Paying for Quality

Quality and Cost are Two Pillars of Effective Healthcare  

We are bombarded with two messages about the healthcare we deliver in America; care is too expensive and the “quality” of that care is not as good as that of care in many other industrialized nations. The issue of cost was fodder for my previous post and, I’m certain, for many subsequent posts. Right now, though, I would like to focus on “quality”. What is quality? Is it as defined by Webster “degree of excellence; superiority in kind”? Or, when asked to define “quality”, would most of us respond as did Justice Potter Stewart when he wrestled with the definition of “hard core pornography” in Jacobellis vs.Ohio, “I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description; and perhaps I could never succeed in intelligibly doing so.
But I know it when I see it…”

The definition of “quality” is more than just an academic exercise. Just as the method by which clinicians and hospitals are paid for the delivery of care almost certainly must change, so will the criteria upon which we receive such payment. As previously noted, providers are currently paid on the basis of the type and number of units of care they render (i.e. “stuff”) without regard to the effectiveness of the “stuff” and without regard to the outcome experienced by the patient. I believe that this too will change. Just as many voices are now calling for more affordable healthcare, many voices; employers (e.g. the Leapfrog Group), healthcare providers (e.g. the Institute of Medicine, the Institute for Healthcare Improvement), insurers, including Medicare, and ordinary citizens are demanding higher quality care. The Centers for Medicare and Medicaid Services (CMS) has already announced that it will stop paying for additional costs associated with preventable complications like blood stream infections after insertion of a catheter into a large vein. Right now, the types of complications to which this penalty would apply are the result of fairly egregious lapses such as those found on the Leapfrog Group’s list of “never” events (see www.leapfroggroup.org for details). If you wind up with a Kelly clamp left in your belly after an abdominal surgery, there is a good chance that CMS will not pay the hospital or the surgery team for the costs associated with going back to fetch it, but if you wind up with said Kelly clamp in your abdomen, not being paid by CMS is unlikely to be their only, or for that matter, their worst problem. There would be any number of plaintiff’s attorneys lined up to throw your x-rays; the ones with the bright, white Kelly clamp gleaming against the black and grey background of bowel gas and abdominal organs, in front of a jury and scream “res ipsa loquitur” (which is Latin for “I’ll take my 30 percent in small bills, if you please.”) And, they would probably find themselves visiting with one or more hospital quality committees (picture a warm room and a cool reception). So there already significant deterrents against the commission of egregious medical errors and yet they keep happening. So how will refusal of payment make care any better?

When applied to individual episodes of care, a penalty might not have a significant impact, but suppose a different approach is taken. What if CMS and other payers decide to offer a bonus payment to institutions that offer “high quality care”, as measured by things like the overall rate of blood stream infections and pneumonias in patients who are on ventilators and, conversely, to reduce payments to institutions that do not meet their definition of “high quality care”? A two or three percent reduction in Medicare payments alone could have a crippling impact on some hospitals and would almost certainly serve as an incentive for these institutions to change their practices. I believe that this is almost certain to happen. And, things could be even worse for low-performing facilities. Through the ACE demonstration project (see my March 12^th post), CMS has already indicated a willingness to designate certain facilities as preferred providers and direct their beneficiaries to those hospitals and clinics. They could, and probably will take the same approach with those hospitals and other facilities that they designate as “high quality” providers. Additionally, certain measures of quality have already been posted on the internet by government agencies and by private rating services. The impact of such postings remains to be seen but providers and facilities must be prepared to have detailed information about their care readily available to the public. Just as you can pick a copy of Consumer Reports and see how a car you are considering fared in crash tests, you will be able to see how several local hospitals and surgeons compare. Taken to its logical conclusion, this kind of approach means that hospitals with a commitment to safe, effective, and efficient care will thrive and those who consistently fail to provide this kind of care will risk failure.

So is anything wrong with this approach? To be sure, transparency is usually a good thing but, nothing is perfect. The problem with the public dissemination of quality information can be summarized by two quotes; one by those 80’s icons, The Talking Heads and the other attributed to Albert Einstein. In their song Crosseyed and Painless, The Talking Heads sing “Facts all come with points of view; facts don’t do what I want them to.” And Albert Einstein had a sign over his desk that said the following: “Not everything that counts can be counted and not everything that can be counted counts.” The former quote aptly describes the problem of bias in the selection of which data are reported. The type of information reported can make institutions or providers appear to be significantly different even when they are not. For example, one commonly reported measure is the in-hospital death rate for patients with certain diagnoses. Even when evaluators attempt to level the playing field by insuring appropriate comparisons things can go awry. Let’s say that we have two hospitals, “Outside General” and “Medical Center General”. Outside General is a very capable and well-regarded community hospital offering a wide range of services including cardiac care. Medical Center General is a tertiary care facility staffed by faculty physicians from a medical school and, as such, often manages very complicated and difficult patients. Assume, then, that two 65 year-old men with coronary artery disease are admitted on the same day to Outside General Hospital for the same procedure performed by the same physician. We’ll call them “Bill” and “Joe” Bill’s procedure goes just as planned and he makes a reasonably quick recovery and is discharged home within a few days but Joe isn’t as fortunate. Although his procedure seems to go well, he gets a post-operative infection and becomes critically ill. After several days in the intensive care unit, the team caring for Joe decides that his only hope is transfer to a tertiary care hospital and so he is transferred to Medical Center General. Shortly after Joe arrives at Medical Center General, however, the physicians there recognize that Joe is very unlikely to survive and, indeed he dies a day later. So, when Medical Center General and Outside General are compared on the basis of mortality for cardiac patients with similar characteristics, Medical Center General might not look as good because it has received in transfer many patients like Joe, whose illnesses have progressed to the point that further advanced care is almost certainly futile. And, Outside General has transferred many such patients out before they died, so their mortality rates are quite low. Now, this is not intended to be an indictment of the physicians at hospitals like Outside General. Physicians and families alike want to sure that the patient has been given every chance to recover. But, by the same token, it is not fair to compare a hospital that receives many transfers and one that does not as if they are like institutions; they simply are not.

Einstein’s quote reminds us that many things that we would like to know about simply cannot be effectively measured and much that we can measure and report provides no useful information. In a desperate attempt to find some data to compare two people or institutions, we sometimes employ data that borders on the silly. Important, but difficult-to-measure data is unlikely to be recorded or reported while easily measured but meaningless data can be on the front page.

Then, there is the entire issue of incentives and what they do and do not do in terms of producing “quality” outcomes but that topic will have to wait.