious stakeholders are placing a greater emphasis on
achieing higher !ualit" care and improed health outcomes at a lo#er cost. $an" hospitals and other large
health care organi%ations hae implemented !ualit" improement initiaties to measure and track s"stem&
#ide performance' ho#eer' fe#er initiaties hae focused on measuring the performance of indiidual
ph"sicians. (" #a" of e)ample' onl" one in fie large emplo"er health plans offer enrollees !ualit" and cost
information on indiidual ph"sicians. *he stakeholders' or consumers of ph"sician performance information'
include+
patients ,choosing a proider-.
emplo"ers' the federal goernment' and indiiduals ,choosing among insurance options-.
insurers ,placing proiders #ithin particular net#orks/tiers of coerage based on performance-.
primar" care proiders and other ph"sicians ,referring patients-. and
medical group practices' hospitals' and other organi%ations ,re#arding high&performing ph"sicians-.
Deeloping more accurate information about the effectieness and efficienc" of care proided b" ph"sicians
could help enhance the alue of care b"+ 0- disseminating this information ia a public reporting s"stem that
#ould encourage pa"ers and patients to seek out high performers' and 1- creating peer pressure and financial
incenties ,e.g.' pa" for performance- to stimulate proider bu"&in.

Measuring in1ivi1ual physician performance+ 5elevance to health outcomes. 2*o actuall" hae an
impact on the delier" of care' the researcher must be able to persuade the medical care communit" that the
3health outcomes4 findings trul" reflect realit"' rather than simpl" being a theoretical abstraction5 ,6ane' p.
078-. *hus' progress in measuring ph"sicians9 performance to improe the delier" of care and' ultimatel"' to
achiee better health outcomes re!uires that stakeholders and decision&makers first address a number of
barriers.
Pleasing all players. Patients' pa"ers' and ph"sicians e)pect that different leels of methodological rigor
#ill be met #hen reporting on the performance of indiidual ph"sicians. Patients and pa"ers ma" be
more likel" to accept less scientific ratings of proiders #hile ph"sicians demand robust statistical
approaches. Stakeholders #ill need to find a middle ground #ith regard to measurement precision in
order to achiee sufficient bu"&in for performance measurement initiaties.
%vercoming 1ata limitations. Gien the slo# and limited adoption of electronic health records b"
indiidual ph"sicians' administratie data ,i.e.' claims billing data- remains the richest and most easil"
accessible source of information aailable on the performance of ph"sicians. $easurement' therefore' is
limited to data re!uired for billing as opposed to data collected for more clinical purposes. :n addition'
small sample si%es of particular episodes of care managed b" indiidual ph"sicians hamper meaningful
anal"ses. E)panding re!uirements for billing data ,e.g.' numerical laborator" results- and making
aailable $edicare claims data to combine #ith priate health plan data hae been suggested as
strategies for oercoming these challenges.
%vercoming measurement limitations. *here is concern' particularl" on the part of ph"sicians' that
current measurement methods do not accuratel" attribute episodes of care to indiidual proiders #hen
patients hae had encounters #ith multiple ph"sicians across multiple settings. Also' current seerit"&of&
illness and other risk&ad;ustment methods leae man" critics skeptical that differences in the case mi)
from one ph"sician to the ne)t hae been sufficientl" controlled for. Proponents of measuring ph"sician
performance adocate a 2best aailable5 measurement approach in #hich appl"ing current methods is
Lauren Silver HPM564: Health Outcomes 10-22-2009
preferable to 2remaining in the dark about performance ariation5 until more rigorous statistical
approaches can be used.