Daniel L. Dunn

Bio: Daniel L. Dunn is an academic researcher. The author has contributed to research in topics: Quality management. The author has an hindex of 1, co-authored 1 publications receiving 114 citations.

Benchmarking Physician Performance: Reliability of Individual and Composite Measures

Abstract: Measuring physician performance is becoming commonplace as health plans and purchasers look for ways to drive quality improvement and to increase physicians' accountability and rewards for achieving quality goals. A recent study1 reported that, among 89% of health maintenance organization plans using physician-oriented pay-for-performance programs, more than one-third measured and rewarded quality at the individual physician level. In addition, public and private purchasers are demanding more information about America's physicians and hospitals to aid in value-based purchasing and selection of health plans and providers.2 However, concerns remain regarding the validity and reliability of such physician performance profiles. Several factors are needed to support fair and accurate comparisons among physicians. These include evidence-based quality measures, complete and accurate data sources, and standardized methods of data collection. Physician-level reliability of a quality measure is another key consideration in this measurement. Physician-level reliability refers to the ability of a quality measure to distinguish an individual physician's performance from the performance of physicians overall. Good physician-level reliability requires the following 2 factors: (1) a sufficient number of patients eligible for a given quality measure and (2) performance variation across physicians on that quality measure.3-5 The greater the number of a physician's patients who are eligible for a quality measure, the more precise the estimate of the physician's performance. When performance variation for a given quality measure across physicians is limited, the likelihood that a physician's performance is statistically significantly different from that of his or her peers is also decreased. Hofer and colleagues6 showed that not controlling for a quality measure's physician-level reliability significantly misrepresented performance differences across physicians. However, adjusting performance profiles in such a manner is not commonplace across the healthcare industry. Ensuring that measurement results are valid and reliable is important when purchasers and plans (and potentially consumers) use the data to make decisions about which physicians get financial rewards or other benefits. The stakes are particularly high when profiling results are used for public reporting or eligibility for participation in a health plan network. Paying attention to the validity and reliability of data will help to ensure that these decisions are based on real differences in performance among physicians rather than any shortcomings of the measurement. Although performance results based on limited sample sizes could be adjusted for the reliability of individual measures,7-9 the creation of composite scores may also be a useful way to increase the reliability of physicians' performance scores.10 Little is known about the extent to which constructing composite scores mitigates the limitations of sample size and reliability, while continuing to provide useful and understandable information.11 To date, there have been few reports regarding the reliability of physician-level performance scores associated with commonly used practices and methods in the healthcare industry. To begin to address this deficiency, this study relied on a large data set that combined patient-level administrative data from 9 large health plans to compute performance for primary care physicians (PCPs) using 27 commonly measured quality indicators. This data set is typical of data sources often used by individual health plans to profile physician performance. Specifically, we examined for each quality measure and composite score the proportion of PCPs who could be evaluated given different minimum sample size criteria and the physician-level reliability under those minimum sample size criteria. Our primary research questions were the following: (1) What is the physician-level reliability of commonly used performance measures calculated exclusively based on administrative data? (2) Can more physicians be reliably evaluated using a composite score?

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America

Abstract: America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost.The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances.About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.

Physician Cost Profiling — Reliability and Risk of Misclassification

Abstract: BACKGROUND Insurance products with incentives for patients to choose physicians classified as offering lower-cost care on the basis of cost-profiling tools are increasingly common. However, no rigorous evaluation has been undertaken to determine whether these tools can accurately distinguish higher-cost physicians from lower-cost physicians. METHODS We aggregated claims data for the years 2004 and 2005 from four health plans in Massachusetts. We used commercial software to construct clinically homogeneous episodes of care (e.g., treatment of diabetes, heart attack, or urinary tract infection), assigned each episode to a physician, and created a summary profile of resource use (i.e., cost) for each physician on the basis of all assigned episodes. We estimated the reliability (signal-to-noise ratio) of each physician’s cost-profile score on a scale of 0 to 1, with 0 indicating that all differences in physicians’ cost profiles are due to a lack of precision in the measure (noise) and 1 indicating that all differences are due to real variation in costs of services (signal). We used the reliability results to estimate the proportion of physicians in each specialty whose cost performance would be classified inaccurately in a two-tiered insurance product in which the physicians with cost profiles in the lowest quartile were labeled as “lower cost.” RESULTS Median reliabilities ranged from 0.05 for vascular surgery to 0.79 for gastroenterology and otolaryngology. Overall, 59% of physicians had cost-profile scores with reliabilities of less than 0.70, a commonly used marker of suboptimal reliability. Using our reliability results, we estimated that 22% of physicians would be misclassified in a two-tiered system. CONCLUSIONS Current methods for profiling physicians with respect to costs of services may produce misleading results.

Key issues in the design of pay for performance programs

Abstract: Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages “selection” and “teaching to the test” should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally “decoupled” form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.

Pay for Performance in Health Care: An International Overview of Initiatives

Abstract: Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.

Vital Signs: Core Metrics for Health and Health Care Progress

Abstract: Thousands of measures are in use today to assess health and health care in the United States. Although many of these measures provide useful information, their usefulness in either gauging or guiding performance improvement in health and health care is seriously limited by their sheer number, as well as their lack of consistency, compatibility, reliability, focus, and organization. To achieve better health at lower cost, all stakeholders-including health professionals, payers, policy makers, and members of the public-must be alert to what matters most. What are the core measures that will yield the clearest understanding and focus on better health and well-being for Americans? Vital Signs explores the most important issues-healthier people, better quality care, affordable care, and engaged individuals and communities-and specifies a streamlined set of 15 core measures. These measures, if standardized and applied at national, state, local, and institutional levels across the country, will transform the effectiveness, efficiency, and burden of health measurement and help accelerate focus and progress on our highest health priorities. Vital Signs also describes the leadership and activities necessary to refine, apply, maintain, and revise the measures over time, as well as how they can improve the focus and utility of measures outside the core set.If health care is to become more effective and more efficient, sharper attention is required on the elements most important to health and health care. Vital Signs lays the groundwork for the adoption of core measures that, if systematically applied, will yield better health at a lower cost for all Americans.