The problem of basing physician pay on quality indicators

New York City’s Health and Hospitals Corporation (HHC), which runs 11 hospitals in four of the five boroughs of New York, is negotiating a new deal with the union representing some 3,300 salaried physicians. The corporation wants to base MD pay raises on 13 quality indicators.

The New York Times article that broke the story does not list all of the indicators but mentioned the following: how well patients say their doctors communicated with them, rates of readmission within 30 days after discharge for heart failure and pneumonia, how quickly emergency department patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.

The union has countered with suggestions that more indicators be used such as “going to community meetings, giving lectures, getting training during work hours, screening patients for obesity, and counseling them to stop smoking.” And they may ask that more doctors and support staff be hired.

As is typical of the doctors’ union, they had problems with the plan. They already get paid for giving lectures and training during work hours. Aren’t screening patients for obesity and counseling them to stop smoking considered part of a physician’s normal work? I do agree that doctors should receive combat or hardship pay for attending community meetings.

Another feature of the plan, which was glossed over in most secondary reports, is that the bonuses “would be given to physicians as a group at each hospital, rather than as individuals, so that even the worst doctor would benefit.” (More on this below)

The Times piece quotes officials from both sides and outside experts who offered opinions ranging from it’s a wonderful new world order to it will never work.

I tried to obtain a list of all 13 performance indicators, but it is nowhere to be found. However, looking at the ones in the Times article may be enough.

Patient assessments of how well their doctors communicated with them is going to be confounded by the fact that there are no private patients and few one-to-one doctor-patient relationships in the HHC system. Add in layers of medical students, physician assistants, residents and fellows combined with a patient population that, in many cases, suffers from a language barrier and may not even know who their doctors are, and it will be difficult to tell just who is a poor communicator.

I have discussed rates of readmission within 30 days after discharge for heart failure and pneumonia in a previous blog. This is a very poor indicator of quality and depends greatly on patient compliance with medications and instructions such as diet and activity.

How quickly emergency department (ED) patients go from triage to beds is a function of the census in the ED. This depends on many variables the MDs can’t control, such as availability of inpatient floor and ICU beds, nurse staffing, promptness in room cleaning, and many other factors.

Whether doctors get to the operating room on time is an interesting issue. As a former chairman of surgery, I have tackled this one in three different hospitals without success. First of all, what does this have to do with quality? Secondly, I truly believe that it will never be solved.

How quickly patients are discharged: Does this mean the time from admission to discharge, or is it the time from when the decision to discharge a patient is made until he actually leaves? If it’s the latter, again there are many forces at work. Does the patient want to go home? Can he get a ride? Is the bed ready at the nursing home or rehab center? If he’s being transferred by ambulance, will it arrive promptly? Is the nurse too busy to do the paperwork? Is the doctor, who may be a resident, too busy to do the paperwork?

The fact that bonuses will be tied to group, not individual, performance dooms the plan to failure. It reminds me of high school when someone threw a spitball and the teacher made everyone stay after school.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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