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AQA Invitational Meeting Summary

Keynote Remarks

Carolyn Clancy, Agency for Healthcare Research and Quality (AHRQ)

Carolyn Clancy opened the meeting by relaying several items discussed by the steering committee at its meeting the previous evening. One major issue, she said, is the strong focus on the need for transparency in health care. She noted that the subject was getting attention in terms of both pricing and quality. Having information on quality without information on cost, or vice versa, will not get us to a place where consumers can make informed and good choices, she said.

Because of the focus on addressing both quality and cost, Clancy said that there has been considerable attention on the six AQA pilot projects. These pilots will focus attention on both quality and cost to accelerate the movement toward value. Clancy also noted that questions have been raised about expanding the number of pilot sites and that no decision on this had been made.

Next, Clancy addressed the issue of what the expanding AQA coalition should be called. If we are going to have a cooperative and collaborative effort, she said, we need to make sure we get the name right. She noted that the steering committee struggled with the word ambulatory, especially since surgical specialists and others who do not see themselves as focused on ambulatory care take part. As a result, the steering committee agreed that the coalition should be referred to simply as the AQA.

Taking up the issue of endorsements, Clancy noted that the AQA steering committee had been asked a couple of times about endorsing an activity of another group. The committee agreed that it was not in a position to endorse anything.

Finally, Clancy noted that the steering committee had held a robust discussion—without reaching consensus—on whether the analysis for performance measurement should take place at the level of the individual or the group. She said she suspects this is an issue on everyone's minds, adding that the pilot projects should provide some valuable information to help guide that ultimate decision. Clancy added that consumers and employer groups clearly want information as close to the physician level as possible.

Mark McClellan, Centers for Medicare & Medicaid Services (CMS)

Mark McClellan opened his remarks by noting that the AQA and its workgroups have made tremendous progress and that collaborative efforts are continuing to help identify and support high-quality, low-cost care.

The bulk of McClellan's remarks focused on three areas:

  • Physician voluntary reporting.
  • Cost and efficiency measures.
  • AQA pilot projects.

Regarding physician voluntary reporting, McClellan noted that Centers for Medicare & Medicaid Services (CMS) was committed to getting performance measures into use as quickly as possible to test and evaluate their implementation. He said that his agency's goal was to get 100 physician groups to participate in each of the 10 regions; initial enrollment numbers throughout the country have exceeded expectations.

McClellan explained that CMS was starting with 16 primary care measures. As the AQA adds more measures, CMS wants to incorporate them into its physician voluntary reporting program. The idea is to put measures coming from the AQA into testing as quickly as possible, stressed McClellan, who added that his agency expects to release its first confidential report later this year.

Regarding measures related to cost and efficiency, McClellan said the principles developed by the AQA are likely to be a big help. He specifically cited principles regarding value of care measures. McClellan added that CMS is already examining cost and efficiency measures in its own demonstration projects.

Turning to the AQA pilot projects, McClellan stressed that so much of the work being done is new, more evidence based, and designed to address problems that have challenged the health care system for years. He noted that the pilots would collect information on patient quality, cost of care, patient experience of care, efficiency, and how to get patients the best help at the best cost while avoiding complications.

A key element will be getting real transparency into the health care system, said McClellan, who noted that roadblocks have in the past gotten in the way of getting physicians appropriate pay for delivering high-quality care. He also stressed the need to publish and disseminate information on performance to consumers and the need to then move to payment models that support high-quality care.

We must find ways for consumers to use the information being developed on quality, efficiency, and cost of care, stressed McClellan. He tossed out as an example a Web site where patients could put in information about their health status or a procedure and find out how physicians in their community measured up in the spectrum of care and in communicating with their patients, and whether patients were satisfied with the care and the resources used. We need personally meaningful health care information for consumers, he said, which will then invest consumers in paying for care that is more effective.

McClellan noted excitement around the country about this approach and the opportunity for true transparency. He emphasized that there was a lot of potential for the AQA pilots to work through the challenges related to getting more transparency into the system and in helping consumers and other decision makers use performance measures effectively.

Finally, McClellan touched on two areas where CMS would like to see further work on measurement development:

  • Coordination of care.
  • Post-acute care measurements and instruments.

Regarding coordination of care, McClellan observed that the AQA was blazing a path on rapid, effective consensus-based development and adoption of measures. The aim should be to provide support across the health care system that is coordinated across efforts and across settings of care. McClellan said we need alignment and support to deliver care of the highest quality.

Noting that some of the current approaches have not been fully developed, McClellan said he wanted to see better approaches to care coordination. We will support them, he pledged. McClellan added that it was important to end silos of care and to support measures that involve shared and aligned data in an effort to avoid bounce-backs, complications, and rehospitalizations. To that end, he noted the need to align the efforts of AQA and the Hospital Quality Alliance.

Regarding post-acute care measurements and instruments, McClellan indicated that CMS would be conducting a post-acute care demonstration to evaluate and coordinate post-acute care across multiple settings. Payment systems and the ability to adjust payment and cost vary considerably right now, and CMS wants to do something about that. We want to assess patients at hospital discharge and as they move to post-acute settings, he explained. The idea, said McClellan, is a patient-centric process in which the quality measures follow the patient and not the care setting. What should matter is not where patients go, but rather the care they receive. Using a common instrument will let us evaluate quality and cost of care, regardless of where they go, he added.

Two comments were raised following McClellan's remarks. The first addressed the issue of cost and transparency. Noting that there was a large bureaucracy between himself and his patients, the participant said he was starting to worry that cost was a huge factor and [that people] might be ignoring the issue of quality of care. He said his  patients need to know he is working for them and not saving costs for an insurance company or anyone else, adding that everyone needs to be more sensitive to this issue.

McClellan agreed, noting that the best approach is one that puts quality first. That includes best outcomes at lowest possible cost, he said. He observed that what the participant was seeing in his practice was exactly the reason for this effort: to show people the right way to approach quality (including cost and efficiency) so as not to put physicians in an impossible position where the quality measurement and payment systems don't support efforts to provide best quality care.

The second comment concerned McClellan's remarks about continuity of care, which the participant said she appreciated. She said she thought we can assist in the continuity of care planning so that the primary care physician and the specialist are both involved. In conclusion, McClellan reiterated that the key is what is best for patient outcomes.

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