Quality measures should not separately evaluate cost of care from quality and appropriateness.Quality measures should be practical given variations of systems and resources available across practice settings.
#Quadruple aim for better administrative workflow professional#
Quality measures should be based on best evidence and reflect variations in care consistent with appropriate professional judgment.Quality measures should be focused on improving processes and outcomes of care in terms that matter to patients.With many family physicians submitting claims to more than 10 payers, the adoption of a single set of quality measures across all public and private payers is critical. Most of the measures are disease-specific process measures, rather than more meaningful evidence-based outcomes measures. Quality measures have proliferated in the past 15 years, leading to a significant compliance burden for physicians. Quality Measures and the Need for Measure Harmonization Prohibiting payers from requiring repeated PAs for effective medication management for patients with chronic disease and PA for standard and inexpensive drugsĢ.Requiring payers to pay physicians for PAs that exceed a specified number of prescriptions or are not resolved within a set time period.Requiring payers and pharmacy benefit managers (PBMs) that design PA specifically to save the payer or PBM money rather than benefit the patient to pay physicians for their time, as decided by the 2008 Merck-Medco v.Adopting a standardized form and process for PA among all payers.Limiting and reducing the number of products and services requiring PA.There should be a goal of eliminating PA for durable medical equipment (DME), supplies, and generic drugs.shared savings, etc.) and proven successful stewardship. PA for imaging services should be eliminated for physicians with aligned financial incentives (e.g.For medications, it should provide alternative choices to eliminate a guessing game. If a service or medication is denied, the reviewing entity should provide the physician with the criteria for denial. Rules and criteria for PA determination must be transparent and available to the prescribing physician, at the point of care.Activities requiring prior authorization (PA) must be justified in terms of financial recovery, cost of administration, workflow burden, and lack of another feasible method of utilization control.The frequent phone calls, faxes, and forms physicians and their staff must manage to obtain prior authorizations (PAs) from prescription drug plans and durable medical equipment suppliers, and others impede this goal. Physicians strive to deliver high-quality medical care in an efficient manner. Adherence to these principles will ensure that patients have timely access to treatment while reducing administrative burden on physicians. The American Academy of Family Physicians has developed the following prioritized list of principles on administrative simplification. Despite the good intent of underlying health care policies, the burden has expanded to an untenable level and is a significant barrier to achieving the Quadruple Aim. The administrative and regulatory burden is one of the top reasons independent practices close and is a leading cause of physician burnout. The regulatory framework for physician practices has driven operating costs up and caused reduced face time with patients. This is time that physicians could better spend caring for patients. Thus, physicians spend countless hours reviewing documents and checking boxes to meet the requirements of health insurance plans. Physicians are forced to learn and navigate the rules and forms of each payer. The regulatory framework with which primary care physicians must comply is daunting and often demoralizing. Standardization is not required among public or private payers, and many physicians participate with 10 or more payers. Principles for Administrative Simplification
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