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Project Combines Medicare, Private Insurer Data to Measure Physician Quality

By John Reichard, CQ HealthBeat Editor

October 3, 2007—Health policy leaders announced a watershed development Wednesday in the effort to compare how doctors stack up against each other—a new program that combines Medicare claims data with commercial health insurers to give a more complete and accurate picture of the quality and cost of care that doctors deliver.

The program aims to address a shortcoming of existing quality measurement efforts: that too often they are based only on limited claims data, not data from the full range of insurers that cover patients treated by an individual doctor or medical practice.

"Data will be aggregated by physicians from many health plans and from Medicare to develop a more comprehensive picture of patterns of care across the physician's entire practice," said the Robert Wood Johnson Foundation (RWJF), which announced $16 million in grants to fund the program for 30 months. "This work represents the first time that data have been aggregated nationally in this way, overcoming one of the major barriers to effective measurement and reporting," the foundation said in a news release.

The data pooling effort builds on the success of the quality improvement movement in developing consensus among doctors, hospitals, consumers and insurers on specific measures of quality. Without agreement on uniform measures, data pooling would not be possible, noted Karen Ignagni, president of America's Health Insurance Plans (AHIP), in a telephone press briefing on the grants. The program will rely on quality measures that already have been vetted by a consensus-setting process led by a public-private organization known as the National Quality Forum (NQF).

However, the project aims to eventually go beyond an initial "starter set" of quality measures, organizers said. It also aims to develop measures allowing consumers to compare providers on the cost of care they provide for 20 common medical conditions, such as diabetes and congestive heart failure. "Measures for cost generally do not exist, but cost information is important for consumers to make good health care decisions," the foundation said. The project will work with the NQF to develop consensus on the cost measures.

The information on how well doctors provide a specific type of care will be distributed through public-private "Value Exchanges" that initially will be established in 20 to 25 communities, said RWJF Senior Vice President John Lumpkin. Doctors will be able to use the data to compare their performance to their peers and to make improvements, project organizers said. Consumers will be able to use it to compare providers, but organizers were vague about how soon the public would be able to compare individual doctors, saying that initial comparisons would be of group practices.

Leaders of the program did not specify what quality measures would be used, but did offer one specific example: a consumer might be able to compare medical practices on how well they control the blood sugar of diabetics and how often they order cholesterol tests to help ward off complications, such as heart disease.

The grants will assist the efforts of the Quality Alliance Steering Committee, which represents a wide range of players in health care and says its mission is to spur the adoption of consistent, clear performance measures across the health care system. The Engelberg Center for Health Care Reform at the Brookings Institution will receive $8.7 million and America's Health Insurance Plans Foundation will receive $4.2 million. Another $3 million in grants will be made to identify cost measures, and to fund other activities.

Leading the program will be Mark B. McClellan, the head of the Engelberg Center and the former administrator of the Centers for Medicare and Medicaid Services. McClellan emphasized that the data also will be used to reduce disparities in the quality of health care based on race and ethnicity. "We're seeing big differences in quality of care across racial and ethnic groups," McClellan said. "A critical aspect of this project will include identification and measurement of these gaps in order to help practitioners develop specific interventions that attempt to minimize these differences," the foundation noted in its news release.

Project participants said the data-pooling effort and the chartering of Value Exchanges will start this year. All aspects of the project—gathering data on measures, reporting it to doctors and consumers through Value Exchanges, developing cost measures and analyzing disparities—will be completed by 2010, they said.

Ignagni described the new program as "transformational," and having McClellan, with his top-level connections, in charge means it will get high-level attention from major players. But organizers said the program is not mandatory. Asked whether a group practice could arrange to exclude its claims data from the data-pooling project, Carolyn Clancy, who co-chairs the Quality Alliance Steering Committee with McClellan, said that at bottom, the program is voluntary. But she also noted the possibility that payers will pay doctors lower rates if they don't submit the data.

Clancy, who heads the Agency for Healthcare Research and Quality, indicated that doctors are likely to take part and predicted a big payoff from the program. "By bringing all stakeholders in the health care system together, this new project is an important step in accelerating the current slow pace of improvement in health care quality," she said.
The Centers for Medicare and Medicaid Services has issued a statement clarifying how its data will be pooled with that of private insurers in a new program, funded by the Robert Wood Johnson Foundation, to compare the quality of care at individual medical practices.

Organizers of the program, which includes grants to the Engelberg Center for Health Reform at the Brookings Institution and to a foundation sponsored by America's Health Insurance Plans, said the comparisons will be based on medical claims data and be distributed publicly through "community values exchanges" in selected communities.

CMS Spokesman Jeff Nelligan said CMS will not provide Medicare claims data to the value exchanges, the Engelberg Center or AHIP. Rather, CMS will calculate quality comparisons based on Medicare claims and the value exchanges will be able to combine those results with results based on private sector claims to produce "all-payer performance results," Nelligan said. He added that CMS is not currently providing any data on cost comparisons to the value exchanges or to the Engelberg Center.

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