Wednesday, February 10, 2016

Performance [Measure] Anxiety

Just as the U.S. healthcare system is about to make performance measurement a central feature of…well, just about everything doctors do…some prominent and highly influential physicians are asking for a pause and reassessment.  

Writing for the New York Times, Dr. Bob Wachter argues that “Two of our most vital industries, health care and education, have become increasingly subjected to metrics and measurements. Of course, we need to hold professionals accountable. But the focus on numbers has gone too far. We’re hitting the targets, but missing the point ...“

The drive to performance measurement, he says, started “innocently enough” as "evidence mounted that both fields were producing mediocre outcomes at unsustainable costs.” Now, though “the measurement fad has spun out of control.  There are so many different hospital ratings that more than 1,600 medical centers can now lay claim to being included on a ‘top 100, ‘honor roll,’ grade ‘A’ or ‘best’  hospitals list. Burnout rates for doctors top 50 percent, far higher than other professions. A 2013 study found that the electronic health record was a dominant culprit. Another 2013 study found that emergency room doctors clicked a mouse 4,000 times during a 10-hour shift. The computer systems have become the dark force behind quality measures.  Education is experiencing its own version of measurement fatigue. Educators complain that the focus on student test performance comes at the expense of learning. Art, music and physical education have withered, because, really, why bother if they’re not on the test?”

He’s not the only Dr. Bob who is anxious about performance measures.  Dr. Bob Berenson, who has for years played a key role in influencing Medicare payment policies as a former Vice Chair of the Medicare Payment Advisory Commission and, in the 1990s, as acting administrator of CMS, takes on the “myth” that W. Edwards Deming, the famed quality improvement guru, said that “if something cannot be measured, it cannot be improved”—the justification offered by many for the proliferation of performance measures.   According to Dr. Berneson, Deming actually wrote the opposite, “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth.”  Dr. Berenson continues  “The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by Deming, other management experts, or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.”

He argues that the Medicare Access and CHIP Reauthorization Act (MACRA), which will steadily increase the amount of Medicare payments to physicians that are based on measures of value, will likely turn out to be “a doomed attempt to measure value.”   “Practical challenges aside, pay for performance for health professionals may simply be a bad idea. Behavioral economists find that tangible rewards can undermine motivation for tasks that are intrinsically interesting or rewarding. Furthermore, such rewards have their strongest negative impact when they are perceived as being large, controlling, contingent on very specific task performance, or associated with surveillance, deadlines, or threats..."

And then there is Dr. Bob Centor, chair Emeriti of the ACP Board of Regents, who is a long-time critic of performance measures.  Writing in his DB’s Medical Rants blog, Dr. Centor notes “I first wrote about my concerns [about performance measures] over 10 years ago.  In those early days of the blogosphere, few experts paid attention to our ranting.  .  .We can only hope that these commentaries will stimulate greater attention on the problems of performance measurement.  Read these [Dr. Wachter’s and Dr. Berenson’s] commentaries and understand the bloggers made these points 10 years ago.  We understood what could go wrong and predicted the current problems.  Of course we were labeled kooks back then.”

As a Bob myself (albeit not a doctor!), I think we all need to consider the advice of these three very thoughtful and respected Dr. Bob’s about the hazards of performance measures.   The potential for unintended consequences is real, including contributing to physician burn-out by adding more unnecessary administrative burdens to an already burdensome system, undermining professionalism, exacerbating health care disparities (because physicians who serve underserved populations may not score as well on some of the measures), and creating the medical equivalent of teaching to the test, as physicians divert their attention to the aspects of care being measured at the expense of those not being measured.

Yet I disagree with Dr. Berenson that MACRA was a “bad idea” and “likely doomed attempt to measure value.”  Not only was MACRA the means for getting the universally loathed Medicare SGR formula repealed (without it, we’d still likely be facing double-digit SGR cuts in payment to physicians), MACRA is really about making fundamental, and, I would argue, needed reforms to how physicians are paid and care is delivered—moving payments away from rewarding volume, engaging patients in their own care and in shared decision-making with their physicians, and moving care delivery away from silos of care into integrated, team-based, and patient-centered models like Patient-Centered Medical Homes.   Keep in mind that paying physicians based on volume—that is, fee-for-service—itself has many documented adverse consequences on patient care, including higher costs, over-testing, and the over-valuation of procedures at the expense of primary care and cognitive care.  Under FFS, physicians who see the most patients and spend the least time with them, and who order or perform the most procedures, are rewarded; physicians who see fewer patients yet spend more time with them, and who do not order or perform procedures, are penalized.  MACRA is an effort to change all of this by putting the emphasis on value rather than volume, moving physicians and Medicare payment policies away from fee-for-service.

Yes, performance measurement is an important part of MACRA, but the goal really isn’t for Medicare to impose ever more measures on physicians just because it can.  Rather, it is to use Medicare payment policies to encourage innovation in how care is delivered, and then carefully apply measures to assess how well those innovations are contributing to the Triple Aim of better individual health, better population health, and lower per capita costs—all things that, it seems to me, can be measured, especially the latter two, even if the most commonly used measures today don’t yet fit the bill.  Further, MACRA itself calls for harmonization of measures across the current Medicare reporting programs, creates a process for the medical profession and others to propose new and better measures, and other needed improvements.

The three Dr. Bobs are right, in that we shouldn’t design payments and delivery systems around performance measures. We shouldn’t think that care will be better if we dangle a few dollars out to physicians for meeting this measure or that.  Instead, we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences.  MACRA may very well turn out to be an imperfect framework to achieve this, but it is a good start and should be given a chance to work.

Today’s question: Do you agree or disagree with what the three Dr. Bobs have to say about performance measures?


PCP said...

Once again a bit disingenuous for the ACP to have supported the ACA which ushered/accelerated in much of these demoralizing issues for the profession, and then come out now saying this is not workable/cumbersome/costly etc.

It is obvious that EHRs are more about control and command from the central planners.

This reminds me of the line "the operation was successful but the patient died".

Professionals should be respected, and reviewed by peers. Accountability ahould be at a global level, not micromanaged.

Jay Larson MD said...

Performance measures can have an adverse effect on patient care depending on how much it impacts payment. If it has a substantial impact, physician behavior will change, but not in a good way. It probably won't slow an already busy practitioner, but it encourages the physician to select out the patients that meet the performance measures and have the rest transfer care. I have taken a number of patients into my practice from other PCPs because the patient was "Non-compliant". Poor performance on quality measures can be due to many factors. Patient population being one of them. If you are the only internist in town and take care of the sickest of the sick, there won't be healthy patients to improve the measures. Besides the best qualities of a physician...empathy, compassion, dedication, humanism cannot be measured by a number.

MACRA will have a deleterious effect on primary care. The extra work to improve and report "metrics" will not be adequately compensated by the meager payment increases. Most of the MACRA requirements fall onto primary care. It will have little impact on the proceduralists. All they have to do is add another 1-2 procedures and they make up any decrease in payment for not doing quality reporting, there by increasing volume even more.

With all the hassle that primary care providers go through already, isn't in time for insurances to just increase payment to PCPs without any more hoops to jump through?

Angus Worthing, MD said...

MACRA has 2 components: MIPS with various performance measures and lock step cuts,and APMs which allow avoiding cuts but force doctors to share a risk of costs. Thus MACRA appears to use threats of measures and cuts to incentivize doctors into risk bearing contracts in APMs. The success or failure of MACRA will rest on this herding process and whether APMs succeed.

DrJHO7 said...

I think that performance measures might be useful if we had the right ones. In clinical medicine we are cautioned not to focus our concerns excessively on "surrogate markers" such as blood pressure measurements or cholesterol levels, but rather to focus on the treatment of the patient's condition or disease, taking into account the nuances of their individual characteristics, their medical history, the potential for treatment to influence clinical outcomes, their preferences. A lot of that stuff is impossible to measure, but it is the essence of doctoring and it is really important to the health of our patients.

I have been surprised, in participating on the quality improvement committee of a Clinically Integrated Network, how very difficult it is to agree on meaningful quality measures that can be measured with any accuracy, for a specialty, that have any relevance in assessing what those physicians actually do for their patients. If such "measures" are to be the mainstay of how the work of physicians is assessed, and based on that, how we are paid, then I think the future of medicine in America is doomed to wasting an incredible amount of time, effort and resources on a massive, convoluted mess of irrelevance. There has to be a better and easier way.