Physician Accountability and Quality: A Brave New World

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Ready or not, the landscape for physicians is drastically changing. New rules will be driving reimbursement, continuing education, credentialing, and licensure. Some changes, such as those that assess and incentivize physicians' “quality” of health-care delivery (ie, process measurements and pay for performance), are already in play. There have been arguments that these so-called quality measures are no more than a veiled attempt at physician profiling and cost containment, rather than a movement to improve health-care delivery and minimize medical errors. Regardless of one's perspective, the train has left the station and it is accelerating.

But it's not all about money. As the proponents of change declare, for physicians to deliver higher quality care, they must maintain more rigorous standards of continuous self-assessment. For example, Maintenance of Certification, which impacts many AAPM&R members, emphasizes the need to sustain more focused and practice-based, career-long learning. Although the measures and methods of defining continuous learning are currently in flux, the theme that underscores this process is evidence-based information. This is becoming the new model of enhancing quality health-care delivery—using best evidence to improve practice performance and patient outcomes. Of course, this same evidence that drives physician behavior modification also serves as the measure of such change. In other words, physicians will be rewarded for practicing evidence-based medicine and penalized for not.

In this issue of PM&R, I present 2 articles that speak to various aspects of this metamorphosis. First is an Invited Perspective from Mark Rattray, MD. Dr. Rattray is an obstetrician/gynecologist by training, a former national medical director of a major health insurance company, and the founder and president of CareVariance, LLC. He addresses the current movement toward so-called value-based reimbursement and identifies the challenges in defining “value,” the various stakeholders in play, and the economic impact on both physicians individually and the field of physiatry as a whole. You may be surprised to learn that physiatry may be better positioned for this change than other specialties. The second piece is a special report from AAPM&R that discusses the noneconomic consequences of the move toward enhancing quality care, including the direct impact on how physicians obtain continuing education credits, and the impact on how physicians are credentialed and certified at national board and state levels. It will likely be mandated that physicians will need to demonstrate quality performance through more pertinent self-assessment examinations and will also need to demonstrate improvement in patient outcomes. The common thread (and challenge) weaving through both the economic and noneconomic impact of these changes will be the measurement of “quality,” likely to be judged against any existing guidelines that have been developed using evidence-based medicine.

So why might physiatry be well situated in this transition? Historically, payers have viewed PM&R as a low priority specialty, as physiatric care has been generally considered a cost-effective alternative to more expensive interventions. And although all medical specialties can expect a much greater degree of scrutiny in the future, physiatry has already placed a stake in the ground. For example, physiatrists have already demonstrated an expertise in specific clinical areas such as managing low back pain and stroke, and may be assigned primary responsibility for episodes of care in some of these newly conceived health-care delivery models. There will of course be comparisons to peers both regionally and nationally, but PM&R may be positioned to set the standard in certain areas.

Further, functional measures regarding patient outcome may become a metric in assessing quality care. Functional measurement and assessment is universally woven into the fabric of physiatric practice. In addition, measurement of patients' experience with health-care providers may also be ready for prime time. Proponents claim that outcome measures should be consumer (ie, patient)-oriented to be fully meaningful. Of course, these measures would need to be validated and standardized, but the tenets of patient-centered physiatric care should be favorable if such measures are instituted. Such patient-based experiential measures can also adjust for outcomes based on certain differences in patient characteristics (eg, chronicity of health condition), thereby leveling the playing field when comparing physiatric outcomes with those of other specialties.

Finally, the following are the steps that AAPM&R can take to support its members in this process:

Physician accountability and quality—it's a brave new world. Like all physicians, physiatrists will be subject to new rules regarding recertification and licensure, but physiatrists may be uniquely positioned to both influence and successfully maneuver through the changing landscape of quality outcome measures. There will undoubtedly be increasing scrutiny from the government, payers, employers, and patient-consumer groups. But with challenges come opportunities. Get ready; this is going to be a big one!

• † Disclosure: nothing to disclose