Accountability measures tied to funding must be based on process, not outcome

Most reasonable primary care physicians would agree that as we strive to provide high-quality care to our patients, certain performance measures should be evaluated and that tying performance to specific funding is not an unreasonable proposal. This is certainly a hot-button topic in Ontario, with a government moving forward with primary care reform, yet no clearly articulated vision for how to connect performance and funding most efficiently.

Any discussion about primary care performance measures must start with the terrific document that Health Quality Ontario unveiled in fall 2014, A Primary Care Performance Measurement Framework for Ontario. Over 100 stakeholders from across the Ontario primary care spectrum collaborated to create this document which outlines 112 practice-level and 179 system-level measures. This is as thorough a document as you will see on the topic, and is a must-read for anyone with any interest in performance and quality in primary care.

Part of my disappointment with the proposed New Grad Entry Program was that of all of the available performance measures that the ministry could tie to funding, they chose three highly flawed measures. Percentage of patients with same day/next day appointments is a laudable goal, but is prone to reporting bias and may miss other forms of access provided. Preventative care targets provide a perverse disincentive for physicians to take on complex patients who are unlikely to complete screening measures. And patient experience surveys…c’mon now.

We can do better. We can take the work done by HQO and create a set of measures that primary care physicians agree have value, and should be tied to funding. With one small caveat.

We should always reward the process, not the outcome.

Here’s an example. The ministry wants colorectal screening to be maximized, and provides financial incentives based on the percentage of completed fecal occult testing. I am fortunate that I have a motivated patient population, and consistently meet the maximum targets. But what about a physician serving immigrant or homeless populations, who may find it impossible to meet the ministry targets? Should we not reward the fact that the physician discussed and offered colorectal screening, rather than the completion?

This same argument can be made to any proposed intervention and measure. Reward the process. Make the measures self-report. Allow for external auditing with an agreed-upon process to ensure honesty. And set the bar high for the targets.

Pap smears, colorectal screening, breast screening, flu shots, and childhood immunizations. Set the bar at 95% for offering the intervention to all patients. Meet the standard, get the money. Don’t meet the standard, get nothing.

I’ll add a few other measures I see as useful to tie to chunks of funding. Offering a yearly medication review to those over 65. Offering a periodic health review to all patients once a year (can be part of regular visit) where BP and weight are done, with an update of medications, immunizations, screening, family history, social history and other recent changes in health. If a patient refuses to come in, that’s fine, but it was offered, and that’s what is measured. Offering pneumococcal vaccination to targeted populations. Offering appropriately timed visits to those with diabetes and COPD. Offering statins when appropriately. Again, never rewarding whether the patient took the statin or not, because that financial incentive will result in coercive, non-patient-centred medicine. And of course, tying certain funding to participation in EMR Maturity Model & Reporting.

The ministry is quite fond of 30-day re-admission numbers and primary care follow-up visits within 7 days. What they fail to understand is that whether my patient is readmitted to hospital is largely out of my hands. We are largely helpless to the ultimate outcome. But again, could we reward the process instead? Incentivize a mandatory medication review following discharge, and rather than continue the E080 code, make it a tracking code that measures any contact (phone or in person) in the 7 days following hospital discharge. Many physicians object to mandatory visits within 7 days of discharge (eg. they were the admitting physician in hospital, or the diagnosis does not require follow-up), but this simple change to the E080 would be a compromise.

I would argue that the measures in the HQO report related to patient-centredness are best addressed by providing the physician-level data privately, with no ties to funding, with physicians having the ability to reflect personally on their opportunities for improvement in their practice.

As for tying access to funding…that’s the million dollar question that I won’t pretend to have the answer to. We need to continue to have open discussions about what access should look like, how it should be measured, and how culpable physicians should be for patient demand.

Physicians would be happy to be accountable to certain primary care measures. But judge us on what we can control, and primary care physicians will rise to the occasion.

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