Table 2 Representative Quotes for Themes

Theme #1: Minnesota’s current quality scores are influenced more by patients and clinic systems than by clinician

Differences in patients at NSNCs and SNCs

 I think that (NSNCs) have “better patients”...they have middle class people who can do the things that they are asked to do. And they have better health literacy and they have different sets of motivations and priorities. If they are not having to worry about their housing they can probably take care of their diabetes a little better. (KI#2),

 (I)n the populations that we serve (at SNCs)...it’s harder to get patients engaged in their disease processes. And it’s multifactorial...(different) cultural understanding of disease process.... and a (different) culture of patient engagement.... I think it’s a lot harder to engage (our) patients...when you’re trying to survive...all the other things just fall to the side, including management of your chronic disease. (It’s poverty.)…it’s how close is a real grocery store, that’s affordable...how safe is the neighborhood...(KI#1)

Differences in clinic structures and processes at NSNCs and SNCs

 The (NSNC) clinic systems...were quite effective in management of patients with chronic diseases. ..There was an RN…who had the…list of the patients with diabetes but she didn't just tell him to come in--which is what happens now at (SNC) until you end up with like ten patients with diabetes who haven't been seen in over a year—she would go to their medicines and she would. ..adjust medication.... It was very efficient and...she would have them see a PharmD. (FG#1-3)

 A lot of pressure (about QMs in our NSNC). It dominates our meetings always.... You just get all the statistics all the time, and provider spreadsheets of who is at goal, who is not.... There are pool dollars that can be distributed. We are told that how it’s distributed is reflective of your scores...(FG#3-2

 The (SNC) organization doesn’t really push the measures hard. It’s not your (clinician’s) salary depends on that (quality measures). Your pool—the money that NSNCs puts out there (for clinicians)…is not at risk. (KI#4)

 At NSNC system), they encouraged providers to send their difficult patients to that (one) primary care clinic. They encouraged them to do that, so that they can sort of get them all in one setting so that their overall clinic numbers will improve, because if you pull out those outliers... (KI#1)

Differences in clinicians at NSNCs and SNCs

 (T)here’s the whole range of, you know, quality of providers (regardless of SNC or NSNC system they work in).... I don’t (think SNCs clinicians are reason for lower quality scores). I think, if anything, our providers are more activated to try to comply with the measures.... Generally people are very engaged, and they want to do better and have the patients do better as well. (KI#2)

Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare

Perspectives about measurement

 You know that famous statement by Einstein: "Everything important can't be measured."... So when I thought about this, I thought about trust and about how do you get patients from a different culture to trust you?...but it's a two-way street so the provider also needs to trust them.... I thought: but it starts with the patient. They'll think it's quality if you...really care about them...and then you really have to just accept them for whoever and where they're at. And just be in that place with them and go along together them and then they'll think this is quality because this is someone who (cares)…. And I think it's the relationship that matters to them. And then, as that is established, then you have more influence... and then you can try and get them do things that they might not want to do....and that it is truly patient-centric and not doctor-schedule centric. (FG#2-3)

QMs are valuable

 (S)o I think they (quality measures) are important because they do help improve (care), at least we think they help improve, health ... (KI#3)

 (T)here should be systems in place that make sure that people aren’t truly falling through the cracks…(KI#1)

QMs are not valuable

 P1: (At NSNC), that's where that big push in your 160 person lists is...a medical assistant checks these things when you come in (weight counseling)...and you check the box you had counseled them (unhealthy living).... You check the box or hand them a piece of paper (tobacco counseling). Um, I thought some of those things well were not very meaningful.

 P2: It was meaningful to the business people running the show.

 P1: The boxes were checked.

 P2: That's what mattered. [group agreeing]

 P3: And again, it gets at the measures themselves, but what are really the expectations of the measures? (FG#1-1, #1-2, #1-3)

Responses to competition about QM scores

 To be honest, I was very competitive (at NSNC).... I was personally kind of motivated to say we need to beat them (other clinics in same system).... I was also kind of the cheerleader that the other physicians could get behind and I kind of drew them into some of the competition...(KI#3)

 At [NSNC] a larger and larger proportion of compensation is aiming to be based on quality numbers. And there was…a difference of...take home (pay) at the end of the year which made people really mad.... (Some) were much more driven by money and productivity.... (Others) would look at the sheet and toss it aside and take care of their patients however they wanted to. But when it comes to, you know, $30,000 at the end of a year, you get kind of crabby. (FG#1-1)

 At (NSNC), they broke it down by provider and they kept saying, we’re breaking it down by provider because it shouldn’t matter, the population that you’re taking care of. So I had trouble to begin with because I think it does matter who you’re taking care of. And when they would do that then, then it would be very punitive. And that’s where the problem, I think that’s not a good thing. Because it shouldn’t be punitive. It shouldn’t be punitive for the provider and it shouldn’t be punitive for the patient either. And it’s both. (KI#1)

 I found that the people (clinicians at NSNCs) who were high-performing were long-term part-time and they had a small population, so their percentages were very high. They didn't do a damn thing. They didn't have hard patients. They didn't have long days. They didn't take new patients. They were closed practice--that's another issue. If you had a closed practice, you stabilized that group. You know, if you were fortunate, a lot of these guys they were smart enough that they chose their population. They knew something was coming. They dumped their bad patients and they kept the ones that were good. I mean duh we weren't that stupid that we couldn't see that. (FG#1-2)

Financial costs of QMs

 (Percent administrative cost is) way too high....(A NSNC system) is investing way too much in getting these numbers better without really improving healthcare...without adequately improving quality, I would argue that. And not just that…those funds are being shifted…so that money is being shifted (away from other aspects of care.) (KI#1)

 Why do we have this kind of competitive sense of things? Are we really making that much more money if we have better scores?... Are we elevating the quality of our communities? That’s what I want (to know). (FG#2-1)

Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare

Patients do not know about QM scores

 I’ve never heard, even in (Suburb at NSNC), I’ve never heard one person say ‘I chose your clinic because I read Minnesota Community Measures’ (scores).... (P)eople choose clinics and physicians ... for many reasons but I don’t think online reviews or quality ratings are one of them. (KI#3)

Patients define quality of care differently than QMs

 P2: And there's a lot of mistrust. There's a lot of: “you talking over my head so you don't care about me”.... I hear that all the time..."Do you care about me?"..."Really, do you care?".... But it takes a long time. It takes a long time to develop those relationships.

 P1: ...I think to them it's (quality) just completely different (from quality scores), like "Do you know my history when I walk in the room? "Do you know what's going on with me and are we picking right up where we left off the last time?.... It’s...“if I feel I've been heard, you care about me”, that's quality to my patients.

 P2: (T)hat's what I'm saying. It's that sense of: “you know me, I trust you”...and I really take that seriously. (FG#2/1, #2-2)

Clinicians define quality of care differently than QMs

 Quality (is) so much more complex than this (quality score) could ever get at, for me. Because quality is, for me as a family doc, quality is continuity in care. It’s that I know my patient. That they know me. That they trust me. That I trust them. That we have a combined working relationship. That I give them what I can offer, but that they take responsibility for what they can offer. (KI#1)

 I feel that quality is just moving someone into the right direction, whether if it’s the endpoint or not, just getting them to head in the right direction is already quality for them and for me. It’s good to know that you’re doing something without having those objective numbers at the end. Relative improvement towards various health goals for them to feel good about themselves and their health and the decisions that they’re making (is what quality healthcare is to me). (FG#3-3)

Theme #3: Current quality measures are a product of and embedded in the social and structural inequities of the American health care system

QMs are based in social inequities

 All of this (quality measurement) has some political aspects…at various levels…and certainly the pharmaceutical industry has run research and guidelines in the US for generations. (KI#2)

 (P)eople that are in Minnesota, it’s still pretty white folk land and the decision makers are still coming from that heritage. And they don’t have...an understanding that other people live differently than they do. (KI#2)

QMs measure unequal processes

 I think one of the troubles we have is (that) many of the measures and the programs and much of what comes from the state is coming from an upper-or middle-class perspective. People who have resources, who have insurance, who have the means, the wherewithal, the transportation to do the kinds of things they need to do, to take care of diabetes, for instance, better. When people don’t have those things then they experience barriers to that care.... And what doesn’t seem to get lots of lip services at the DHS (Department of Health Services) about...is social determinants. (They say;) Oh yeah we get it. (But I say:) Oh no you don’t! ‘cause you have not changed how you’re approaching this whole process (of measuring quality care). (KI#2)

Sub-theme #3.1: The current inequitable healthcare system should not be reinforced with financial payments

Finances tied to QMs

 I want to make sure that...at least we (NSNCs and SNCs) are all on the level playing field, and we've never been that way, and that's just the nature of our practice so…we (SNCs) shouldn't be penalized, because we have a diverse population that no one else wants to care for.... (FG#2-2)

 It’s not fair (P4P based on quality metrics). You’re penalizing the clinics that are trying to work with people and do the best they can, from where they (patients) are coming from, for the insufficiencies of people’s real lives in the real world that don’t conform to what somebody has decided is what they should do and then we (the clinics/ physicians) are being penalized for that? It’s not fair...because you know: no money no mission. (KI#2)

Sub-theme #3.2: Health equity requires new metrics and a new healthcare system

New metrics

 I think anyone in poverty already has a level of complexity that they start with....We need some way of recognizing that (when choosing measurements). I think part of it is figuring out the (quality) services and not docking the organizations that are trying to help these people.... You want to reward the good, but you don’t want to dock people who aren’t meeting these. (FG#3-3)

 I feel that quality is just moving someone into the right direction, whether if it’s the endpoint or not.. (We could measure) relative improvement towards various health goals for them to feel good about themselves and their health and the decisions that they’re making. (FG#3-2)

New healthcare system

 That’s foundational to quality: give everybody health insurance and cover their medications, all their chronic medications should be covered. And then there’s all these other stuff like outcomes (that we have to deal with), but at least get that off the table. (FG#3-1)