Potential Consequences of Physician Performance Measurement on Patient Care: Maintaining Bioethics Awareness

Physician performance measurement is here to stay. With programmatic requirements enacted under healthcare reform, private-payer mandates, as well as the high degree of public interest in physician performance transparency, there is a growing and evolving movement to measure the quality of care that physicians provide, and subsequently report that quality performance to the public.

Patients, payers, and government are searching for methods of measuring and comparing the quality of care that physicians and physician groups provide to patients, mainly in the interest of transparency in consumer choice and accountability, but also clearly to limit costs.

For physicians, performance measurement, whether private or public, allows them to objectively assess the quality of care they provide, which can direct CME efforts and clinical behavior. This is important, as physicians have a limited ability to accurately self-assess in the absence of objective feedback (1). Thus, accurate measurement of physician performance is necessary and important to promote quality and safety in healthcare.

The Problem: How?

Unfortunately, how to evaluate the quality of care that physicians provide has been a tremendous challenge. At the outset, measures currently being used in programs, while typically evolving from clinical practice guidelines, do not always reflect high-quality care in specific patient circumstances (2). Areas of concern have been raised regarding attribution of patients to providers, longitudinal care, accuracy of data with respect to sample size, as well as provisions for patient autonomy when declining recommended management (2–5). Nonetheless, despite the need for measures to evolve and improve, quality outcomes measures (whether internal or external, private or public) continue to be used. In this context, several areas of bioethical concern for physicians arise that may impact patient care. Some of these are reviewed below.

“Treating for the Lab Number”

In the interest of meeting quality goals, physicians could potentially be pressured to prescribe multiple medications to demonstrate control of a single clinical issue, despite the risks that polypharmacy may create for patients. For example, Boyd et al. presented the case of a hypothetical patient (6) who, if treated according to current clinical practice guidelines, would encounter several “potential adverse effects on other diseases when treating the target disease, interactions between recommended medications, and interactions between food and medications” (6).

However, the danger of polypharmacy in patients under clinical performance measures can be further exacerbated by a physician’s interest in “treating to the test” to meet measures of quality care. For example, overaggressive treatment of blood pressure, LDL, hemoglobin A1C, or any number of clinical values may be a temptation to achieve quality targets at the expense of truly considering the needs or complicating social situation of an elderly or complex patient first and foremost.

“Treating for the Patient Satisfaction Number”

Physicians have been reported to increase drug prescriptions when they deem a patient desires the therapy (7). The thought is, by increasing desired prescriptions, patient experience and satisfaction scores will rise, and financial incentives in this area will increase (8). Clearly, this is inappropriate clinically as well as ethically. Beyond inappropriate use of drugs, as well as untoward effects such as increasing drug resistance when antibiotics are inappropriately prescribed, this is ethically suspect because of the lack of medical appropriateness for providing treatment. Thus, when patient satisfaction is measured as an indicator of physician performance, physicians must guard against prescribing unwarranted therapies in the context of patient desire for therapy.

“Treating Only Measured Care”

Several studies have suggested that the quality of unmeasured care falls as physicians focus their efforts on the quality of measured care (9,10). These studies imply that the very act of choosing which areas of care to measure performance represents an act of agenda-setting that can adversely influence a physician’s judgment on which areas of care delivery are a priority for a given patient or set of patients.

The work of Higashi and colleagues also demonstrates that “the quality of care, measured according to whether patients were offered recommended services, increases as a patient’s number of chronic conditions increases” (11). This suggests that physicians may, in fact, inadvertently provide sub-optimal care to patients perceived as “less complex” and less likely to affect performance measures in lieu of directing focus to patients perceived as more likely to affect performance scores.

This reduced care may result in missed opportunities for effective screening and prevention. In this setting, physicians must be cognizant that all care is relevant to be assessed, rather than simply care that will be the basis of performance measurement.

“Treating Only Advantageous Patients”

Some physicians have reported that they are more likely to refuse care to patients who have severe disease or have treatment intolerance because of the potential to adversely affect physician performance measures (9,12). However, boldly refusing to treat a needy patient because of performance measures does not place the patient’s interests first, a key tenet of medical ethics. Such refusal may also implicate civil rights laws and liability if this refusal is seen as inappropriate discrimination (13).

“Treating for Score Outcome”

Take the example of a hypothetical patient, well known by her physician to have controlled blood pressures documented below 130/80 over multiple visits. She shows up for an acute care visit in pain, has not taken her blood pressure medications that morning, and has a documented blood pressure of 155/95.

In an effort to salvage the performance measurement of hypertension control, a physician will theoretically either have to “game” the reading or ask the patient to come back for a follow-up visit just for a blood-pressure check. This repeat visit merely to document a controlled “most recent” blood pressure represents a significant time (and potential financial) burden to the patient. This, too, is highly suspect ethically as it focuses on medical treatment that is not in the best interest of the patient. As well, of course, each additional test, procedure, and medical action has its own risk for patient injury. Treating for score outcome hence places those additional clinical risks on the patient without an accompanying potential medical benefit.

“Treating Against the Patient”

There is a potential strain created in the patient-physician relationship as it relates to patient adherence to recommendations and performance measurement. On the one hand, it is important to respect patient autonomy, and doing so will build trust between a patient and a physician. On the other hand, a good physician who is delivering quality care will arguably be more adept at rationalizing with a non-adherent patient and recruiting the patient’s buy-in to the treatment plan. However, when the performance measure is in place that penalizes a physician for patient non-adherence to clinical measures, patient autonomy can be theoretically compromised as physicians may pressure them to accept treatment plans so as to improve performance measures or build resentment when the patient refuses (9). Physicians must have a high index of awareness in this arena, because financial incentives combined with a desire to provide optimum treatment may justify internally a physician’s decision to push for one kind of care.

Treating the Patient

Given the inevitability of physician performance measurement, it is vitally important that physicians make a concerted effort to understand and mitigate the adverse affects that performance measurement can have on patient care. Many of the issues that arise as the result of performance measurement are not new, but they are magnified by the sometimes-confounding incentives created as a result of measurement. Physicians have an obligation to patient-centered, ethical care. And, despite the implied value that performance measurement places on A+ care for all patients based upon identical criteria for every patient, medicine remains an art and requires the sound and ethical judgment of a physician caring for the patient.

What this means, of course, is that the mission of the responsible physician under performance measurement systems does not change from the standard medical ethics tenets. Avoidance of gaming any system, maintaining clinical competency, and consistent provision of quality care in a patient-centered way is and will be the standard for success, as it always has been. What is different is that we are starting to move to a practice world where we can be provided with important data to help our patients reach their healthcare goals. Although there are challenges, the movement toward performance measurement can eventually reward the best quality, for the most patients, for the benefit of this generation of patients and future generations.

References:

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12. Farber NJ, Jordan ME, Silverstein J, Collier VU, Weiner J, Boyer EG. Primary care physicians’ decisions about discharging patients from their practices. J Gen Intern Med. 2008; 23(3):283-7.
13. Liang BA. Doctor’s Docket: Bragdon v. Abbott. J Clin Anes. 1999;11:494-498.