In the Journal of General Internal Medicine, Tufts University professor Michele Esposito and colleagues question the utility—and in some cases safety—of applying quality measures to pay-for-performance agreements. Medicare has a goal of 30 percent of its payments being value-based by 2016 and 50 percent by 2018. But some of the measures it’s counting on for pay-for-value, such as 30-day readmission rates, are problematic. One recent study, the authors note, has shown that “Large teaching hospitals and safety-net hospitals are most likely to be penalized, suggesting that higher readmission rates might be due to lower socioeconomic status and greater case complexity.” Another study showing 25 percent of patients admitted for heart failure return to the hospital in the 30-day window, yet it is unclear whether they were admitted for reasons beyond their control.

“Future QMs need to be evaluated in a more rigorous and evidence-based manner,” the authors wrote. “With the initiation of value-based purchasing as part of the new ACA standards, a greater number of QMs will now be proposed and marketed on a national platform and will require constant vigilant examination. To reduce the burden of unsafe practice, QMs must be subject to stringent scientific scrutiny, and hence must allow for peer-reviewed pay-for-performance (PR-P4P).”

Our Take: In a recent interview with the CMO of a large integrated health system, we were told that they were currently tracking 208 quality metrics for the health system and three accountable care agreements. She was clearly frustrated that the commercial ACOs had complicated matters by having subtle variations on the metrics compared to what they already had in place with their Medicare ACO.

Guidelines arise from consensus, and metrics are derived from guidelines. The authors’ point here is an important one: “Clinicians may prematurely endorse and propagate new guidelines based on “consensus validity,” when the consensus process itself—sometimes at the expense of other, more relevant criteria—determines the content and/or adoption of new guidelines.” Rarely do we hear such an impassioned case for random, controlled trials as the means to develop and codify guidelines.

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