I'm concerned about the set of assumptions behind HEDIS and “set of biometrics” as overarching understanding of office practice/PCP performance. No question that many insurers and even employers ask for HEDIS measures – they have nothing else to go with at this point. That doesn’t mean that HEDIS tells us what we need and want to know.
There is some concern that HEDIS is not so much an evidence based engine. Example: the goal of “HBA1c less than 7” has been taken up as an issue that highlights the lack of transparency in measure development, raising the spectre of political and not evidence based approach to measure creation.
Aron D, Pogach L. Transparency Standards for Diabetes Performance Measures JAMA 301(2) pp 210-212
We need the ability to track metrics so that we can find patient gaps in care and address them – including those patients who fail to follow up. Biometrics is one approach with which we are familiar. Registry as “database of biometrics” is familiar to many. Registry as “database of indicators with profound effect on patient health trajectory” is another. There is often divergence between these two approaches. The latter is more pointed in finding patients at risk than the former. There is immense overlap and I’m not making an ‘either/or’ case here.
Understanding practice performance is another issue. We need some way to find - in our practices - systems that help or hinder our work for our patients. Barriers to access, wasted time, effective communication, effective self management support (confidence) – these are the systems we create to help our patients.
HBA1c less than 7 is what we hope to help them achieve (when clinically appropriate). A1c is a proxy for measures around access, communication, etc – the core systems of effective primary care. Because of all the other variables that effect A1c it is in fact a weak proxy for the work we do.
It is not wrong or inappropriate to measure A1c and to have systems that help us track it and reach out to those with A1c at unhealthy levels. I am proposing that it is wrong to use a weak proxy measure when so much more powerful measures exist – measures that tell us when the pillars of effective primary care are weak and need to be shored up.
So the fact that insurers and P4P are going down the wrong track is concerning to me. I know we have to live with their rules for now as they make the rules and their rules dictate payment, but we must also stand up to those rules when the rules are wrong and make the case for new rules based in evidence and aligned with supporting effective primary care.
L Gordon Moore MD