Concern over pay for performance

Report Cards for Doctors? Grades Are Likely to Be A, B, C . . . and I

The prospect of a report card in my future always reminds me of a diabetic woman from my past. She spent the year after her divorce sitting on her couch eating ice cream straight from the carton. Her medications went untouched. She still came in to see us quite a bit, but she refused to be weighed, refused to have her blood pressure measured, refused antidepressants, refused to see a psychiatrist. Her blood sugar ran so high the lab invariably called us in a panic. We tried everything; nothing worked.

I felt terrible for her, but had anyone been grading me on my management of diabetes that year, I would have felt even worse for myself because I would have flunked. She would have brought me right down with her. With my reputation (or a cash bonus) at stake, would I have done better at taking care of her? Or would I instead have begun to hate her for bringing down my “diabetes” grade and lowering my income? Would I eventually have told her just to stay home until she could behave, so at least my failure to make her better was not so visible in the record? Would we have lost her trust then for good?

Eventually the patient pulled herself together and got her sugar back under control. She thanked us for all we had done for her in the interim. We thought we hadn’t done much, and certainly the quality mavens would have agreed. But sometimes quality of care transcends the usual markers.

Rewarding doctors for good outcomes may well work out fine. Still, I can’t quite forget the edge in the eye doctor’s voice when she spoke about patients who weren’t doing quite as well as she would have liked. A real dislike hid behind all her cheery disclaimers. Her failures, as she saw them, badly interfered with her self-image. She wanted nothing to do with them.

Of course, when she and all the rest of us are prodded to pursue good outcomes with grades and merit bonuses, we will all still have our failures. Will we have the strength to stand by them, or will we just tell them all to stay home?

The essayist raises one of several important issues about report cards. We already see this issue affect surgeons’ decision making. Many surgeons are reluctant to operate on the more complex, sicker patients because it may adversely affect their mortality statistics.

Will report cards lead to “cherry picking” or increased firing of patients? We must be ready for the unintended consequences which could occur once we have pay for performance.

One way to avoid this is to evaluate process rather than outcome. If one documents that the patient refuses to have an eye exam, a process measure could still give one credit for offering the eye exam.

I also worry about how one constructs the report card. Do we give one summary score? If so, do we value each measure equally, or do we have a weighting scheme. We have done research (presented in abstract form) which shows that physicians do not weight various process measures as having equivalent importance. The weighting scheme could affect ones overall grade.

I hope we have intelligent researchers involved in studying pay for performance. They should consider these and other issues.

Will our report cards really measure physician quality? We measure “low hanging fruit”. We may be victims of this old joke (cited previously on this blog):

Hooker liked good living and high times, so let’s share a joke in his memory. A man sees his drunken friend circling a lampost at night. “What are you doing there Bill?” “I’m looking for my house key.” “But you lost it in the tavern, Bill.” “I know, but there’s more light here.”

I believe that report cards can have a positive impact. I suspect that impact to be modest, as the report cards will only address process on common quality issues. They cannot possibly evaluate skills like diagnostic acumen, bedside manner and recognition of drug side-effects.

We (physicians, and especially academic physicians) must point out these issues to everyone who might listen. Report cards are an interesting idea, but are they really a good idea? Will they pervert our focus? Will they really improve medical care?