Blog | Thursday, December 5, 2013

Finally! Physician performance measurement questioned in the NEJM


In 2006 I participated in a Medscape debate about pay for performance (P4P) – April 2006: Point/Counterpoint on Pay for Performance.

Here are some of my thoughts then:

The pay-for-performance movement (and does not the phrase evoke a sense of moral virtue?) assumes that physicians will provide better care if we provide financial incentives to do the right things. The concept has great validity on its face. Pay-for-performance has become a sound-bite phrase, which politicians eagerly adopt.

So who could oppose motherhood, apple pie, and quality? No one can oppose the drive for improved quality, but I do oppose current efforts to adopt pay-for-performance.

Excellent medical care requires excellence in at least 3 dimensions. First, one must make the correct diagnoses. If we expect correct treatments, we must assume diagnostic accuracy. Of course, difficulty with diagnosis ranges from trivial to very complex.

Second, one must deliver the appropriate care for an individual problem. If the patient has one problem, then an algorithm can direct quality care. I know that all patients who have congestive heart failure should have an angiotensin-converting enzyme inhibitor prescribed. However, we know less about how one should consider quality when patients have multiple diseases. In adult medicine, many patients have multiple diseases, each having complex care guidelines.

Third, we should develop a plan given the context of the patient’s situation. We must understand the financial and social constraints of our patients. We must communicate with our patients, understanding who they are and what kind of care they desire.

I submit that current pay-for-performance plans only address part of one dimension of care. They will reward physicians for caring “correctly” for patients having a single known problem. But I also submit that this formulation may not reward the right physicians, or even encourage total excellence.

Over the past 8 years, this blog frequently raises concerns about performance measurement. I have tried to look at this issue carefully, and have featured a rationale against P4P and pointed out unintended consequences from ill-designed performance measures.

The New England Journal of Medicine published (free access) this wonderful perspective online – Grading a Physician’s Value—The Misapplication of Performance Measurement. In it Robert Berenson looks at performance measurement with a clear vision.

One definition of physician professional competence is “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served.”2 Patients place emphasis on physicians’ confidence, empathy, humanity, personability, forthrightness, respect, and thoroughness.3 A global measure of value should capture most, if not all, of these diverse elements of desired performance. Yet available measures in the PQRS and elsewhere are relevant to few of these professional qualities.

More concretely, examples of important but mostly overlooked aspects of physician performance that we would want to measure include making accurate and timely diagnoses, avoiding overuse of diagnostic and therapeutic interventions, and caring for the growing number of patients with multiple chronic conditions and functional limitations.4 A radiologist’s primary role is to provide accurate and complete interpretations of imaging studies. Yet because we lack measures of accuracy for radiographic diagnoses, PQRS measures include “exposure time reported for procedures using fluoroscopy” and “inappropriate use of ′probably benign’ assessment category in mammography screening.” The PQRS is predicated on the dubious proposition that measuring and rewarding performance on such obscure clinical aspects of care is worthwhile. Even if such activities are beneficial, performance on these measures is not indicative of a radiologist’s quality as part of the CMS value calculation.

Consider quality for surgeons. We want to be able to measure performance on core competencies that affect outcomes, such as judgment about whether and when to operate and which procedure to use, as well as the surgeon’s technical skill in the operating room. Yet because these characteristics are difficult to quantify accurately and routinely, PQRS measures for surgeons instead include adherence to guidelines for antibiotic and anticoagulation prophylaxis. Again, these measures assess worthy prevention activities but do not reflect a surgeon’s contribution to producing value.

Thanks to Dr. Berenson’s perspective we have a wonderful opportunity to stop the train. You might ask, “what train?” For the past 8 years when I have raised this issue, the first response I heard was that the train had already left the station. We knew, or at least should have known that the train was headed in the wrong direction. The train left prematurely. We have a great chance to derail this process. Kudos to Dr. Berenson for writing so clearly and so convincingly about this most important issue.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.