How do you judge physician quality? Does the AMA have the answer?

Critics call accreditation standards too soft

What defines a good physician — and how can you measure it? That question could be debated endlessly, but nonetheless, the Chicago-based American Medical Association (AMA) is forging ahead with its own definition of physician quality and a seal of approval to go with it. Even while the AMA touts its gold standard, others criticize it as a hollow, marketing-driven effort.

The true test will come in New Jersey and Massachusetts, the first states where physicians are vying for the accolade of the American Medical Accreditation Program (AMAP). Other states will follow gradually as logistical details are worked out.

Marketing is clearly a primary motive for AMAP accreditation. It is designed for the managed care era, in which health plans seek easier ways to credential and rate physicians and physicians, in turn, hope to distinguish themselves and obtain better contracts.

The AMA says it is also answering the demand for quality indicators on individual physicians. Until now, accreditation efforts have focused on medical groups or health plans.

Yet even before AMAP takes its first application, it faces criticism that the standards are too low. More fundamentally, critics question whether the AMA can judge its own constituents.

"You would not want the airline pilots association setting standards for pilots; you’d want the Federal Aviation Administration to do it," says Jerome Kassirer, MD, editor in chief of the New England Journal of Medicine. In a July 6 editorial, Kassirer called for the AMA to release the program to an independent board.

William Jessee, MD, the AMA’s vice president for quality and managed care, notes that the AMAP governing board includes hospital, consumer, and employer representatives, among others. And he insists that AMAP will be rigorous. "There are a lot of physicians who are not going to be able to pass these standards," he says. "We would invite anyone who doesn’t think these are stringent standards to volunteer to go through the process."

A tough site review

An AMAP survey was much more than a simplistic exercise, says practice administratorLisa Cane. As part of field testing, two AMAP nurse-reviewers and two AMAP project managers visited her practice, Women’s Health Care in West Newbury, MA.

The reviewers spent more than an hour on chart review alone, pulling a sample of charts and looking at every page for such items as proper patient identification, provider signatures, and appropriateness of diagnosis or referral.

"They looked at test results to make sure the provider signed off, acknowledging that [the results were] actually seen," Cane says. "They looked for an indication that there had been patient education. They were hoping to find problem lists, medication lists, preventive medicine tracking, allergies indicated both inside and on the front of the chart."

Then the reviewers asked for various written policies and procedures, such as nurse triage protocols for the relaying of messages from patients to physicians and guidelines defining urgent vs. emergency care. They wanted to know how the staff scheduled appointments and how they handled hazardous material.

While Cane’s practice did well, there were some policies and procedures she couldn’t immediately locate. And she changed one procedure because of the site review. "They asked us whether or not we did spore testing on our autoclaves to ensure we are really killing any microorganisms," Cane says. "We didn’t do that, but we do now.

"They went much further into the way my office is run than the managed care plans currently do," says Cane. "It was good for me to get feedback on what I could improve upon."

Relief from multiple asessments

The essence of AMAP is to provide a single credentialing chart and site review, supplanting the multiple, burdensome, and sometimes conflicting reviews of various health plans.

Initially, AMAP focuses on a paperwork review of doctors’ credentials and education plus the site visit of the "environment of care." For example, physicians must have no reported ethics violations and must have completed 100 hours of continuing medical education in the past two years. Physicians do not have to have board certification. (For a list of requirements, see box, p. 99.)

After July 1998, AMAP will require physicians to conduct a self-assessment using an approved tool. By 1999, all AMAP physicians will conduct patient satisfaction surveys and collect clinical performance data.

Eventually, Jessee says, AMAP will collect a set of measures that can be compared against a national benchmark. Currently, participation in a performance assessment system meets one supplemental standard toward accreditation. AMAP physicians are required to comply with 11 of 22 supplemental standards.

Jessee predicts that physicians will seek the chance to be recognized by their peers, and the public will also appreciate having a quality gauge of physicians.

"When our first certificates come out, we’ll be blitzing the airwaves advising consumers to look for the AMA seal of approval," he says. "Good Housekeeping is exactly the prototype we have in mind."

But in his editorial in the New England Journal of Medicine,1 Kassirer called the AMAP standards too low. He wondered whether physicians without board certification might seek accreditation as an apparent substitute when marketing themselves to health plans and the public.

Kassirer also urged the AMA to turn over the accreditation program to an independent governing body. (Currently, AMAP’s governing body includes AMA and medical society representatives, as well as individuals representing hospitals, managed care, other accrediting bodies, employers, and consumers. Several physicians are also on the board.)

"I was concerned that a membership organization shouldn’t be setting standards for its own members," Kassirer told Patient Satisfaction & Outcomes Management.

Facing the critics

AMAP organizers acknowledge that it will take several years for the standards to fully evolve, incorporating clinical performance measurement. They note that there is no other program that provides a comprehensive review of individual physicians.

Moreover, physicians — not health plans, employer groups, or others — should be setting the standards for their profession, argues Joseph Heyman, MD, FACOG. Heyman is an obstetrician/gynecologist in West Newbury, MA, and state society representative to the governing board of AMAP. In fact, AMAP standards are much tougher than those currently imposed by the National Committee for Quality Assurance in Washington, DC, which accredits health plans, he says.

Although a list of AMAP accredited physicians will be available to the public, AMAP is actually targeted at the managed care community and health care purchasers. Jessee says he hopes the public eventually will seek physicians who are both accredited and board certified, with each designation as an indicator of different aspects of physician training and quality.

Assuming that health plans accept AMAP accreditation and pay to receive the accreditation reports, AMAP physicians would face only a single review rather than a barrage of inquiries, Heyman says.

"We have to recognize that we’re in an age of accountability now," says Heyman, who is also president of Women’s Health Care and immediate past president of the Massachusetts Medical Society.

"NCQA is requiring insurers, hospitals, everyone to invade our offices," he says. "By becoming an AMAP accredited physician, you’ll be able to have someone come into your office every two years. You’ll fill out a single application form."

Heyman calls AMAP a "timesaver, money saver, and lifesaver" for physicians. He hopes to be among the first physicians receiving AMAP accreditation.

Already, some changes are taking place in his practice. Although he and his colleagues have long tracked cesarean rates and discussed ways to lower them, the practice has now created multidisciplinary groups to study seven categories, from scheduling and telephone access to clinical issues.

"I think the profession is the best source for finding out what is quality care and what isn’t," says Heyman. "The criteria we’re using are stiff enough so that people will realize we are not just rubber-stamping people. It is going to be difficult to get AMAP accreditation."

[For more information about AMAP: Contact Lynn Thomas, American Medical Association, 515 North State Street, Chicago, IL 60610. Telephone: (312) 464-4755.]

Reference

1. Kassirer JP. The new surrogates for board certification — What should the standards be? N Engl J Med1997; 337:43-44.