The Hammer and the Anvil

Another issue arises if patient autonomy dictates that a treatment plan has to deviate from established guidelines; in such a case, hospitalists and other physicians may be forced to provide a care plan that is entirely reasonable from a medical standpoint but counts against them when compared with a benchmark. Ethical principles dictate that patient care be given priority, but unless consideration is made within the scoring system, performance measures that do not accommodate the ethical mandates to respect patient wishes or physician judgment are substantial pitfalls in the pursuit of better quality.7,8

One last issue concerns the question of whether or not providers have an obligation to disclose quality data to patients in the context of shared decision-making. This is a murky subject that involves determining the boundaries between the best means of pursuing quality improvement and the ethics of patient advocacy. The AMA’s Code of Medical Ethics states, “Patients should receive guidance from their physicians as to the optimal course of action,” and the issue of competence and responsibility to the care of the individual patient is the focus of several of the Principles of Medical Ethics. However, there is practically nothing published regarding the ethics, implications, or results of such disclosure, presumably because the availability of large amounts of quality-based data is such a new phenomenon and the considerations of such disclosure are so uncomfortable for many physicians.

Of course, some information—“CABG report cards,” for instance—is publicly available, but the evidence that patients actually utilize this information to a significant extent or that quality has improved due to its use is mixed.5 The question of whether an obligation exists to disclose non-public information when a provider knows that there is a question about performance relative to a benchmark or comparative peer group is uncharted water, ethically speaking; the issue is further complicated by the fact that appraisal of quality is far from a perfect science. It may be that the benefits of P4P result primarily from transparency, rather than from financial incentives. If so, disclosure may be the major component of quality reform, giving further weight to this question.

The ethical problems raised by P4P are underappreciated and inadequately discussed in the literature, particularly for how rapidly and rampantly these programs are being piloted and implemented. Although the AMA has taken a fairly clear and reasonable stance on the appropriate considerations for P4P programs, it is not clear that payers are incorporating all these concerns. A substantial number of hospitalist groups receive payments from medical groups or hospitals, which in turn are already involved in P4P for some diagnoses.

All hospitalists should read and familiarize themselves with these guidelines and carefully assess the implications of forthcoming P4P proposals for their own practices and patients. On a larger scale, SHM and its membership should strongly consider taking the lead in defining appropriate processes and outcomes for hospital care that incorporate these ethical concerns and allow for meaningful conclusions regarding both quality of care and opportunities for improvement.

Dr. Harte works at the Cleveland Clinic, and Dr. Rajput works at the Robert Wood Johnson Medical School, Camden, N.J. The authors wish to thank Tom Baudendistel and Donald Krause for their review and suggestions.

References

1. Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006 Mar 16;354:1147-1156.
2. American Medical Association. Pay-for-performance principles and guidelines. Accessible at: www.ama-assn.org/meetings/public/annual05/bot5a05.doc. Last accessed September 13, 2006.
3. American Medical Association. CEJA 3-1-05 Report, July 2006. Available at: www.ama-assn.org/ama/pub/category/4325.html. Last accessed September 13, 2006.
4. Morreim EH. Result-based compensation in health care: a good, but limited, idea. J Law Med Ethics. 2001 Summer;29(2):174-181.
5. Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005 Mar 9;293:1239-1244.
6. Lindenauer PK, Pekow P, Gao S, et al. Quality of care for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. 2006;144(12):894-903.
7. Walter LC, Davidowitz NP, Heineken PA, et al. Pitfalls of converting practice guidelines into quality measures: lessons learned from a VA performance measure. JAMA. 2004 May 26;291(20):2466-2470.
8. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716-724.