The November 6, 2013 issue of the New England Journal of Medicine has an important editorial entitled Grading a Physician’s Value: The Misapplication of Performance Measurement. It begins by acknowledging that
perhaps the only health policy issue on which Republicans and Democrats agree is the need to move from volume-based to value-based payment for health care providers. Rather than paying for activity, the aspirational goal is to pay for outcomes that take into account quality and costs.
But even as the authors
agree that value-based payment is appropriate as a concept, the practical reality is that the Centers for Medicare and Medicaid Services (CMS), despite heroic efforts, cannot accurately measure any physician’s overall value, now or in the foreseeable future.
They argue that “physicians simply do not respect the (current quality) measures, and for good reason.” Such quality measures
reflect a vanishingly small part of professional activities in most clinical specialties. A handful of such measures can provide a highly misleading snapshot of any physician’s quality. Research shows that performance on specific aspects of care does not predict performance on other components of care. Primary care physicians manage 400 different conditions in a year, and 70 conditions account for 80% of their patient load. Yet a primary care physician currently reports on as few as three (quality) measures.
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.” Patients place emphasis on physicians’ confidence, empathy, humanity, personability, forthrightness, respect, and thoroughness. A global measure of value should capture most, if not all, of these diverse elements of desired performance. Yet available measures in the Physician Quality Reporting System (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. 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.
The bottom line is that the things in health care that are most easy to measure quite often are not what translates into healing, value, and a higher quality of life for patients.
Another issue the authors address is judging a physician by how much money is spent in the care of his or her patients. The government and insurance companies will be increasingly penalizing and rewarding primary care physicians on this basis. This is problematic since
current methods for case-mix adjustment do not adequately capture variations in patients’ illness severity, complicating coexisting conditions, or relevant socioeconomic differences — differences beyond the physician’s control that affect the cost of care.
I am very much for a health care system that rewards high quality, cost-efficient care. But for that to become a reality, researchers must develop much better methods of accurately measuring quality and cost-efficiency.