According to a study done by the Commonwealth Fund, inefficient and poor quality care costs the nation at least $50 to $100 billion every year. As a result, the Obama Administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But who is going to determine how we define quality, and how those determinations and qualifications are applied accurately, effectively, and consistently? The rush toward using quality measures without taking the time to address national standards for interoperability among healthcare providers is problematic, and the government has begun to take notice.
In fact, according to The Washington Post, eight chairmen and subcommittee chairmen in the House have urged the Obama Administration to suspend any further implementation — government-wide — of pay-for-performance. Additionally, a study conducted by the Government Accountability Office acknowledged that the “discretion [pay-for-performance] given to managers to set performance metrics and to pay employees accordingly means these systems lack transparency and accountability and could pose a disparate impact on minorities.”
Dr. Groopman and Dr. Hartzband, who are on staff of the Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School have an excellent editorial in today’s Wall Street Journal entitled, “Why Quality Care is Dangerous,” and they define quality as “clinical practice that conforms to consensus guidelines written by experts,” and then used by physicians as "quality metrics." Medicare pilot projects at more than 260 hospitals have used quality measures to reward physicians and institutions that meet quality metrics since 2003. Interestingly, these "pay-for-performance" incentive programs are now being adopted by many private insurers as well. But there are also penalties for physicians who fail to comply with quality guidelines.
In Massachusetts (where healthcare is basically universal), physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Some of the ramifications that accompany failing to meet quality measures include attending re-education sessions; hospitals being downgraded on their quality rating, thus risking financial loss; and uncertain status as faculty if seen as delivering low-quality care.
While quality improvement initiatives at first focused on patient safety and public health measures, “the federal government and private insurance regulators have turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect,” according to Doctors Groopman and Hartzband. Furthermore, an analysis of the Medicare pay-for-performance for specific procedures, published in the most recent March/April issue of Health Affairs, showed that conforming to, or deviating from, expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients.
As a result, doctors are refusing to see complicated cases and chronically ill patients, because of the impact it will have on their quality rating for all types of procedures, including cardiology. Accordingly, while many doctors call for more flexibility in applying evidence from clinical trials, doctors need to be able to treat individual patients with whatever quality of care they determine for that specific case, without worrying about standards that do not apply evenly to every individual.
Patients are not ingredients in a cookbook and not all medicine works the same in everyone. Policy makers need to think long and hard about what quality actually means.
The Wall Street Journal: Why “Quality” Care is Dangerous