Psychology gains major role in defining quality care

By Paula Hartman-Stein, Ph.D.

Washington, D.C. – In a historic debate and vote by members of a key health care alliance, psychology and other healthcare professions made a giant step toward greater parity with medicine in the national healthcare scene.

At its fall meeting, the Ambulatory Care Quality Alliance (AQA) provided psychology for the first time with voting privileges to decide the merits of over 70 quality improvement measures impacting areas of medical practice ranging from anesthesiology to oncology.

With minutes left in the all-day forum, AQA passed five "best practice" process measures that it will recommend to the Center for Medicare and Medicaid (CMS) for psychologists and other non-physicians participating in Medicare, resulting in 1.5 percent bonus payments, part of the voluntary Physician Quality Reporting Initiative (PQRI) in 2008, pending Congressional approval.

If the discussion and voting of these measures had been tabled until the January 2008 meeting of AQA because of time restrictions, psychologists’ participation in the bonus incentive program would have been delayed to 2009.

A psychology/social work expert work group (consisting of Mirean Coleman, MSW, Craig Piso, Ph.D., and me), convened by Quality Insights of Pennsylvania (QIP), crafted three Phase I measures including patient co-development of treatment plans, screening for depression and screening for cognitive impairment in adults over age 65.

The measures have been up for public comment and have gone through field beta testing. They can be viewed on QIP’s website, www.usqualitymeasures.org

QIP presented the Phase I measures to the Performance Work Group of AQA on a large conference call in early October. The measures passed the rigorous scrutiny of this subcommittee before being presented and voted upon at the meeting of the entire membership of AQA.

Two additional measures, documentation and verification of current medications in the medical record and pain assessment, created by expert work groups involving physical therapy, clinical nurse specialists and other non-physician clinician groups, are also available for psychologists.

The reporting system for the quality measures includes filling out a worksheet that verifies that the clinician has completed and documented the procedure or measure.

In a commentary in the Journal of the American Medical Association (Oct. 17), there is widespread interest in public reporting of healthcare quality measurement, but the measurement of quality is "neither standardized nor consistently accurate and reliable."

In September 2004, the AQA, a broad-based national coalition of more than 135 organizations was formed to improve health care quality representing physicians, consumers, employers, government, health insurance plans and accrediting organizations. There is currently no fee to join. The APA was not involved with the alliance until CMS requested in 2007 that quality measures be developed for psychology.

At the recent meeting, the membership of AQA disagreed as to the types of clinician measures that ought to be tied to incentive bonuses, with arguments from physician groups such as the American Medical Association suggesting that measures should reflect basic competencies of healthcare, filling gaps of care documented in research studies. Other stakeholders such as representatives from the insurance industry argued that only higher order, aspirational measures that "raise the bar" of healthcare practice should be financially rewarded.

The Phase I measures passed in this first round of discussions largely fell into the realm of "best practice" or standard of care measures that are evidence-based and fill gaps in care.

AQA is still in the process of forming its governance structure. Prior to the Oct. 18 meeting, non-physician organizations had voting privileges but no representation on the governing board of the organization. After debate and with consensus of those present, non-physician clinicians have one seat in AQA’s governing body, with no specific plans yet regarding which professional group will take the lead as spokesperson.

According to Debra Long, R.N., project manager of QIP, "The success that occurred with the passage of the measures and defining "other clinicians" as an important sector of healthcare with inclusion on the governance of AQA and all that may transpire in the future provides hope for transformation in healthcare."

Development of psychology measures for Phase II for potential use in 2009 is under way. Members of the Phase II work group include Merla Arnold, Ph.D., chair, and members Katherine Nordal, Ph.D., Jean Carter, Ph.D., and me.

 

Paula Hartman-Stein, Ph.D., past president of the Society for Clinical Geropsychology, has a consulting practice in Kent, Ohio, was chair for the Phase I Psychology/Social Work Expert Work Group and was the APA representative at the AQA meeting on Oct. 18. She can be reached through e-mail, cha@en.com or her website, www.centerforhealthyaging.com

National Psychologist, Vol. 16, No. 6, pp. 1 & 3. (November/December 2007)