Friday, September 04, 2015

The Unintended Consequences of Performance Measurement

When it rains, it pours.

So it is with the unintended consequences of performance measurement.

Performance measurement is an important part if our new health care law. The problem is, most of the people who wrote the law have no idea how to define "proper" performance or "quality" care. And when these bureaucrats and political minds attempt to apply individual health care principles to the arena of public health, they simply cannot perceive all of the unintended consequences their policies unleash in turn, especially when payments to physicians are tied to them.

Like a "V-8 head-slapping moment," two important articles have appeared this week, one by Lisa Rosenbaum, MD in the New England Journal of Medicine, and the other on Robert Centor, MD's blog. Each discusses the unintended consequence of performance measurement tied to medical payments: risk aversion.

Rosenbaum's article chronicles how New York's cardiothoracic surgical services are cherry-picking less complicated patients and pairing them with less experienced surgeons in the name of assuring better Medicare payments, and Centor's blog discusses his recent epiphany of the lack of proof of the benefits of performance measures but lots of examples of their unintended consequences.

Yet medicine is inherently risky, especially when caring for the complicated, critically ill, indigent, poor, and uneducated.

This same problem exists with the American Board of Medical Specialties' (ABMS) Utopian vision of improving physician performance by requiring them to perform their highly lucrative Maintenance of Certification re-examinations every six to ten years without EVER understanding the negative consequences of this mandate. No where has any member board of the ABMS ever studied the repercussions of their mandate upon practicing physicians and the patients they care for.  Rather than acknowledging the reality that their MOC program is expensive and increasingly tied to physician's hospital credentials and can directly affect their employment, their member boards deflect and create new "design principles" that promise "shared purpose and impact first," to make patients "the North Star," "simplicity and relevancy," to "think internal and external," to "always include the WHY, HOW, and WHO," "to balance the community centered-design with ABIM's expertise and research," to promise "participation and not just communication," and transparent decisions."

I'm not sure I've ever heard such doublespeak to justify the unintended consequences of an unproven and potentially dangerous exercise that could do more harm than good to patient care.

Perhaps as these unintended consequences of performance measurement gain an understanding with patients and legislators, we'll see a change in our health care law that could really help reduce costs and help patient care:

... the dissolution of these needless, unproven, and expensive exercises in futility.



Anonymous said...

My favorite is the insipid "SHARED VALUES" meme.

Just a way to justify moc and the useless "secure" exam.

They wont get my palm print anymore however I can give them the finger.

Dr. Baron... time to answer 22800 internists.

Anonymous said...

Have you seen the CMS performance measure of readmission rates? All of the health systems have been bragging about their improved quality as measured by this metric. As it turns out, there has been a 100% increase in the number of observation status "admissions" which do not fall into the category of inpatient. This makes it appear that there are less readmissions.

All of medicine has turned into a high stakes shell game with the escalating costs of hiring case managers to obfuscate and circumnavigate CMS measurements. CMS makes up the rules and we figure out how to jump through their hoops. What a waste!!

Anonymous said...

I'd love to see some constructive improvement in ACA. Too bad the Republican congress is unhinged and will only spend time in repeal efforts - no effort at all in trying to make improvements.

Anonymous said...

By constructive improvement, are you suggesting that Mr. Gruber is paid more to implement state insurance exchanges that eventually fail but result in tremendous wasted sums of money being distributed to consultants.

Is that the improvement that you suggest? Maybe, it's more money for the insurance companies like United, Humana, Aetna, etc. who actually wrote the law. Possibly, it's more money for the NQF to reduce re-admissions by shifting to observation status.

Could improvement of the law entail forcing physicians to complete more mandated MOC as a quality measure?

Actually, you must be referring to more patients covered with Medicaid since there are studies in the literature showing that Medicaid patients have better access to care and better outcomes than patients with no coverage.

Would an improvement in the law include more exemptions for unions from the cadillac tax?

You are right Anon! The republicans have failed us miserably.

Anonymous said...

MOC seems like the product of those who were very successful at test-taking in medical school ("gummers"), who want to continue in the role of successful test-taking or making, when it has little relevance to the practice of medicine in this day and age.
The powers at ABIM seems particularly oblivious to the current concerns of physicians. Patient care comes first, but doctor's lives matter too, and there seems to be no concern for our profession. The increasing bureaucracy imposed by fellow physicians who seem to care only about their own self promotion (and money) in the name of a non-evidence based "quality" is intolerable... Chris Cassel was known as an unethical person who "slept her way to the top" as far back as her fellowship in Portland (maybe that's why the ABIM luxury condo was down the street from her apartment). Her conflict of interest in working for Kaiser and Premier while head of ABIM shows a complete lack of ethics. Her persecution of other physicians for sharing test questions, (doesn't everyone with any intellectual curiosity do that?), and complete lack of concern for competent physicians in practice who fail the recertification shows that she will destroy competent physician's practices and lives who jeopardize her lucrative career. She has not practiced medicine for years... Baron inherited a mess, but ABIM needs to acknowledge the many mistakes and revert to a single lifetime board certification. They can transfer money back from their foundation instead of making money off physicians.

Anonymous said...

I recall reading in comments on some older DrWes blogpost about Federal Regulations prohibiting using 'certification' as a requirement for hospital privileges. Anyone recall when these were posted? Wanted to include this in appeal to Med Exec.

Anonymous said...

No, Anon, your 'suggestion' were not what I had in mind. I was thinking more along the lines of the ability to negotiate drug prices. A frivolous idea in comparison to your 'suggestions' I know, but perhaps it would a starting place for our congress - lord knows they are ever so anxious to govern.

OSWJ said...

Heavens to mergatroid ! Who do you think will " win " the battle to control healthcare ( RN's , PA's , MD's, drug companies , device companies , techs ) ---- ? Who Is Winning ! Let's see : ACA, AARP, AMA, United/ Aetna / Blues, hospital groups , ambulance chasing lawyers ,,,,,,,, and all your friends at
ABIM !! A new organization is needed ! A powerful physician ( real doc leader - not shills) lead organization ! Across all specialties !
Demand accountability ! Jeez --- who will want to become physicians in the next 10-20 years !! When all we really need are good technicals doing what Blue Cross or Medicare or Medicaid says you can do ---- ( sarcasm ) ! They are already brain washing the young residents , med students ---- Where are the Physicians to lead us out of this maze of incompetent govt officials & so called medical society
Leaders ?? Set up a simple organization/web site !! Ask for donations ! declare your Mission ! Enlist the public ! Buy cable time !
Move medicine in this profound age of advanced science to its next level !!

ct report said...

ABIM Persecution. Cassel/Langdon/Baron/O'Grady's Cruel and Unusual Adhoc Policy Continues. Is this how they define 'professionalism'?

A sobering example of ABIM injustice and violation of civil liberties from 2009.

Pacer, American Board of Internal Medicine 01/11/2015
Docket #1 01/11/2015, Complaint; Docket #6 01/28/2015 Counterclaim with Exhibits.

Filing New Jersey moved to San Juan. Physician has been held suffering in limbo by ABIM with revoked certification status for several years. ABIM claims: typical copyright violation. """"""

ABIM withholding exculpatory evidence from 2008 registration. ABIM complaint makes unreasonable demands that Aug. 2009 pledge should be made to retroactively cover pretesting period from registration to testing date. Study groups, no contact after test. No violations. Clean exemplary record.
ABIM policy and procedure for candidates engaged in unethical conduct: none, forming, adhoc at best. Prejudged guilty. 10 day notice to respond. Certification revoked. Exhibits. Met ABIM officers with attorney to speak for in Philadelphia, etc.
Read all exhibits.