Well, this should be fun.
In line with the goals of national health care reform, New York City’s public hospital system has embarked on a radical change in the way it will pay doctors. Instead of granting automatic pay increases, it will pay them based on how well they reduce costs, increase patient satisfaction and improve the quality of care. The Health and Hospitals Corporation, which runs the city’s 11 public hospitals, deserves praise for an ambitious proposal that will need to be refined as it is put into practice.
The corporation has now jettisoned that approach in new contracts with three “affiliates” — the New York University School of Medicine, the Mount Sinai School of Medicine and the Physician Affiliate Group of New York — which together employ more than 3,300 doctors who deliver care in the public hospitals. There will be no cost-of-living increases for the next three years. Instead, the contracts will give annual bonuses to the affiliates if their doctors do well in meeting performance goals, like improving the coordination of care and reducing the average length of stay.
One flaw is that there will be times when the doctors who actually provide the services cannot through their own efforts meet some of the standards by which they will be judged. One standard holds emergency room doctors responsible for reducing the time between deciding that a patient needs hospitalization and sending the patient out of the emergency room. Yet the patient cannot leave the emergency room unless there is a bed available, the room is clean, the head nurse on the floor agrees to accept the patient and an orderly arrives to transport the patient.
First of all, a disclosure: I have old professional connections with two of the three listed “affiliates.” More on that in a second.
But on to quality. Who doesn’t agree that better quality deserves higher reward? You pay more for a Lexus than you do for a Scion. The egg roll at Shun Lee costs more than the one that’s been sitting under a heat lamp all day at the hole-in-the-wall ptomaine factory around the corner. The bill from Debevoise & Plimpton will set you back a lot more than the one from the legal office you found through an ad on the bus.
Nobody disputes the rightness of any of this. And why should it be any different for medicine? As we prepare the winding cloth for the expiring fee-for-service carcass, why shouldn’t some kind of quality model take its place?
Well, first of all, who determines quality? Under our current spaghetti-pile of a healthcare “system,” third-party payers determine what gets rewarded. Unlike with luxury automobiles or affordable home furnishings or the like when consumers themselves decide whether they’ll pay more for a particular good or service, with Acura or Ikea or what have you rising or falling based on how happy it ends up making people with their purchases, with healthcare it ends up being Blue Cross (to pick a random example) who doles out the dough. Sure, “patient satisfaction” is an oft-referenced quality measure, but some satisfaction survey is at least one step removed from patients simply deciding if the care they receive is worth the money they’re paying for it. [Edited to add: For a further beef with patient satisfaction surveys as quality measure, see roto_tudor’s comment below.]
And how does one determine quality? Which measures does one use? How accurate are they?
I happen to know one of those “affiliated” public health hospitals all too well. And I can tell you that every single step in the sequence described in the last sentence of the above quote is fraught with delay and complication. In some cases, said difficulty or delay can be mitigated or circumvented. (I learned real fast not to wait around for the patient transport orderly to take my patients where they needed to be, at least if time was of the essence and I didn’t want to get yelled at because they’d missed their scheduled CT scan. I wheeled them there myself.) But heaven help you, Mr. Emergency Physician, if you got too testy that one time with Miss Smith on 8 (and yes, you had better call her by her last name, and yes, she might well go by “Miss”), because damned if that room doesn’t take forever to get cleaned. And now, if your paycheck is on the line? My friend, you’d best march up there with the Windex yourself. (Conciliatory flowers will be cheap at any price.)
I’m hardly immune to this out here in Private Practice Land, either. And I assure you that the menu of quality measures we can shoot for is arbitrary and confusing. (As of now, at least, I believe we’re still allowed to a certain extent to select which quality benchmarks to meet. We try to select goals we can hit, as opposed to pie-in-the-sky attempts at solving intractable problems. Obesity reduction? Forget it.) If our asthmatic patients are supposed to get a set number of check-ups per year, do we have to have them schlep back to our office even if they’re seeing an allergist for asthma management? If I’m supposed to have a certain percentage of my teenage patients screened for a common STI, must I order a test on my Tanner II boy who evinces utterly no interest in sex at this time? (Particularly when that test will then freak the crap out of the parents when it appears on their Explanation of Benefits statement sometime in the future?)
What’s the solution to this problem? Hell if I should know. Since the Affordable Care Act seems to have doubled down on our current hash of a system, clearly we’re stuck with profit-based outside entities deciding what kinds of healthcare are paid for at what level for everyone for a while yet. Do I agree with the Times editorial board that doctors should be compensated in a manner that takes account of how good a job they’re doing? Sure. But I think we’re a long way from a system that will reliably do that.