DECEMBER 17, 2024
The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) reports finding six performance measures that address pain management in adults, but deemed only three as valid for use in national accountability programs (Ann Intern Med 2024 Sep 24. https://doi.org/10.7326/ANNALS-24-00773).
The ACP committee distinguished measures of performance from quality measures, as the former serve to incentivize physicians to improve their performance for reimbursement, whereas the
The Performance Measurement Committee (PMC) of the American College of Physicians (ACP) reports finding six performance measures that address pain management in adults, but deemed only three as valid for use in national accountability programs (Ann Intern Med 2024 Sep 24. https://doi.org/10.7326/ANNALS-24-00773).
The ACP committee distinguished measures of performance from quality measures, as the former serve to incentivize physicians to improve their performance for reimbursement, whereas the latter identify clinical areas for improvement independent of a reporting or payment program. Performance measures also differ from clinical guidelines, the PMC notes, as guidelines allow flexibility in clinician decision-making, whereas performance measures precisely define numerator and denominator from collectible data on treatment.
“Performance measures for assessing care are often tied to financial incentives,” said Caroline Goldzweig, MD, MSHS, the PMC vice chair and chief medical officer of quality and clinical performance at Cedars-Sinai Medical Care Foundation, in Beverly Hills, Calif. “So, to the extent that you know that people are motivated by those financial incentives, they have the potential to drive care and make people focus more on those areas.”
The PMC contrasts the paucity of performance measures for physicians managing pain to the “plethora of performance measures that provide minimal or no value to patient care [that] have inundated physicians, practices and systems with the burden of collecting and reporting data.”
“There is a need for a higher standard for a performance measure when reputation and reimbursement are on the line,” said Amir Qaseem, MD, PhD, MHA, the chief science officer of the ACP and a co-author of the review.
Qaseem and colleagues noted that addressing pain promptly and accurately is vital to improve patient outcomes, but these aspects of treatment are not assessed by most measures. Their review suggests that many measures that pertain to quality of treatment may not be evidence-based, scientifically sound or actionable.
The six performance measures on pain management found relevant to internal medicine were identified by the Centers for Medicare & Medicaid Services Measures Inventory Tool (CMIT), and the consensus-based entity (CBE) website of the National Quality Forum. One assesses the overuse of imaging for low back pain (LBP); four address treatment of pain using opioids; and one evaluates the patient’s experience with the help received for pain.
The PMC supports the following performance measures:
Distinguishing Measures for Physician, Group or Health Plan
In the position paper, the PMC considered whether the three performance measures were implemented at the level of individual physician, group practice or health plan. For the three measures, only attribution at the health plan level was supported by the PMC because the measures were only tested and validated at that level, according to Goldzweig. She further explained that without testing, it is not possible to know whether results would be reliable when measured for individual physicians or groups.
“There are certainly positive aspects of performance measures, but they need to be balanced against the burden that they can pose,” Goldzweig commented. “Those administrative burdens really come when the performance measure itself is driving workflows. That may not be the natural way that physicians practice or document care.
“We’re still a way from having the mechanisms to validate the quality of care taken from, let’s say, just the physician’s progress notes or other means, however,” Goldzweig said. “That is definitely part of the whole performance measurement conundrum.”
The PMC supports “Use of Imaging for Low Back Pain” as a valid performance measure at the health plan level. The measure is based on high-quality evidence that many patients with uncomplicated LBP receive unnecessary imaging studies. The PMC finds the measure includes appropriate exclusion criteria, and can be drawn from health plan claims data across locations.
“Use of Opioids at High Dosage in Persons Without Cancer” is also supported as a performance measure at the health plan level, to contribute to the reduction of unintended consequences of opioid medications. The PMC noted the need to balance providing sufficient opioid medication to relieve pain and enable patients to maintain function while avoiding medication harm.
Although the PMC also supports “Use of Opioids from Multiple Providers in Persons Without Cancer” at the health plan level, it cautions that its application is limited by several factors: electronic health records that do not recognize free text directions, and so do not properly calculate prescribed morphine milligram equivalents; holding physicians accountable for measures of another jurisdiction outside of an integrated health system; or physicians who may come into an area to cover for other physicians while they’re unavailable.
The ACP also develops clinical practice guidelines that, Goldzweig noted, follow from robust reviews of literature. “Clinical guidelines have a role to play because they really can provide, one, the evidence-based intervention; and two, a little more nuance, based on the individual patient situation,” she said.
“The thing that we know about guidelines and about physician practice, though, is that sometimes physicians can be slow to take up new evidence and it’s often hard to operationalize guidelines into our own practice,” Goldzweig said. “So, that’s one reason why performance measures or quality measures have been developed.”
Despite the intent of the ACP position paper, these performance measures may not help physicians provide appropriate and individualized pain management, Charles Argoff, MD, the director of the Comprehensive Pain Center at Albany Medical Center and a professor of neurology at Albany Medical College, in New York, told Pain Medicine News. “They may be based on the best available metrics, but there’s no substitute for individualizing assessment and individualized care.”
Noting that four of the six performance measures identified by the ACP involved the use of opioids for pain, Argoff suggested that these drugs in particular require individualized considerations rather than population-based criteria.
“The complexity of this class of medication and its effects on people beyond pain relief prompt consideration of other medications for pain management whenever possible, but there are individuals for whom these are the only treatments that help them and/or are the treatments that have been shown to be the best for that particular person,” said Argoff, a Pain Medicine News editorial advisory board member. “With data and metrics like these [performance measures], physicians wind up being told they can’t do something for an individual, or of being afraid to do what’s in the best interest of the patient.”
—Kenneth Bender
