Physician Performance Measurement and Improvement in The American Medical Accreditation Program (AMAPSM)

Editor’s Notes:The AMAP standards are available by calling the AMAP Resource Center at 1-888-881-AMAP (2627) or visiting the AMAP website at http://www.ama-assn.org/amap

For more information on AMAP Physician Performance Measurement, contact Karen Kmetik, Manager of Clinical Performance and Patient Care Results, 312-464-4221 or karen_kmetik@ama-assn.org.

Introduction

The guiding principle of the American Medical Association (AMA) is to “promote the art and science of medicine and the betterment of public health.” Consistent with this principle, in 1997, the AMA launched the American Medical Accreditation ProgramSM (AMAPSM), in partnership with state and county medical associations and national medical specialty societies, to set standards that can serve as a national benchmark of quality for individual physicians.

Prior to AMAP, no nationally recognized program has existed for individual physician quality accreditation. Typically, physicians, most of whom are associated with multiple health plans and hospitals, underwent fragmented and duplicative processes for credentialing, office site review, and performance measurement. Often, physicians have been evaluated against multiple, and sometimes conflicting, criteria.

AMAP collects, verifies, and consolidates into a single portfolio information on a physician’s credentials, continuing education, and practice site review. The AMAP physician portfolio acts as a single source of comprehensive information which health plans and hospitals can use to make their credentialing decisions—and at a lower cost to plans and hospitals of collecting the information themselves. In addition, in the near future, AMAP will provide to each physician key information on both processes and outcomes of care as a foundation for quality assessment and improvement.

The Five Components of AMAP

AMAP measures and evaluates individual phys- icians against national standards, criteria, and peer performance in five areas:

Credentials
Personal Qualifications
Environment of Care
Clinical Performance
Patient Care Results

At the physician’s request, AMAP sends his/ her portfolio to a plan or hospital. Furthermore, an individual physician who meets or exceeds standards in each of these areas becomes AMAP accredited. For patients and the public, AMAP accreditation is an indicator that a physician meets a new national benchmark of quality.

How AMAP Accreditation Works

1. Physician completes an application for AMAP accreditation one time.

2. AMAP verifies credentials information with primary sources one time.

3. AMAP conducts an office site review one time.

4. AMAP provides a report to each physician who applies and a certificate to each physician who meets or exceeds the AMAP standards.

5. AMAP provides a comprehensive portfolio of individual physician information to health plans, hospitals, or other organizations with which a physician is associated.

AMAP and Physician Performance Measurement

Many health plans and hospitals attempt to profile physicians on the basis of process or outcomes measures, or cost. But each plan or hospital includes in their analysis only their own patients, usually a small fraction of a physician’s total practice. Furthermore, each plan or hospital often defines measures differently or applies different methods of risk adjustment. As a consequence, physicians receive fragmented and confusing feedback on their performance.

Through the Clinical Performance and Patient Care Results components of AMAP, the Program seeks to encourage physicians to participate in clinical performance measurement and improvement activities that promote high quality health care for all patients. Performance measurement is defined as the quantitative assessment of health care processes and outcomes for which an individual physician may be accountable.

Current and Future Standard: The 1998 AMAP standards enable a physician to earn 2 supplemental points toward AMAP accreditation if he/she participates in an ongoing clinical performance measurement system. When physician clinical performance systems are widely available, as described below, this standard will be revised in such a way that physicians must participate in an “AMAP-compatible” system in order to earn supplemental points. When a sufficient number of these systems are widely available, the standard will become a requirement for accreditation. And finally, when the science of performance measurement supports it, the AMAP standard will require physicians to participate in an AMAP-compatible system and demonstrate related clinical quality improvement.

Development Activities: Three parallel activities are ongoing to further develop the Clinical Performance and Patient Care Results components of AMAP.

One activity involves the development of criteria for AMAP-compatible physician performance measurement systems. A physician performance measurement system collects physician-level data on health care processes and outcomes, analyzes the data, and provides feedback reports to physicians that enable a physician to compare his/her performance with that of relevant peers. Systems may be developed by national medical specialty societies, state or county medical societies, healthcare or physician organizations, or other public or private entities.

Two AMAP Advisory Committees are developing the criteria for AMAP-compatible systems. The Performance Measures Advisory Committee (PMAC) includes 16 expert methodologists and physicians with practical experience in performance measurement. The Specialty Advisory Committee (SAC) includes representatives from 30 national medical specialty societies.

A second activity will define AMAP’s attributes for good performance measures and select performance measures for AMAP disease-specific core measurement sets. In time, AMAP-compatible systems will be required to incorporate relevant AMAP core measurement sets into their systems. AMAP will pool data on core measures from participating systems for the purpose of national comparisons and to identify opportunities to re-evaluate and refine clinical practice guidelines and core performance measures. In other words, this activity reflects the quality continuum, whereby clinical practice guidelines, derived from well-designed studies of outcomes and clinical experience, in turn define process and outcomes measures, which themselves may be used in studies that lead to refinements in guidelines.

PMAC and SAC will develop the core measurement sets with input from additional specialty societies who are represented in the AMA House of Delegates. Specialty society input is critical to this activity as these organizations are the profession’s leaders in quality measurement and physician self-assessment. The Committees and AMAP staff are assisted in this effort by the national contractor for the development of the clinical performance component of AMAP, the Iowa Foundation for Medical Care (IFMC). IFMC is the Quality Improvement Organization (or PRO) for Iowa, Nebraska, and Illinois.

The third activity addresses a common criticism of performance measurement activities: measurement requirements are fragmented and costs for data collection and reporting are too high. Together, AMAP, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the National Committee for Quality Assurance (NCQA) will work to coordinate performance measurement activities across the entire health care system. The three organizations have developed a 15-member Performance Measurement Coordinating Council (PMCC). The Council will work to identify and/or develop groups of “universal” measures, whereby data can be collected at the physician level and aggregated to the plan or hospital level for other levels of analyses. This approach promises to minimize the burden of data collection on the physician, plans, and hospitals; reduce overall data collection costs; and provide patients with standardized, credible information. The PMCC held their first meeting in September, 1998.

AMAP Implementation

AMAP is becoming available to physicians on a state-by-state basis. New Jersey is the first AMAP state; over 3,000 physicians from New Jersey have submitted AMAP applications. AMAP began accepting applications from Idaho, Montana, and the District of Columbia this summer, with the intent to roll out AMAP in all fifty states over the next several years.

	November 1998 - Volume 3 - Issue 4 A Publication for Members of Medical Outcomes Trust
				Clinical Practice Applications Physician Performance Measurement and Improvement in The American Medical Accreditation Program (AMAPSM)

				Editor’s Notes:The AMAP standards are available by calling the AMAP Resource Center at 1-888-881-AMAP (2627) or visiting the AMAP website at http://www.ama-assn.org/amap For more information on AMAP Physician Performance Measurement, contact Karen Kmetik, Manager of Clinical Performance and Patient Care Results, 312-464-4221 or karen_kmetik@ama-assn.org. Introduction The guiding principle of the American Medical Association (AMA) is to “promote the art and science of medicine and the betterment of public health.” Consistent with this principle, in 1997, the AMA launched the American Medical Accreditation ProgramSM (AMAPSM), in partnership with state and county medical associations and national medical specialty societies, to set standards that can serve as a national benchmark of quality for individual physicians. Prior to AMAP, no nationally recognized program has existed for individual physician quality accreditation. Typically, physicians, most of whom are associated with multiple health plans and hospitals, underwent fragmented and duplicative processes for credentialing, office site review, and performance measurement. Often, physicians have been evaluated against multiple, and sometimes conflicting, criteria. AMAP collects, verifies, and consolidates into a single portfolio information on a physician’s credentials, continuing education, and practice site review. The AMAP physician portfolio acts as a single source of comprehensive information which health plans and hospitals can use to make their credentialing decisions—and at a lower cost to plans and hospitals of collecting the information themselves. In addition, in the near future, AMAP will provide to each physician key information on both processes and outcomes of care as a foundation for quality assessment and improvement. The Five Components of AMAP AMAP measures and evaluates individual phys- icians against national standards, criteria, and peer performance in five areas: Credentials Personal Qualifications Environment of Care Clinical Performance Patient Care Results At the physician’s request, AMAP sends his/ her portfolio to a plan or hospital. Furthermore, an individual physician who meets or exceeds standards in each of these areas becomes AMAP accredited. For patients and the public, AMAP accreditation is an indicator that a physician meets a new national benchmark of quality. How AMAP Accreditation Works 1. Physician completes an application for AMAP accreditation one time. 2. AMAP verifies credentials information with primary sources one time. 3. AMAP conducts an office site review one time. 4. AMAP provides a report to each physician who applies and a certificate to each physician who meets or exceeds the AMAP standards. 5. AMAP provides a comprehensive portfolio of individual physician information to health plans, hospitals, or other organizations with which a physician is associated. AMAP and Physician Performance Measurement Many health plans and hospitals attempt to profile physicians on the basis of process or outcomes measures, or cost. But each plan or hospital includes in their analysis only their own patients, usually a small fraction of a physician’s total practice. Furthermore, each plan or hospital often defines measures differently or applies different methods of risk adjustment. As a consequence, physicians receive fragmented and confusing feedback on their performance. Through the Clinical Performance and Patient Care Results components of AMAP, the Program seeks to encourage physicians to participate in clinical performance measurement and improvement activities that promote high quality health care for all patients. Performance measurement is defined as the quantitative assessment of health care processes and outcomes for which an individual physician may be accountable. Current and Future Standard: The 1998 AMAP standards enable a physician to earn 2 supplemental points toward AMAP accreditation if he/she participates in an ongoing clinical performance measurement system. When physician clinical performance systems are widely available, as described below, this standard will be revised in such a way that physicians must participate in an “AMAP-compatible” system in order to earn supplemental points. When a sufficient number of these systems are widely available, the standard will become a requirement for accreditation. And finally, when the science of performance measurement supports it, the AMAP standard will require physicians to participate in an AMAP-compatible system and demonstrate related clinical quality improvement. Development Activities: Three parallel activities are ongoing to further develop the Clinical Performance and Patient Care Results components of AMAP. One activity involves the development of criteria for AMAP-compatible physician performance measurement systems. A physician performance measurement system collects physician-level data on health care processes and outcomes, analyzes the data, and provides feedback reports to physicians that enable a physician to compare his/her performance with that of relevant peers. Systems may be developed by national medical specialty societies, state or county medical societies, healthcare or physician organizations, or other public or private entities. Two AMAP Advisory Committees are developing the criteria for AMAP-compatible systems. The Performance Measures Advisory Committee (PMAC) includes 16 expert methodologists and physicians with practical experience in performance measurement. The Specialty Advisory Committee (SAC) includes representatives from 30 national medical specialty societies. A second activity will define AMAP’s attributes for good performance measures and select performance measures for AMAP disease-specific core measurement sets. In time, AMAP-compatible systems will be required to incorporate relevant AMAP core measurement sets into their systems. AMAP will pool data on core measures from participating systems for the purpose of national comparisons and to identify opportunities to re-evaluate and refine clinical practice guidelines and core performance measures. In other words, this activity reflects the quality continuum, whereby clinical practice guidelines, derived from well-designed studies of outcomes and clinical experience, in turn define process and outcomes measures, which themselves may be used in studies that lead to refinements in guidelines. PMAC and SAC will develop the core measurement sets with input from additional specialty societies who are represented in the AMA House of Delegates. Specialty society input is critical to this activity as these organizations are the profession’s leaders in quality measurement and physician self-assessment. The Committees and AMAP staff are assisted in this effort by the national contractor for the development of the clinical performance component of AMAP, the Iowa Foundation for Medical Care (IFMC). IFMC is the Quality Improvement Organization (or PRO) for Iowa, Nebraska, and Illinois. The third activity addresses a common criticism of performance measurement activities: measurement requirements are fragmented and costs for data collection and reporting are too high. Together, AMAP, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the National Committee for Quality Assurance (NCQA) will work to coordinate performance measurement activities across the entire health care system. The three organizations have developed a 15-member Performance Measurement Coordinating Council (PMCC). The Council will work to identify and/or develop groups of “universal” measures, whereby data can be collected at the physician level and aggregated to the plan or hospital level for other levels of analyses. This approach promises to minimize the burden of data collection on the physician, plans, and hospitals; reduce overall data collection costs; and provide patients with standardized, credible information. The PMCC held their first meeting in September, 1998. AMAP Implementation AMAP is becoming available to physicians on a state-by-state basis. New Jersey is the first AMAP state; over 3,000 physicians from New Jersey have submitted AMAP applications. AMAP began accepting applications from Idaho, Montana, and the District of Columbia this summer, with the intent to roll out AMAP in all fifty states over the next several years.