Dr. Sandeep Jauhar wrote an essay this week in the New York Times about the perils of pay-for-performance (P4P). Specifically, Dr. Jauhar discusses how P4P may have unintended consequences and create perverse incentives due to poorly designed performance measures. The point is well taken, but it’s important not to confuse the merits of P4P with the measurement issues that exist.
With respect to the latter, back in my days as Director of Measure Development for the National Committee for Quality Assurance (NCQA), I co-authored a paper with Partners’ cardiologist Tom Lee, Jim Cleeman from NHLBI, and others working with us at NCQA on the development of new HEDIS cholesterol management performance measures. In the JAMA article, “Clinical Goals and Performance Measures for Cholesterol Management in Secondary Prevention of Coronary Heart Disease,” we tried (among other things) to communicate the difference between quality improvement measures and comparative performance measures.
Although the multi-stakeholder Cardiovascular Measurement Advisory Panel and NCQA’s measurement policy-making body, the Committee on Performance Measurement supported the goals of NHLBI’s practice guidelines, we believed that there are signficant differences “between a clinical goal for the management of individual patients (LDL<100 mg/dL) and a performance measure used to evaluate the care of a population of patients (LDL<130 mg/dL).” We described several reasons including: gaps in reasearch; drug efficacy; realistic performance measures; simplicity; and implications of physician failure.
Measurement systems designed for internal quality improvement may very well be different from those used to compare provider quality for a diverse population of patients, and we should make sure to consider the differences in establishing the criteria by which clinicians are compared and reimbursed.
However, we can make those distinctions and we need to in order to drive different kinds of quality improvement forward. If we don’t create fair measures that differentiate provider performance, we will continue to lack ways of adequately compensating those who deliver care for anything but the quantity of what they produce (i.e., number of services provided).
Joshua Seidman is the president of of the Center for Information Therapy
that aims to provide the timely prescription and availability of
evidence-based health information to meet individuals’ specific needs
and support sound decision making.