“To become comfortable with uncertainty is one of the primary goals in the training of a physician.”
This opinion was expressed by the late Sherwin B. Nuland, M.D., in his book The Uncertain Art: Thoughts on a Life in Medicine. It appears that physicians will need to continue to draw on their training, because we are living in times of uncertainty and change.
A study published recently in The New England Journal of Medicine found that of 86 Medicare Merit-based Incentive Payment System (MIPS) Quality Payment Program (QPP) measures focused on ambulatory general internal medicine, 37% were rated valid, 35% not valid, and 28% were of uncertain validity.
Examples of measures that were rated “not valid” in the study included “Pain Assessment and Follow-Up” (MIPS 131/NQF (National Quality Forum) 0420; insufficient evidence; implementation could incentivize opioid over-prescribing) and “Anti-depressant Medication Management” (MIPS 009/NQF 0105; time frame goes against evidence-based recommendations and does not take into account what the patient wants). One that was rated “uncertain validity” was "Chronic Obstructive Pulmonary Disease: Long-Acting Bronchodilator Therapy" (MIPS 052/NQF 0102; unclear evidence and possible flawed testing).
Physicians have reason to be concerned, because the Centers for Medicare & Medicaid Services (CMS) is targeting to include 90% of Medicare-based fee-for-service payments to clinicians by the end of this year, using physician performance scores for "quality" measures. If the study is accurate, performance measurement would thus be based on what appears to be a high proportion of measures of doubtful validity. Critics have pointed out that flaws in these measures could result in harm to patients and could increase operational costs.
It doesn't stop with internal medicine docs either. The National Quality Measures Clearinghouse (NQMC) has inventoried over 2,500 performance measures and is used by insurers, government agencies and independent assessment firms.
The U.S. omnibus appropriations bill, signed into law on March 23, 2018, funds the federal government through the end of fiscal year 2018. The Agency for Healthcare Research and Quality (AHRQ) allocation was increased by $10 million over the previous fiscal year, to $334 million. However, notices on both the National Quality Measures Clearinghouse and the National Guideline Clearing House (NGC) websites (both administered by AHRQ), state that funding was not renewed, and as a result, their respective websites will not be available after July 16, 2018, unless alternative sources of funding are identified.
At this point, it is not clear who will be responsible for carrying on the work of the two clearinghouses. There has been talk of folding AHRQ into the National Institutes of Health (NIH), but that was not part of this year’s appropriations bill.
What is clear is that the financial future of AHRQ is only “settled” through the end of the fiscal year. Uncertainty still surrounds NQMC and NGC, as well as the future of the QPP measures.