We are now knee deep in the quality revolution. In some ways, this should have been driven by the hospitals and doctors striving for continual quality improvement. It should have been driven by patients demanding better outcomes, more uniform processes, and the data to help them decide where to receive the best care. In reality it is being driven by those who pay for care—America’s businesses and our government, two entities that want better value for the increasingly dear dollars they spend on healthcare.
Hospitals and doctors have survived (and many have succeeded) by using the traditional compensation system, which rewards the performing of care without rewarding the best or even the better practice of medicine. Today you can do the wrong procedure and do it poorly and still get paid. The mantra of the entire performance and standards effort is to shift at least some of the rewards to those with better outcomes, to processes that are more in line with national practice standards, and to those who have the data to back that up. In marketing shorthand, this is pay for performance—or P4P—and while it seems natural in most of the rest of the American marketplace, it is somewhat revolutionary in healthcare.
While the concept of identifying best practices, measuring performance, collecting data, and then appropriately tying compensation or rewards to performance sounds clear and straightforward, many issues quickly surface to cloud any forward progress.
Decide What to Measure
Unfortunately, you can arrive quickly and efficiently at the wrong destination. Everyone knows that some of the hallmarks of physicians are that we can “perform for the test” and adapt to a new paradigm. It is important that we don’t just settle for what we can easily measure (knowing that most of our systems’ data collection efforts are geared initially to getting paid and not to measuring key performance indicators), but that we make sure that we are selecting performance measures that lead to better patient outcomes and improve care. Hospitalists must constantly examine their hospitals’ plans for data collection to ensure that achieving high marks will lead to better patient care.
Data, Data, Who Gets the Data?
There is no doubt that the by-product of the current P4P movement is that there will be more known about doctors and hospitals than ever before. Like nuclear energy, this volatile resource can be used for good or evil. It is not a trivial issue of who “owns” the data and who has access to it.
How valuable would it be to the pharmaceutical industry to know which doctors treat a lot of heart failure and which medications they use and why? How valuable would it be for insurance companies to see physician or hospital performance data not just for their insured, but for all of a physician’s or institution’s patients? Who will control access to all the data that will be collected?
This plays into another important question: Just how will individual or small independent groups of physicians pay for all this reporting? Very likely, data collection and reporting will be an additional cost of doing business for an already strapped profession. To succeed—or just to stay in the game—physicians will need to upgrade their systems with new hardware and software, while facing the prospect of having their payment diminished or of being cut off from certain patients. What if a hospital offered physicians free systems upgrades in exchange for a look at all the physicians’ data? What if pharmaceutical companies made the same offer? Would physicians potentially sell their information for a handful of beads?