Summary: An excellent commentary describes how two decades of paying to improve quality metrics has failed. Quality hasn’t improved, and we’ve spent billions of dollars and hours on quality indicators of dubious validity. We’ve compromised the practice of medicine, and increased disparities. Universal insurance is the foundation for improving quality.
Reassessing Quality Assessment – The Flawed System for Fixing a Flawed System
New England Journal of Medicine
April 13, 2022
Lisa Rosenbaum, M.D.
[R]ecently, there has been growing recognition of the QI movement’s shortcomings. One study, for instance, showed that only 37% of MIPS measures for ambulatory internal medicine were valid, and even CMS and the Government Accountability Office have acknowledged the need to improve the quality of measuring quality.
[O]nce a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure. Consultants get hired. Electronic health records (EHRs) are changed. And the measures become a source of intense organizational focus. Not only does it become difficult to modify measures that aren’t clearly working, but a tremendous amount of resources are directed toward the appearance of quality rather than its substance.
[V]alue-based payment initiatives can also worsen inequities, even though addressing them ought to be at the forefront of our QI efforts. Indeed, after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties. In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. And hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.
Punishing the hospitals and patients most in need of support makes “zero sense,” says Wadhera. He notes the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices. And though such consequences create hard-to-quantify indirect costs, truly unquantifiable is the loss to society as consummate community physicians become a dying breed. “Community doctors want to practice medicine,” said Wadhera. “They don’t want to practice quality measurement.”
Some early QI leaders recognized the risk of demoralizing the workforce.
Comment by: Jim Kahn
This thoughtful perspective highlights critical points about our efforts to improve quality with financial incentives, often under the rubric of “value-based care”.
First, financial incentives largely failed to improve quality. There have been a few focal benefits, but rare.
Second, they harm the practice of medicine, by distracting physicians from a focus on clinical care to documentation of quality metrics.
Third, and related, the imperative to increase revenue with quality scores makes coding even more onerous. Unwelcome added time in the EHR is the result.
Fourth, medicine “plays to the code” – any modest gains in measured tasks result in less attention to important quality activities that aren’t in the metric set.
Fifth, the onerous requirements for all this coding, too much for small physician offices, instigated a shift to corporate ownership of providers. That increases costs. (And makes medicine more corporate, which many of us dislike.)
Finally, disparities – inferior resources for the poor and sick – are exacerbated. Exactly the opposite of what we want.
The poor theoretical basis of financial incentives in medicine was pointed out long ago, by among others two HJM bloggers and a behavioral economist. Financial incentives diminish the intrinsic motivation that is so widespread and valuable in medicine.
Recently, several leaders in quality improvement described well the failings of numerical quality scores and proposed a new “criterion” approach. The details need working out, but the move away from competitive scoring linked to reimbursement is very welcome indeed.
The other critical element of improving quality is to remove the distraction of missing, inadequate, and inconsistent insurance. Just cover everybody, with exactly the same benefits and same payments. (Single payer!) Let physicians focus on their clinical mission, provide resources to help them keep improving, and measure success with non-punitive outcome tracking and by talking with patients.