Monday, April 29, 2013

Does measurement improve performance?

Like it or not, measuring physician performance is now a key part of the conventional wisdom on improving our health care system. Borrowing from management guru Peter Drucker’s mantra “You can’t manage what you can’t measure” health care policy makers have embraced performance measurement as being central to managing our heretofore unmanageable health care system.  But there is a small but seemingly growing group of Don Quixote-like dissenters who are tilting at the performance measurement windmill, arguing that these measures will not achieve the ends of improving quality and saving money and may instead do considerable harm.

Dr.  Bob Centor, author of DB’s Medical Rant blog, is one of them.   (Disclosure: Dr. Centor is chair-elect of ACP’s Board of Regents, although the views he expresses in his blog are his own, not ACP policy).  One of his posts, titled “What has performance measurement wraught?” calls them madness:

“Most readers know that I am obsessed with performance measurement and why it not only rarely works but often causes negative unintended consequences.  As I have pondered this question recently, computers cannot replace physicians as diagnosticians.  And the same misunderstanding of medicine that would advocate such a position drives the performance measure movement.

Physician decision making requires a complex weighing of disease severity, number of diseases, social situation, cost of medications, the patient's desires and willingness to address issues and more that you can imagine.  To think that we can apply simple rules to such decision making represents an unjustifiable conceit that patient care is simple and can therefore be broken down into RULES.

The unintended consequences of this movement are many.  We now have nonsensical report cards and, here the author gasps, public reporting.  If we could define excellence, then public reporting would make sense.  But we cannot define excellence through rules that cover only selected diseases and only one aspect of doctoring.

How do we stop this madness???"

In an earlier post, he cites  a commentary in the Journal of the American Medical Association (JAMA) which suggests that poorly-designed performance measures can cause harm to patient care.  “Too often we have measures based on a religious belief (e.g. lowering HgbA1c is always the proper goal) and not based upon good prospective data,” he writes.   “Whenever we have to struggle to meet a performance goal, we run the risk of unexpected consequences.  This irresponsible process likely harmed patients.  Let me repeat that sentence. This irresponsible process likely harmed patients.  The reasons now are clear.  Some, including the authors of this commentary complained bitterly back in 2006.  We allow organizations to establish performance measures without expecting the same rigorous testing that any other intervention must have prior to approval.  We would not approve a new drug without careful testing for both efficacy and safety.  Should we not hold performance measurement to the same standard?”

But is it possible to improve clinical performance without measuring it? The Institute for Healthcare Improvement, formerly headed by ex-CMS administrator Don Berwick, MD, says that “Measurement is a critical part of testing and implementing changes; measures tell a team whether the changes they are making actually lead to improvement.”    In 2008, Dr. Berwick co-authored an article published in Health Affairs that presented the Institute’s now widely accepted Triple Aim of improving individual patient outcomes, improving population outcomes, and lower per capita costs.  He writes that “in general, opacity of performance is not a major obstacle to the Triple Aim. Many tools are in hand to construct part of a balanced portfolio of measures to track the experience of a population on all three components. At the Institute for Healthcare Improvement (IHI), for example, we have developed and are using a balanced set of systemwide measures closely related to the Triple Aim.  A more complete set of system metrics would include ways to track the experience of care in ambulatory settings, including patient engagement, continuity, and clinical preventive practices.”

Measurement for the purpose of helping groups of physicians assess how well they are doing in achieving the triple aim may be challenging enough, paying based on performance measures raises a whole host of other issues.  All payment systems create a mix of potentially good and potentially bad results.  Fee-for-service achieves the potentially good outcomes of creating incentives for physicians to actually see their patients and not undertreat them, because FFS pays them on how many patients they see and how many procedures they do, but it can also have the undesirable outcomes of “rushed” assembly line visits and over-testing and over-treatment. Capitation achieves the potentially good outcomes of encouraging physicians to be more efficient and not over-treat their patients, since they are paid the same amount per patient no matter how many procedures or visits provided, but it can also have the undesirable outcome of incentivizing physicians to not see patients enough, not treat sicker patients, or undertreat them.  Payment systems linked to performance measures can have the desirable outcomes of creating incentives for physicians to organize their care to achieve better outcomes for their patients, better care of the patient population they see, and maybe, lower costs (the Triple Aim), but also the undesirable outcomes of “treating to the measure” (paying attention only to things being measured, and less to things not being measured), and creating disincentives for physicians to take care of sicker patients and those with lower socioeconomic status because such patients may adversely affect their performance “score.”

Performance measures though could help level out the potentially undesirable incentives existing in FFS or capitation:  FFS tied to performance measures could help counter the incentives for over-treatment because physicians who over-treat with no improvement in outcomes wouldn’t score as well on measures of individual, population or per capita cost outcomes.  Capitation tied to performance measures—if accompanied with appropriate risk adjustment-- could help counter incentives for physicians to under-treat patients, since under-treatment would result in poorer “scores” on individual and population-based health outcomes and patient experience with the care provided.

My sense is that the performance measurement genie is out of the bottle and isn’t going away.  We live in an era where just about everything and everybody is being measured and held accountable for getting better results as efficiently as possible.  Health care is so damn expensive that the public (through government) and insurance company shareholders will want to know if physicians are achieving the best possible results and the lowest possible cost—how can they know what results they are getting without measuring it?

But as measurement becomes increasingly imbedded in our health care system, we should pay attention to potential unintended consequences. We should insist on meaningful measures that are based on the best available science through a transparent process, not measurement for the sake of measurement.  We should test measures whenever possible before they are widely adopted, just as we do for new drugs, and withdraw measures that turn out to be harmful, just as the FDA withdraws newly approved drugs if they are found to have unforeseen harmful side effects.  We need to be very careful as we design payment models that incorporate performance measure so that what is best for the patient, not what is best for the measure, always comes first.  All of these, and more, safeguards are called for in ACP policy on performance measurement

And rather than starting with measurement as the be-all and end-all goal, we should begin by defining how best to organize care to achieve the best possible results for patients, through models like Patient-Centered Medical Homes, then determine a payment model that best supports those models, and then build and incorporate measures that actually help the physicians in these systems monitor and achieve the best possible outcomes for their patients—not the other way around.

If we really believe, as ACP does, that a well-trained internist, in a system of care designed to achieve the best outcomes for patients, will be shown to be the best bargain in American medicine, then performance measures can be our friends—but only if they are the right measures, measuring the right things, for the right reasons, and with the right oversight.    And we should always keep in mind the cautionary note from sociologist William Bruce Cameron, sometimes misattributed  to Albert Einstein, “That not everything that can be counted counts, and not everything that counts can be counted.”

Today’s question: do you think performance measures will improve or harm health care outcomes?

Thursday, April 18, 2013

What the Senate Gun Vote Says About Washington . . . and About Us


Many experts predicted that the unspeakable murder of dozens of children and adults at Sandy Hook elementary school would be a “game-changer” that would cause Congress to enact meaningful controls over firearms.   How wrong they were.  

Yesterday, the United States Senate rejected every single legislative proposal to make it harder for people—including convicted felons-- to obtain and use firearms to inflict harm on themselves and others.    Because of Senate rules requiring 60 votes to get just about anything passed, a minority of U.S. Senators were able to block a bipartisan plan  for universal background checks offered by two Senators with “A” ratings from the NRA, despite the fact that  90%  of the public supports expanded background checks.

 Proposed bans on the future manufacturing and sale of military style weapons and high capacity ammunition magazines didn’t even get a majority of Senators to vote for them.  These are the weapons of choice of mass murderers, used to gun down children and adults at Sandy Hook; college students at Virginia Tech; a member of Congress and others standing near her (including the murder of a young child) outside a grocery store in Tucson; movie theater patrons in Aurora, Colorado, and so many more people who have been killed or injured, in so many places, by assault weapons loaded with high capacity magazines.  But banning such weapons and ammunition was too big a political lift for most U.S. Senators.

The background check proposal had a much more modest purpose, closing existing loopholes to keep guns out-of-the hands of convicted felons, persons with domestic violence restraining orders, and violent, mentally-disturbed persons under court order (while exempting most sales among family members), but that was also too much of a lift for politicians cowed by the NRA’s opposition and a passionate but small minority of gun owners who oppose expanded background checks.  Support for background checks among gun owners is about the same as the general public, with 88% of them supporting background checks for all gun owners according to recent polls.

I am deeply disappointed that Senate rules allowed a minority to again block the will of the majority of the Senate and the will of an overwhelming majority of the public.  I am deeply disappointed  by the effectiveness of the NRA’s deceptive, cynical “slippery slope” argument that universal background checks would create a federal registry of gun purchases that later could be used by the government to take legal guns away from law-abiding owners, when such a registry is expressly prohibited by the background check bill as well as by current law barring the FBI from retaining records of persons passing background checks. 

I am also disappointed that organized medicine didn’t do more to support the Senate bill.  ACP did its part: we wrote letters of support for the background check bill and asked our 8,000 plus ACP Advocates Network members to urge their own Senators to vote for it.  The American Academy of Pediatrics did at least as much as we did.  But from what I can tell, most of the other national physician membership organizations and state medical societies sat this one out.  They either didn’t engage at all prior to the Senate vote, or limited their engagement to a letter of support, without backing it up with grass roots lobbying, direct lobbying on Capitol Hill, and the other elements one would associate with a high priority campaign.   In my blog post immediately after the Sandy Hook massacre, I asked “Is the Medical Profession Doing Enough About Gun Violence?”   Regrettably, the answer for much of organized medicine, appears to be no.

But my disappointment over the Senate’s failure on guns pales to that of Gabby Giffords, the member of Congress who was grievously injured in the Tucson shooting.   Read what she said in today’s New York Times:

“Senators say they fear the N.R.A. and the gun lobby. But I think that fear must be nothing compared to the fear the first graders in Sandy Hook Elementary School felt as their lives ended in a hail of bullets. The fear that those children who survived the massacre must feel every time they remember their teachers stacking them into closets and bathrooms, whispering that they loved them, so that love would be the last thing the students heard if the gunman found them.

On Wednesday, a minority of senators gave into fear and blocked common-sense legislation that would have made it harder for criminals and people with dangerous mental illnesses to get hold of deadly firearms — a bill that could prevent future tragedies like those in Newtown, Conn., Aurora, Colo., Blacksburg, Va., and too many communities to count.”

She continues:

“I watch TV and read the papers like everyone else. We know what we’re going to hear: vague platitudes like ‘tough vote’ and ‘complicated issue.’ I was elected six times to represent southern Arizona, in the State Legislature and then in Congress. I know what a complicated issue is; I know what it feels like to take a tough vote. This was neither. These senators made their decision based on political fear and on cold calculations about the money of special interests like the National Rifle Association, which in the last election cycle spent around $25 million on contributions, lobbying and outside spending.

Speaking is physically difficult for me. But my feelings are clear: I’m furious. I will not rest until we have righted the wrong these senators have done, and until we have changed our laws so we can look parents in the face and say: We are trying to keep your children safe. We cannot allow the status quo — desperately protected by the gun lobby so that they can make more money by spreading fear and misinformation — to go on.”

My deep disappointment with the Senate’s failure on guns can’t come close to that expressed by the heartbroken father of his beloved seven year old son murdered in Sandy Hook.  Mr. Barden spoke last night at the White House of his anguish at the loss of his son, his disappointment with the Senate vote, and his determination to press forward:

“We'll return home now, disappointed but not defeated. We return home with the determination that change will happen -- maybe not today, but it will happen. It will happen soon. We've always known this would be a long road, and we don't have the luxury of turning back. We will keep moving forward and build public support for common-sense solutions in the areas of mental health, school safety, and gun safety.”

(Click on this link to watch his remarks followed by President Obama’s statement).

I know that some readers of this blog argue that background checks and bans on assault weapons and high capacity magazine’s won’t work in preventing all or even most firearms injuries and deaths, and that may be true, although the best available studies and simple logic suggest that they would help.

Despite gaping loopholes, the current background check system resulted in some 1.5 million persons with criminal records being turned down when they try to buy guns. Logic tells us that a system that closes the loopholes would keep guns out of the hands of even more convicted felons.   Logic tells us that limiting access to certain guns that are designed to kill as many people as possible would result in fewer people being killed when someone tries to obtain them to inflict harm on us and others.

Some of you may also point out that the issue is more complicated than simply regulating firearms purchases—that mental health, culture, substance and alcohol abuse, and other societal factors also play a role—and with that I would agree.  But the need to examine other factors contributing to  firearms-related injuries and deaths isn’t a valid argument for not doing what we can now to keep guns out of the wrong hands and to limit their killing capacity.

Listen to more of what Gabby Giffords had to say about the Senators who voted against background checks:

“They will try to hide their decision behind grand talk, behind willfully false accounts of what the bill might have done — trust me, I know how politicians talk when they want to distract you — but their decision was based on a misplaced sense of self-interest. I say misplaced, because to preserve their dignity and their legacy, they should have heeded the voices of their constituents. They should have honored the legacy of the thousands of victims of gun violence and their families, who have begged for action, not because it would bring their loved ones back, but so that others might be spared their agony.

The should have, but they didn’t. 

Today’s question: What is your reaction to the Senate’s rejecting of expanded background checks and a ban on assault weapons and high capacity magazines?

Wednesday, April 3, 2013

What does ACP have to say about . . .

Medicare physician payment reform?  Medical liability reform?  Performance measures?  Electronic Health Records?   Medicaid expansion?  GME?  Or any of the many other public policy decisions that affect internal medicine and patient care?

Until now, you might have had a hard time finding out.   For years now, ACP has routinely posted all of its position papers, letters to Congress, comments on federal regulations, testimony and other health policy documents on our web site, but you would have had a hard time finding out what we had to say on any specific issue.   Because the College is involved in so many issues, providing policy input in so many different ways, it was very hard to locate any particular document or topic—there were just too many, and the ability to effectively search by topic was limited, at best.

Not anymore.   Earlier this week, ACP launched a total redesign of our site, organizing the content by issue topics and making it easily searchable.  And, we have created a new policy library  that allows searches of public policy documents, as well as clinical and ethical guidelines.  Here are some of the features of the advocacy site redesign that I think will make it particularly useful:

--Three topical, timely and high priority advocacy activities that we think are of greatest interest to members are featured on the landing page and updated regularly to ensure their timeliness and importance.  For instance, the current “spotlight” highlights ACP’s State of the Nation’s Healthcare paper,  released late February, and our newly updated  Internists’ Practical Guide to Understanding Health System Reform.

--On the advocacy landing page, you can click on any one of four tabs to get more information:

Where We Stand, which provides an inclusive link to ACP’s advocacy communications (letters to Congress, testimony, comments on regulations, and policy papers), sorted by eight topics: Affordable Care Act/Access to Care, Medical Liability Reform, Workforce, Medicare reform, Medicaid reform, Physician Payment/Delivery System Reform,  Health Information Technology, and Federal Budget /Appropriations.  Click on any of those topics, and you will see a comprehensive (and constantly updated) list of documents relating to ACP advocacy on that topic.

Advocates for Internal Medicine Network, which provides a link to information about ACP’s grass roots advocacy program (including how to sign up) and our latest Legislative Action Center alert on what members can do to influence an upcoming action in Congress.

State Health Policy, which provides links to resources on public policy issues arising in the states, especially relating to state implementation of the ACA.

Advocacy in Action, which provides links to advocacy events organized by ACP, such as our Leadership Day on Capitol Hill and our policy-related press briefings.

Current Public Policy Papers, also organized by issue.  These are the official policy papers approved by ACP’s Board of Regents, the basis for all of our other advocacy communications and activities.  Think of them as representing our Bible of Internal Medicine public policy.

If clicking on these four tables doesn’t get you exactly what you are looking for, you can search for a document by clicking on the ACP Policy and Recommendations library.  The library enables you to search for documents by key words and search terms, similar to how you would do a regular Google search. You can use filter settings to limit your search by date and type of document (e.g. clinical guideline, policies, testimony, letters to officials).  For instance, if you entered “SGR” as a search word, 118 documents show up; if you limit your search only to ACP “policies” relating to the SGR, 24 documents show up.

The site has other cool features: a policy compendium that summarizes ALL of ACP’s current policies, by topic (just the policies, without the background information, analysis, and references that are included in the actual position papers themselves).  And, this blog is prominently featured on the main advocacy landing page!

If you spend even a few minutes on the redesigned advocacy site, I think you will be amazed at the breadth and depth of the issues that the College has addressed.  (If there is an issue an ACP member is concerned about, it almost certainly has been addressed by the College!).  But the site isn’t just for ACP members: journalists, health policy analysts, members of Congress and their staff, and federal agency officials will now find it much easier to know what the ACP has to say.

So next time, someone asks you “What does ACP have to say about Nurse Practitioners and Primary Care” or any other issue that is on their mind. . . you will know where to get the answer. 

Give the new site and policy library a test drive and let us know what you think. 

Today’s question: what do you think about ACP’s redesigned advocacy page and policy library?