"There was a lot of emphasis at first on process measures because they were easier to do, and physicians felt less threatened by that," Bagley says.
"But I think as time has gone on, everyone realizes the process measures, by and large, are most useful at a local level for quality improvement. If we're going to have a major effort to collect, aggregate, analyze and publish measures on a national basis, then it should be around a relatively few patient-oriented outcome measures," he says.
But if CMS starts measuring physician quality based on "what percentage of your patients have a hemoglobin A1c below 7, doctors start to get a little twitch because there's a lot that goes into that, including patients taking their medications, doing exercise, losing weight, and some of these things that are not perceived to be in the control of the physician," Bagley explains.
"Now, instead of just telling patients, 'Just try harder,' it helps to use known techniques to engage patients in their own self care, motivational interviewing, shared goal setting, contact between visits— all those things help patients get better results in the outcome measure," he says.
Payment will no longer be linked exclusively to care provided during an office visit.
I'm wildly speculating here, but imagine how far this might go for, say the doctor with lots of diabetes patients. Down the line, it might mean blood pressure control, a measure of expected-to-actual revascularizations, or even in the very extreme, how many patients with the disease were so poorly managed that they had to undergo an amputation. Or died.
That, of course would be drastic. And no one I've spoken in recent days suspects it will come to that anytime soon.