Quality Reporting

Some might think pay-for-performance (P4P) is just a passing fancy of the healthcare financing melodrama. I don’t think so. I believe that P4P is just the beginning of a sea change in medicine where healthcare is paid for based on results.

In the past, healthcare has been payment for doing. The more you do, the more you get paid. All cognitive services and procedures are coded by complexity of the service and paid for by doing them. Results have been assumed. No more. One would need to be asleep not to have noticed that quality reporting has permeated healthcare for years now, and both the purchasers and recipients of healthcare want to know what they are getting for their money.

Payment just for doing will become a memory of a simpler time in medicine. Now that we have better information systems, and the cost of healthcare has become a lightening rod for personal or social spending, results matter more than ever.

George Halvorson, the CEO of Kaiser, has a new book, Health Care Reform Now! He describes that purchasers of healthcare will increasingly pay attention to results. He writes, “When we have reached the point where the cost of healthcare at GM exceeds the cost of steel in a car and the cost of healthcare coverage at Starbucks exceeds the actual cost of coffee, then it’s time for the major buyers to stop thinking of healthcare as a cost-plus, un-engineered, externally shaped, seller-defined, completely unmanaged purchasing expense.” Purchasers of care want to know just what results they are buying, much the same as when they buy anything else today, such as the quality of the steel and coffee. Quality reporting is the only way to accomplish this.

Is quality reporting fair? Not always. Every physician knows that quality reporting only captures a slice of the care that is delivered in the physician-patient relationship. The slice that is measured often feels out of context of the total care being delivered. Worse yet, physicians see themselves penalized by patients that are not compliant with their care and do not take responsibility for getting good results. Quality reporting feels like a game that physicians must play, and when that happens, gaming the system becomes a reactionary behavior. A recent editorial in JAMA highlights the potential dark side of quality reporting, with physicians engineering only mild diabetes into their practice and then easily getting them into control and looking great, while others can take care of the more difficult patients (1).

Despite all that, accountability in medical practice will be no longer assumed, but measured. Increasingly sophisticated information systems allow for an analysis of care across a population of patients in every medical practice. When populations of diabetic and hypertensive patients are well controlled, healthcare costs go down. Payers want that, and medical practices will be rewarded for doing that. The processes of care will shift from the traditional “make an appointment, come and get it” reactive style of care to more proactive models in which patients with chronic illnesses will be contacted by the practice to receive care. Such proactive care has been shown to achieve dramatically better results.

Einstein said, “Not everything that can be counted counts and not everything that counts can be counted.” Quality reporting in medical practice will always be a partial and imperfect look at the care being delivered. Like always, physicians will need to derive their own satisfaction from a job well done with challenging patients. But all physicians that are paid by third-party payers will need to accept the challenges of achieving best practice management in medical practice and report their results.

Physicians with extensive practice experience will need to be in control of these payment-for-quality reporting systems to be sure that they recognize the complexities and vagaries of caring for any mixed population of patients. Getting a diabetic patient that is extremely out of control to fair control is just as valuable as getting one in fair control into excellent control. The challenge of the former is usually greater. Quality reporting systems should not be fixed on ideal numbers but should reward clinical improvement at all levels.

I believe that the transition to payment for results will be messy but overall worthwhile. Medical practice will improve, and our patients will be healthier. Population-focused proactive care will be better than traditional, individually delivered, reactive care, where the overall results in a community were unknown. Hopefully, the medical profession will meet the challenge of improved care and not spend time trying to game the reporting systems. Ultimately, new models of accountability will catch up with us all.

References:

1. Halvorson G. Health Care Reform Now! San Francisco: Jossey-Bass, 2007 pp. 173–174.
2. Hayward RA, Kent DM. 6 EZ Steps to Improving Your Performance: (or How to Make P4P Pay 4U!) JAMA, July 16, 2008; 300: 255–256.