By Larry Cuban
Opinion

The Centers for Medicare and Medicaid Systems (CMS) and private insurers have identified numerous pay-for-performance measures, confirmed in large part by evidence-based medicine, and implemented them in hospitals, clinics, and doctors’ offices.

For example, there are process measures for hypertension and heart disease where, for example, periodic readings of patient’ blood pressure and blood sugar levels are reported. But testing does not tell you whether the patient is bringing these diseases under control. So intermediate outcome measures that focus on patients’ actual blood pressure and blood sugar levels are noted to indicate whether the patient is improving, stable, or deteriorating.

Then there are final outcome metrics that demonstrate what happened to patients who received treatment in hospitals, went to another facility, or returned home. Complications after surgery such as infections, strong reactions to chemotherapy that requires re-admission into hospitals for further treatment, or death are examples of such outcome measures.  CMS and private insurers identified scores of such measures as a basis for allocating or withholding payments to hospitals, groups of physicians, and individual doctors ( pay for performance of doctors).

As one would expect when attaching high stakes to metrics in a helping profession such as medicine where there are many stakeholders (e.g., insurers, employers, doctors, medical staff, patients) views on pay-for-performance measures diverge, especially since insurers have published “report cards” displaying rankings, percentages, and results of these different measures for organizations and individual doctors. Divergent views of performance measures and “report cards” are inevitable when one examines the complex terrain that physicians inhabit and the predicaments they inherently face: expertise is never enough, making decisions amid uncertainty is common, and dependence upon the patient for improvement is essential. No surprise, then, these metrics and their outcomes, thus far, have generated mixed reactions. See here, here, and here.

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