With healthcare reform and the move to value-based reimbursement from both governmental and non-governmental payers, health systems across the country have been shifting their employed physician compensation models from purely production-based to a combination of productivity and quality incentives.

Standardized quality measurements have developed over the past 25 years through accreditation entities such as National Committee for Quality Assurance (NCQA) and Healthcare Effectiveness Data and Information Set (HEDIS). In response, many commercial payers have developed physician ‘report cards’ based on quality outcomes for carrier-specific beneficiaries. But the most notable focus on individual physician measurement of care quality has been CMS’s implementation of the Physician Quality Reporting Initiative (PQRI) launched back in 2006, followed by the Physician Quality Reporting System (PQRS) currently in effect.

Financial disincentives for failure to report PQRS data to CMS beginning in 2015 have compelled physician practices to develop and implement systems for the accurate capture and reporting of quality measures for their clinic patients. This introduction of CMS PQRI/PQRS initiatives has facilitated the tracking and implementation of certain quality indicator parameters in employed physician contracts. Though PQRS is pay-for-reporting, not pay-for-performance, health systems can adapt the published data into a program of thresholds and parameters for payment of quality incentives in the physician contracts. PQRS Measures #1 and #2 are two of the most common examples:

PQRS #1 – Diabetes: Hemoglobin A1c Poor Control: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.

PQRS #2 – Diabetes: Low Density Lipoprotein (LDL-C) Control (<100 mg/dL): Percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dL) during the measurement period.

Although these measures are focused on patient outcomes, many organizations may choose to adapt such measures to focus on the process of care. PQRS #1 could, for example, be adapted to focus on the percentage of patients who had Hemoglobin A1c testing within the past year. NCQA benchmark data can then be used to establish the compliance percentages and percentiles that trigger the physician “passing” the quality indicator.

The quality bonus pool can also be staged (example: less than 85 percent patient compliance pays 0 percent quality bonus, 85-90 percent patient compliance triggers payment of 50 percent quality bonus, greater than 90 percent patient compliance triggers payment of 100 percent quality bonus).

Depending on the establishment and progression of best practices in your clinics, you may also elect to alter the thresholds from contract year to contract year. For instance, the D5 lists a goal of maintaining an HgA1c at less than 8 percent as a best practice.

After the first contract year, it’s appropriate to move into qualitative measures. A non-clinical quality measure that can easily be implemented in primary care physician contracts is Patient Satisfaction. Most hospital health systems already routinely survey clinic patients regarding their satisfaction with their overall experience. There are also questions that specifically address the provider who treated them and the care they received. By extrapolating answers to specific provider-oriented questions and setting assertive thresholds, a portion of the quality bonus pool can be tied to the provider exceeding the threshold for patient satisfaction with care received.

Remember, whatever the source or description used for the quality measures in a physician employment contract, it is critically important that the measures are understood by both parties. The time period and frequency for measuring the quality indicators must be spelled out in clear terms. The data must be shared with physicians on a timely basis, so that they know exactly where they stand related to the thresholds. In the spirit of transparency, it’s also a good practice to share performance results so each physician can see how they’re doing compared to their peers. Finally, and most importantly, ensure that there are processes in place to use the data obtained from the quality measures to make changes in the practice to further improve the delivery of care to patients.

Terrence R. McWilliams, MD, FAAFP

Chief Clinical Officer and Managing Director, Employed Provider Networks