Viewpoint: Quality measures fail to determine a physician's value

Although insurers and governments have tried to measure physicians' caliber using various metrics, what constitutes a success in medicine — and who's responsible for it — is often unclear, a physician writes in The Washington Post.

Here are seven insights from the op-ed by Dhruv Khullar, MD, who works at New York-Presbyterian Hospital in New York City:

1. Despite efforts to measure and incentivize the quality of physicians' care, providers often have less control over outcomes than patients think, Dr. Khullar says.

"Patients want longer lives, but they also want healthier lives, care that is more compassionate and more convenient, and judicious use of tests and treatments," Dr. Khullar writes. "Doctors work in teams as just parts of an increasingly complex health system, and they are often less in control of outcomes than we think, especially when treating patients with challenging social circumstances and coexisting medical conditions."

2. "Measurement techniques may grow increasingly sophisticated, but doctors are not ballplayers, and healthcare statistics are not as simple as a batting average," Dr. Khullar writes. Despite this, payers use ­pay-for-performance incentives to improve how physicians care for patients.

3. One example of this effort is Medicare's Value-Based Payment Modifier, which measures the quality and cost of care while giving physicians bonuses or imposing penalties as necessary.

But a recent study suggests the VM program showed no benefit in improving care or cutting costs. "The program's failure adds to a body of evidence finding that financial incentives generally have not been shown to improve patient outcomes," Dr. Khullar writes.

4. Patients pay a price for these programs as well, Dr. Khullar says. "Financial incentives can encourage doctors to avoid sick or socially disadvantaged patients, who are harder to care for and who may negatively affect their quality ratings," he writes. Many payment programs, including the VM program, don't adjust for patients' illness severity or socioeconomic status, Dr. Khullar says. "So if I'm trying to pad my stats, it makes sense to gerrymander my patient panel into the richest, healthiest, most-educated panel possible."

5. But having some measurement in place is still critical to ensure physicians are honest and patients are informed, Dr. Khullar says. "One step may be to solicit more physician input into the measures they feel most accurately capture the value of their care," he writes. "Another is to ensure that all measures are carefully adjusted for patients' medical and social complexity."

6. Although physicians are skeptical of online reviews, these sources of feedback could be a big part of the solution, Dr. Khullar writes. "Already, more than three-quarters of patients use online reviews to find a new doctor, though concerns persist about their accuracy and representativeness," he says.

7. "Despite prolonged and costly attempts, insurers and governments have not been able to accurately measure a doctor's value and won't be able to anytime soon," Dr. Khullar concludes, recalling a "legendary" co-resident who made diagnoses others hadn't heard of and rushed patients to lifesaving procedures when they showed the smallest clinical change.

"No currently available measures, for example, would have captured my co-resident's worth as a physician," Dr. Khullar writes. "And yet, every doctor in our program knew of his worth, and every patient he cared for benefited."

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