Pay for performance: Not everything that can be counted counts

There is a lot of talk these days about changing our health care system from “pay for volume” to “pay for value.”  The idea is that we currently reimbursement doctors and hospitals according to the number of services delivered rather than how well they make us.  This perverse system of incentives results in runaway health care spending that doesn’t necessarily result in a more healthy citizenry.

There is certainly truth in this way of thinking.  But to my mind, it very much oversimplifies the situation.  To illustrate why I believe this to be the case, I present a letter entitled, “Performance Indicators and Clinical Excellence” from the Lancet.  

The author Chris Kenyon writes:

Attending post-intake ward rounds in various National Health Service (NHS) trusts around the UK, I am concerned that clinical expertise is being crowded out by a need to meet various key performance indicators.

In one hospital, I was told on arrival that the trust had, over a year, moved from the bottom to the top category of performing trusts. I was therefore puzzled when soon thereafter I attended a consultant post-intake ward round where a patient seen had ascending leg weakness mistakenly diagnosed by the admitting doctor as Guillain-Barré syndrome. The consultant spent little time reviewing the history of the patient (missing the history of pseudo-seizures), did not test the patient’s reflexes or power in the legs, and concluded that the patient required intravenous immune globulin. The consultant did, however, introduce all members of the ward round to the patient, check that any drug allergies were filled out on both pages of the drug chart and a checklist of 23 other items, which were ticked off or not according to the consultant’s compliance thereof. A sticker containing the 25 items ticked off was duly placed in the notes, the patient received intravenous immune globulin for their somatisation disorder and the patient contact scored 100% for audit purposes.

On post-intake ward rounds in the past, the consultants would, with a few pertinent questions and clinical findings, recognise the most likely diagnosis. This would determine a streamlined approach to the further investigations and management. Performance indicators are necessary, but with the limited time available for each consultant-patient contact, I wonder how much thought has been put into how the setting of performance targets such as this list of 25 items has crowded out the time available for clinical excellence.

 In this story, the doctor had met all of the quality measures.  The auditors assessing the “value” of the doctor’s care could feel good about what he had done since the checklist of performance indicators had been completed. The only problem is that the patient was given a wrong diagnosis and, therefore, received a very expensive, unnecessary, and potentially harmful treatment.  This is illustrative of an important defect in the way that doctors’ performance is currently being measured.  These quality measures all assume the presence of an accurate diagnosis.

But, in fact, making the right diagnosis — finding the real reason for what is wrong with the patient–is one of the most challenging and patently crucial parts of helping a sick person get well.  And yet I am not aware of a quality measure that takes this important clinical activity into account.  The quality indicators focus instead on what is easy to measure–whether people’s cholesterol, blood pressure, and diabetes readings are at goal and how many have received their age-indicated vaccines and cancer screening tests. These are no doubt important parts of care, but to reduce being a good doctor to this is a grave error.  I believe a payment method based entirely on meeting quality measures risks de-emphasizing less quantifiable yet equally vital components of the healing profession.

With all its flaws, the current fee-for-service system is often an indirect measure of quality — perhaps in some instances superior to a method based on quantifiable quality indicators.  In Austin, where I practice, there is a particular orthopedic surgeon known both in the medical community and among patients for getting very good results with his knee and hip replacements.  It, therefore, takes a long time to get an appointment and a surgery date with him.  This is not because he is looking to do more surgeries.  Indeed, he is known to turn away people seeking joint replacements if he does not believe doing so would be appropriate.  He is busy because doctors and patients know he is good at what he does.  This is same reason that many of the best doctors’ schedules are full.  And this is something that people working to re-engineer our health care delivery system often seem to miss.

I close with words from a sign that hung in Albert Einstein’s office at Princeton.  ”Not everything that counts can be counted, and not everything that can be counted counts.”

James Marroquin is an internal medicine physician who blogs at his self-titled site, James Marroquin.

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