Tuesday, April 29, 2014

Health care policy is rife with fads, unsupported and analytically flawed approaches to try to influence the way care is delivered with simple--but wrong--metrics used to determine unwarranted penalties.

There, I've said it.  But please don't put me as an ally of nay-saying doctors and hospitals who really don't want to improve the quality of care.  I've been devoting many years to advocating for patient-driven care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement.

The problem is that poorly thought through interventions of government policy not only fail to improve care, but they raise levels of resentment and cynicism among the people we need to engage in making changes in the system.  Those interventions also have harmful unintended consequences.

The latest validation of the dangers of wrong-headed thinking is summarized in Robert Pear's article in the New York Times.  The lede:

Federal policies to reward high-quality health care are unfairly penalizing doctors and hospitals that treat large numbers of poor people, according to a new report commissioned by the Obama administration that recommends sweeping changes in payment policy.


The panel found that existing payment policies unintentionally worsen disparities between rich and poor by shifting money away from doctors and hospitals that care for “disadvantaged patients.”

Measures of health care quality and performance — widely used by Medicare and private insurers in calculating financial rewards and penalties — should be adjusted for various “sociodemographic factors,” the expert panel said. The panel was created by the National Quality Forum, an influential nonprofit, nonpartisan organization that endorses health care standards.

“Factors far outside the control of a doctor or hospital — patients’ income, housing, education, even race — can significantly affect patient health, health care and providers’ performance scores,” said Dr. Christine K. Cassel, the president of the organization.

Sorry, but this isn't news.  Here's a related point noted by anyone who was paying attention three years ago: 

Karen E. Joynt and Ashish K. Jha from Brigham and Women's Hospital published an article in Circulation: Cardiovascular Quality and Outcomes, entitled, "Who Has Higher Readmission Rates for Heart Failure, and Why? Implications for Efforts to Improve Care Using Financial Incentives." Excerpts:

Among 905 764 discharges in our sample, patients discharged from public hospitals (27.9%) had higher readmission rates than nonprofit hospitals (25.7%, P<0.001), as did patients discharged from hospitals in counties with low median income (29.4%) compared with counties with high median income (25.7%, P<0.001). 

Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates.  As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.  (Circ Cardiovasc Qual Outcomes. 2011;4:53-59.)

Look though, at the response of the Administration, as reported by Mr. Pear:

The Obama administration commissioned the study, but is not entirely comfortable with the recommendations, officials acknowledged. 

The Obama administration has championed the idea of pay for performance, with financial penalties for hospitals where deaths, readmissions or complications occur at rates above the national averages. The administration has said adjusting the data for social or demographic factors would be equivalent to accepting a double standard, with lower expectations for the care provided to low-income patients.

“We do not want to hold hospitals to different standards of care simply because they treat a large number of low-socioeconomic-status patients,” said Dr. Kate Goodrich, the director of quality measurement programs at the federal Centers for Medicare and Medicaid Services. “Our position has always been not to risk-adjust for socioeconomic status within our measures because of concern about masking disparities, and potentially rewarding providers who provide a lower level of care for minorities or poor patients.”

Sorry, but this is the response of a government that has let ideological purity stand in the way of common sense.  The issue is not about rewarding lower levels of care to poor patients.  It is about not penalizing hospitals that care for poor patients.


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