Thursday, August 9, 2007
Limits of Technology - Data Uber Alles: Or: P’s (Physician Profiling, Physician Protocols, and Pay-for-Performance) Be Upon You
In God we trust. All others use data.
Mary Walton, The Deming Management Method, Perigree Press, 1986
I’m part of a drowning minority swimming against the incoming data tide. Numbers don’t capture human interactions or intangibles, and I don’t believe data alone captures physician quality.
Mine is a hard position to defend. I have frequent conversations with two friends. One is a former VP of medical affairs for an international corporation. The other is a prominent health care analyst and reformer. Both are wholly dedicated to this proposition:
Scientific and process data on physicians is an effective tool for separating and rewarding high performers from also-rans, and will measurably improve health care performance and cut costs.
I’m dubious. My question is: cut costs for whom? For government, health plans, society? EMRs may save money for society but not for doctors.(1) And it’s yet to be determined if quality gains outweigh costs. (2)
•Many patients have idiopathic, vague, and emotional conditions that don’t lend themselves to scientifically-evidence or treatment. Further, I have yet to see a comprehensive study of serial patients in a busy medical practice documenting what conditions can be pigeon-holed as scientifically based or indeterminate.
•If you try to apply data-driven physician profiling and pay-for-performance cookie-cutter measures to masses of physicians, you will drive many out of the profession they entered because they thought they could use their own judgment – not that of some detached health plan or government agency. This doctor exodus may exaggerate an already acute physician shortage.
•Combinations and permutations of patient-physician interaction are so vast that the various Ps (physician profiling. protocols, and P4P) can’t pin down physician behaviors or define outcomes--mortality, morbidity, changed habits, good patient experience, or patient understanding and control of their disease. P4P may be a good first step, but it’s not the final step, and costs often outweigh benefits.
But to my friends, it’s data uber alles. CMS and health plans have mounted the data bandwagon, and they’re not to be denied. Judging physician by the Ps has become “imperative” separating the wheat from the chaff. I appreciate the logic of the P’s initiative; I applaud its intent; I simply assert it may have unintended and costly consequences. What you foresee may not be what you will get.
In any event, here are 15 strategies advanced for the P’s argument as set forth as a future “provider profiling and pay for performance” conference to be attended by CMS and health plan grandees
•Reward physicians who consistently demonstrate safe, timely, effective, equitable, and patient-centered care.
•Evaluate appropriate incentive options and select the best measurement strategy that will achieve your goals.
•Measure ROI from P4P and profiling initiatives.
•Create viable options for both primary physician and specialists.
•Measure physicians and hospitals, tying results directly into a program that links rewards to Centers of Excellence hospital-ranking process.
•Reap robust financial and quality rewards without expanding health care expenditures.
•Link hospital ranking and physician ranking to get results.
•Leverage economic profiling data on PPO network physicians in multiple specialties.
•Develop new revenue streams by offering profiling data served service to employers.
•Improve transparency and build collaborative profiling by openly sharing prance information with providers.
•Achieve clinically appropriate variation management by incorporating evidence-based medicine into clinical practice.
•Reduce variation in utilization.
•Leverage coalitions of employers, physicians, hospitals, patients, health planes, and other shareholders to drive quality improvement and efficiency.
•Develop reporting mechanism that compares health care quality performance in clinics and hospitals to improve decision making in all constituencies.
•Capitalize on a P4P program that pools reliable information from multiple health plans.
There you have them – noble goals all. They describe plans for your future. What about these strategies? Will they accomplish their goals of rewarding good doctors and improving quality? Or will they simply be another layer of bureaucracy?
1. Steve Lohr, “Who Pays for Efficiency,” New York Times, Juue 11, 2007
2. Am Epstein, “Pay-for-Performance at the Tipping Point,” New England Journal of Medicine, Februa