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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  • http://www.facebook.com/shirie.leng Shirie Leng

    Absolutely true. I have written about this myself at medicineforreal.wordpress.com and I think on this site as well. You can’t tie pay to quality because quality is a group effort. The system and the patient can stymie even the most stellar physician.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    First of all this has nothing to do with quality. These are business indicators for which the company gets additional revenue from payers, and since the business indicators are at a system level, there is no value in having a few individuals perform well while many others do not. By imposing a group standard, you trigger peer pressure to stick to the corporate Key Performance Indicators (KPIs). Welcome to the world of employment.

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    Thanks Margalit and Shirie for commenting.

    I agree that these are not quality indicators, but that’s the way the article presented it. Margalit, you explained it better than I.

    Shirie, I read your post and agree.

  • http://www.twitter.com/alicearobertson Alice Robertson

    Combat pay? I like it!:) I want some too! But putting that aside this is a bit astonishing that it’s even being considered. It feels like Guwanda’s Checklist Unionized with a board of communistic minded leaders trying to find a way to make all doctors of equal ranking. The patient feedback seems so interesting, but feels like an accessory used to sell the public. It should be kept only by the employer of the doctor because we already know patient feedback at online ratings sites has tended to be pretty useless (but it made some sites money). Feedback usually comes from passion (just check out some of my old posts when I was mad as hell at the doctor who twice neglected to read my daughter’s lab reports and let cancer spread through her blood and lymphs)…it just reflects the highs and lows of medicine. Ombudsmen will share that a patient who is disappointed in the results usually blames the doctor. And, sadly, sometimes what a patient likes in a doctor just isn’t a good indicator of the doctor’s capabilities (some want a good bedside manner as if the doctor should be the Entertainer of the Year and some of the poor performers are covered by nurses who know the doctor doesn’t care enough to be careful. But they may get a good ranking because of the good outcome…while the nurses are the true caregivers playing clean up lady to a lousy doctor).

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      Alice, I agree with everything you wrote.

  • 2BZ

    Holy Bureaucratic baloney, Batman ! there needs to be a method of evaluation that rewards doctors who care, can communicate well (including listening) and who consistently have “good outcomes” in tough cases. But this is nonsense from a corporate HR manual they want to apply without much fine tuning. and since when did group punishment work to motivate the slackers to fess up and do better !?? peer pressure and doctors ? in a union environment ? the peer pressure will be on the best performers.
    BTW, here you have unionized doctors. which means it is a group process with no ability to reward individual performance or “disincentivize” (wow, I luv that concept) the bottom 20%.
    This is DOA.

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      2BZ, thanks. There isn’t one thing about the plan that makes sense to me.

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