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 drastically 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 October 5-11th 2013 issue of 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.
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.”