AQA Invitational Meeting Summary

Report of the Reporting Workgroup

Randy Johnson, Motorola

Nancy Nielsen, American Medical Association

Randy Johnson discussed the workgroup's activities since the last meeting, including incorporating comments from the January AQA meeting and evaluating the appropriateness of merging the two separate principles documents. He said the AQA is involved in groundbreaking work, and stressed that the focus of employers, consumers, and purchasers is on quality and efficiency, not on procuring the deepest discount. Purchasers and consumers are already moving forward on reporting initiatives, he said, so it is important that we come up with principles earlier rather than later to provide guidance to these constituencies.

Johnson noted that reaching agreement on reporting principles has been a challenge:

• Are we going to have simple or complex reports?
• Longer or shorter reports?
• More or less due diligence?

He also referred to the need to figure out how best to serve multiple customers, including consumers, purchasers, clinicians, and health insurance plans.

Johnson said that while there has been a good-faith effort to merge the principles, the workgroup has reached no consensus. Regarding separate versus blended principles, he noted that separate principles might be more useful to their respective users and would be easier to come to consensus on separate principles. At the same time, he noted that there are fundamental principles that apply to all, which might make one document easier.

Finally, Johnson said the workgroup was asking the AQA to:

• Approve the concept of separate, rather than blended, principles.
• Approve the language in each document.

Following Johnson's remarks, Nancy Nielsen reiterated that the workgroup had discussed whether and how to create a blended document. We realized people didn't want a preamble and two separate documents, she said, but we have not come to consensus on how to blend the two. Rather than trying to come up with a blended document, the workgroup is recommending coming to closure on the two documents we have here. She noted that each was very different from what was first approved a year ago, including changing the title of one from Physicians and Hospitals to Clinicians and Hospitals to include nonphysicians.

Johnson added that the word quality was taken out of the AQA Principles for Reporting Health Care Information to reflect that the principles include dimensions other than quality (including efficiency). He opened the discussion on the topic of adopting two separate sets of principles.

The discussion opened with support for a single set of principles on the grounds that principles for reporting should be universal. When we have multiple standards and principles, a participant said, it is more difficult to make sure we are meeting the same standards for all audiences. A second participant also spoke in favor of a single set of principles.

Another participant said that while she supports separate documents, she thought it would be appropriate to add two of the bullets in the Clinicians and Hospitals document (items No. 5 and No. 6, dealing with transparent methods) to the Public Reports document. Nielsen replied that was intended that item No. 5 in the Clinicians and Hospitals document would be encompassed in item No. 6 in the Public Reports document.

One participant said he realized that there may be different reports but why not one set of principles? Johnson responded that the principles for reporting to clinicians and hospitals have been constructed to include more due diligence and to include elements that aren't of value for consumers.

Regarding a question on "portrayal of performance differences," Johnson said that the new language reflects editing and rewrites that have taken place since the last meeting.

Next, a participant spoke in favor of approving two separate sets of principles. He noted that the pilot programs can test the applicability of the principles and that the AQA could revisit the issue at a later time. A couple of others also spoke in favor of separate reports.

Another participant expressed concern with the concept of individual reporting. Calling it troublesome, he said that reporting on physicians might not be a good way to resolve quality problems. He suggested that databases and registries might be a better option.

A participant recommended adding or group to items No. 3 and No. 4 in the Public Reports document (so that each will read "individual or group provider performance").

Motion: To add or group to items No. 3 and No. 4 in the AQA Principles for Public Reports on Health Care and the AQA Principles for Reporting to Clinicians and Hospitals. Result: The motion was adopted.

One participant noted the lack of language on ranking versus rating. He also expressed concern about the final item in the Public Reports document (on timely results), saying that timeliness should not occur at the expense of accuracy. In response, Nielsen said that there was no intent that this be timely but not accurate.

Motion: To add patient experience into item No. 2 of the AQA Principles for Reporting to Clinicians and Hospitals so that the language in the document parallels that in the AQA Principles for Public Reports on Health Care. Result: The motion was adopted.

Motion: To accept the consensus of the workgroup that there be two separate sets of reporting principles. Result: The motion was adopted.

Motion: To adopt the AQA Principles for Reporting to Clinicians and Hospitals, as amended. Result: The motion was adopted.

Motion: To amend, by substitution, item No. 6 in the AQA Principles for Public Reports on Health Care. Result: The amendment was rejected.

There was considerable discussion of this motion, which would replace the one-paragraph language on transparent methods with an edited version of the language contained in the Clinicians and Hospitals document. The new language would add a principle on the need to make explicit and disclose to physicians and hospitals data specifications for reported performance data, such as sample size and methods of data collection and analysis. The proposed amendment would also provide that clinicians whose performance is reported have an opportunity to review and comment on the methodology for data collection and analysis. It also includes language about giving clinicians and hospitals written notification, in a timely manner, of any changes in program requirements and evaluation methods.

Johnson warned that self-funded employers would likely ignore the Principles for Public Reports if they had to ask clinicians and hospitals to comment on the methodology and reports.

Several participants expressed strong support for the proposal. One said it was important to include the language in the Public Reports document so that physicians could understand exactly how they are being rated. Another asked: Why wouldn't we give clinicians the same protections in the Public Reports document that exist in the Clinicians and Hospitals document? Others, however, questioned the feasibility of having 600,000 individual practitioners offer comments (versus the far smaller number of hospitals), and suggested perhaps modifying the language to include where feasible.

Johnson said that item No. 6 in the Public Reports document, as drafted, is intended to accomplish what the amendment suggests while being a bit more general. He reiterated that there is considerable urgency from employer and consumer groups to move forward quickly. He also voiced concern that while some of these items might be desirable (depending on circumstances and how they are done), adding them into a principles document may deter many employer groups from participating.

The amendment was rejected.

A subsequent vote on whether to hold a roll call vote was also defeated. Several people then expressed willingness to allow people who wished to record their votes on this motion to submit their votes in writing for inclusion in the meeting report.

Motion: To add physicians to the phrase "consumers, purchasers and other stakeholders" in item No. 6 in the AQA Principles for Public Reports on Health Care. Result: The motion was adopted.

Motion: To adopt the AQA Principles for Reporting to Clinicians and Hospitals, as amended. Result: The motion was adopted.

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