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Performance measurement metrics should be enlarged to give patients "shared accountability" for the success or failure of their treatments by healthcare providers, a new report from a consortium of medical specialty societies and advocacy agencies suggests.

Bringing the patient's own response into the therapeutic picture will help focus attention on patient-centered outcomes, the report's authors believe, and will present a more accurate portrait of how well the physician and patient are working together toward common goals.

Patients have enormous influence on treatment outcomes. It is up to them to take medications as directed, follow treatment plans, schedule follow-up appointments, report symptoms honestly, and make lifestyle changes. If they don't, this paper suggests, the physician or healthcare organization shouldn't be held solely accountable for a poor outcome, as the current performance measurement regimen often does.

"We can prescribe a medicine, but if the patient doesn't take it, we have failure. We're not going to reach our goals of modifying behaviors or improving health," said , in an interview with 番茄社区. He and , led a writing committee of 15 on behalf of the and Task Force on Performance Measures. The article was published in .

Physicians and hospitals are under increasing pressure to score well on the various metrics that have been imposed over the past 10 years to make providers more accountable for patient outcomes and the health of the populations they serve.

Medicare and private payers now add bonuses or extract penalties for how well physicians meet certain quality targets. Medicare's Physician Quality Reporting System (PQRS) ties reimbursements to how well practitioners report on a wide assortment of quality measures. Those who have poor scores on their 2014 performance measures, for example, will see a 2% subtraction on their 2016 Medicare payments. Performance measures also affect physician ranking and reputation.

Doctors may perceive these metrics as unfair to them when they are penalized for something that wasn't under their control. If their patients don't attain designated targets for blood-pressure management or reduce their cholesterol on statins, doctors wonder why they should be held accountable.

"We have to realize these measures are shared, but we need to realize we too can influence patients' behaviors," Peterson said. "That has not been a thrust of medicine up to this point."

Whether or not patients adhere to medication protocols has not generally been looked on as the doctor's responsibility. But perhaps waving away the adherence question isn't addressing the problem fully, Peterson said. It is the physician's obligation to persuade the patient of the value of the therapy. "If I explain to you the reason why you need to be on the medication and the consequences if you don't do it, your odds of taking the medication will be higher," he said.

The Institute of Medicine has pushed for a system of "shared accountability" in which all stakeholders in the health system and all participants in the care team, including the patient, contribute to the overall success of the care plan. "Underpinning this concept is recognition that the actions of clinicians and the patient are not independent but rather inextricably linked," the authors wrote.

The report was developed in collaboration with the National Committee for Quality Assurance, the American Society of Health-System Pharmacists, and the American Medical Association-Physician Consortium for Performance Improvement. The American Academy of Family Physicians was also represented on the panel.

Despite its luminous pedigree, the report might not have a smooth and easy entry into the prevailing narrative around performance measurement. For one thing, operationalizing its recommendations will be challenging. It is not easy to directly measure patient adherence to instructions. For another thing, some physicians and patients might view the perspective of the drafting committee as overly directive and intrusive.

"I am concerned that in the effort to achieve good performance, we don't start blaming patients for problems or coerce patients into complying with what the medical system wants them to do," said , director of the Yale-New Haven Hospital .

It should be the goal of providers to help patients "make informed choices that are guided by their preferences, desires, and goals, and work with them to achieve them," Krumholz told 番茄社区. There shouldn't be impediments to patients' ability to live their lives as they want. But they might not necessarily share the same perspective or goals that the health system has in mind for them, he added.

Patients must define success in their own terms, and that will vary from person to person. "I don't necessarily think driving them to the lowest risk is necessarily what they want. We don't want to tell them what to do."

For physicians it is easy to assume that everybody is aiming for the same target and the same outcomes and healthy behaviors, he said. Yet for some people the most important thing might not be to lower their risk of a certain outcome; it might be to maintain a certain lifestyle or enjoyments.

"Some people will opt to live their life in a way that always promotes their best health," Krumholz said. Other people won't. "As a society, how do we gently encourage people to pursue healthy behaviors, in terms of food choices and physical activity? We have to be careful about imposing a singular view about how people live their lives."

Payers also have a role in achieving desired patient outcomes, Peterson said. If a medication has a large copay, chances are that fewer patients will fill the prescription or complete the regimen of therapy. And if it is a long-term treatment for a chronic condition, the design of the insurance plan could have huge consequences for success.

For instance, a strong program of cardiac rehabilitation after heart attack may be more helpful in encouraging the patient to stop smoking. "If the payer has paid for this program, it will increase the likelihood you will quit," Peterson said.

These new ideas about shared responsibility are already playing out on the field of standard treatment guidelines. The jointly developed and published by the ACC and AHA earlier this year recommend that physicians talk to patients deemed high risk, “but it doesn’t say you have to prescribe statins,” Peterson said. The guideline reads: “Clinicians and patients should engage in a discussion of the potential for ASCVD (atherosclerotic cardiovascular disease) risk-reduction benefits, adverse effects, drug-drug interactions, and consider patient preferences for treatment. This discussion also provides the opportunity to re-emphasize healthy-lifestyle habits and address other risk factors.”

"That is a big change," Peterson said, "and very different from how we used to do performance measures, which held we should prescribe statins." Performance measures for lipid control are being formulated now, taking into account the recommendations of the ACC/AHA report.

One of the complexities of actualizing these recommendations will be how to ascertain what the patient is actually doing. In principle there are three basic ways to measure the patient's adherence to a medication regimen, Peterson said: 1) you can see whether and how often she filled the prescription, 2) you can measure medication levels in her bloodstream, 3) you can rely on her self-report.

Those can deliver three very different answers to the question. "We're not trying to get at which is the truth in our paper," Peterson said. It is more constructive to look at the degree to which patients and providers and the health system might influence success or failure of the intervention, he said.

These concepts are still at an early stage of development. The document was vetted by large array of specialty societies and stakeholders. "We wanted to gain general consensus across all these perspectives" so they could be quickly turned around into new rules for performance measurement and partnering with patients to get better health," Peterson said.

Krumholz said the writing committee deserved "kudos for jumping into this issue," but added that there are a lot of complexities to it and potential concerns.

"From a public health perspective, maybe we're trying to drive down certain behaviors. But from an individual level we're just trying to make sure people understand the consequences of their actions.

Not everybody wants to drive a Volvo."

From the American Heart Association:

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