After years of research, design, pilot programs and technology investment, the movement for quality improvement and pay-for-performance is facing skepticism from outside and within.
In a new survey in JAMA Internal Medicine, health system executives express doubts about the benefits of public quality reporting and pay-for-performance. Peter Lindenauer, MD, and colleagues asked CEOs and quality improvement leaders at 380 hospitals for their thoughts on publicly-reported quality measures required by the Centers for Medicare and Medicaid Services.
While 70 percent of hospital leaders agreed with the statement that "public reporting stimulates quality improvement activity at my institution," less than 50 percent believed that differences among hospitals were clinically meaningful -- and almost half reported trying to maximize their progress largely through changes in documentation and coding.
CEOs and quality improvement directors are also somewhat split in their beliefs. Almost 60 percent of chief quality officers said they were concerned that quality measurement could distract from other priorities, compared to 45 percent of CEOs in agreement. Almost 60 percent of quality improvement directors also said they believed hospitals are gaming the system or "teaching to the test" through documentation and coding, rather than changes in actual patient care, a fear held by just 32 percent of CEOs.
The results of the survey raise a number of questions for skeptics of the pay-for-performance movement, who worry the growth is more bureaucracy rather than patient-centered care.
"Is there too much focus on measuring and reporting quality rather than on the conditions needed for improving it?" asks Lara Goitein, MD, an internist and intensive care specialist at Christus St Vincent Regional Medical Center, in Santa Fe, in a perspective in JAMA Internal Medicine.
"CMS and private payers are tying reimbursement partly to data from such measures in pay-for-performance programs," Goitein writes. "However, as the director of an intensive care unit performance improvement program, I know that it is difficult -- and sometimes counterproductive -- to try to improve a complex system simply by rewarding or penalizing the results."
Pay-for-performance "is graceful in theory," but "in application it proves awkward," Goitein argues, adding that the approach is essentially more of the same of what causes problems in the first place. "At present, the problem is too many financial incentives, not too few."
Because reported quality measures "reflect national rather than local priorities, they may divert attention from other, perhaps more important problems in individual hospitals -- a form of teaching to the test," Goitein writes.
Some healthcare professionals "may avoid high-risk or nonadherent patients" or "base triage decision on their effect on performance measures," such as choosing not to admit patients likely to be readmitted by the emergency department, or omitting screening that may identify conditions like hospital-acquired venous thromboembolisms or infections.
A large part of the problem with the current pay-for-performance models, Goitein argues, is that the initiatives tend to "take quality improvement out of the hands of clinicians and uncouple measurement from its clinical context."
"Hospital hallways are full of displays of charts showing progress on various quality metrics, and administrators send newsletters that congratulates staff on accomplishing quality goals. However, in many hospitals, patient care is largely unaffected. Busy physicians and nurses rush by hallway displays and do not read newsletters that report quality metrics. When they pay attention, they tend to regard the data with skepticism: after all, they do not perceive much change save perhaps for some additional requirements for documentation."
For Goitein, a particular problem with Medicare's quality reporting program is the lack of local nuance. At her hospital last year, "the substantial resources currently used to measure and report the use of venous thromboembolism prophylaxis would be much better applied toward improving the treatment of sepsis, or the use of sedation or antibiotics in the ICU."