Wednesday, March 6, 2013

New rules for paying MDs proposed by hospital system in NY

New York City’s Health and Hospitals Corporation (HHC), which runs 11 hospitals in four of the five boroughs of New York, is negotiating a new deal with the union representing some 3,300 salaried physicians. The corporation wants to base MD pay raises on 13 quality indicators.

The New York Times article that broke the story does not list all of the indicators but mentioned the following: how well patients say their doctors communicated with them, rates of readmission within 30 days after discharge for heart failure and pneumonia, how quickly emergency department patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.

The union has countered with suggestions that more indicators be used such as “going to community meetings, giving lectures, getting training during work hours, screening patients for obesity, and counseling them to stop smoking.” And they may ask that more doctors and support staff be hired.

As is typical of the doctors' union, they had problems with the plan. They already get paid for giving lectures and training during work hours. Aren't screening patients for obesity and counseling them to stop smoking considered part of a physician's normal work? I do agree that doctors should receive combat or hardship pay for attending community meetings.

Another feature of the plan, which was glossed over in most secondary reports, is that the bonuses “would be given to physicians as a group at each hospital, rather than as individuals, so that even the worst doctor would benefit.” (More on this below)

The Times piece quotes officials from both sides and outside experts who offered opinions ranging from it’s a wonderful new world order to it will never work.

I tried to obtain a list of all 13 performance indicators, but it is nowhere to be found. However, looking at the ones in the Times article may be enough.

Patient assessments of how well their doctors communicated with them is going to be confounded by the fact that there are no private patients and few one-to-one doctor-patient relationships in the HHC system. Add in layers of medical students, physician assistants, residents and fellows combined with a patient population that, in many cases, suffers from a language barrier and may not even know who their doctors are, and it will be difficult to tell just who is a poor communicator.

I have discussed rates of readmission within 30 days after discharge for heart failure and pneumonia in a previous blog. This is a very poor indicator of quality and depends greatly on patient compliance with medications and instructions such as diet and activity.

How quickly emergency department (ED) patients go from triage to beds is a function of the census in the ED. This depends on many variables the MDs can’t control, such as availability of inpatient floor and ICU beds, nurse staffing, promptness in room cleaning, and many other factors.

Whether doctors get to the operating room on time is an interesting issue. As a former chairman of surgery, I have tackled this one in three different hospitals without success. First of all, what does this have to do with quality? Secondly, I truly believe that it will never be solved.

How quickly patients are discharged: Does this mean the time from admission to discharge, or is it the time from when the decision to discharge a patient is made until he actually leaves? If it’s the latter, again there are many forces at work. Does the patient want to go home? Can he get a ride? Is the bed ready at the nursing home or rehab center? If he’s being transferred by ambulette, will it arrive promptly? Is the nurse too busy to do the paperwork? Is the doctor, who may be a resident, too busy to do the paperwork?

The fact that bonuses will be tied to group, not individual, performance dooms the plan to failure. It reminds me of high school when someone threw a spitball and the teacher made everyone stay after school.

What do you think?


Sheri said...

Every measure listed is a publicly reported measure for which hospitals are held accountable by the public, payors, and regulators. Performance on these measures is increasingly affecting hospitals' financial bottom line. While every physician may not have complete control over each measure, physician behavior and practice does collectively impact overall performance for the hospital, and their engagement in performance improvement initiatives is critical to success on these measures. In the hospitals I've worked at over the last ten years, every employee from the president to the landscaping crew has had their annual performance review and compensation tied to hospital performance on mandatory national quality measures, so I don't see why physician employees should be any different. They have as much or more ability to improve these scores as anyone else on the team.

Skeptical Scalpel said...

Sheri, thanks for reading and commenting but I'm going to have to take issue with you.

I don't know of any hospital that is tying individual compensation to "performance on mandatory national quality measures."

What national quality measures are landscaping crews held to?

Prominent authorities agree with me that readmission rates, for one, are not good measures of quality.

Communication would have to be assessed by patient satisfaction surveys which are notoriously inaccurate.

cynthia said...

The problem with hospitals isn’t that they are providing low quality care — something that the architects of ObamaCare wrongly assume. The problem with hospitals is that they are generating way too much unnecessarily costs. And most of these unnecessarily costs aren’t being generated at the patient care level, they are instead being generated behind the scenes at the administrative level. This is largely why hospitals have become way too top heavy, and why administrative costs are starting to outstrip the cost of providing care.

So it would make more sense, at least to me it would, for Medicare and Medicaid, as mandated through ObamaCare, to simply make across-the-board reimbursement cuts to hospitals, instead of cutting reimbursements to hospitals whenever their quality indicators fall below a certain level. (By the way, most of these so-called “quality indicators,” such as patient satisfaction scores and readmission rates, have little, if anything, to do to improving patient outcome or reducing hospital stay.)

Basing reimbursement on quality indicators is not only causing hospitals to find more creative ways, thus more wasteful ways, to game the system, but it is also causing hospitals and insurers to waste a lot of precious healthcare dollars on hiring an outrageous number of people, most who are overpaid and over-benefited RNs, to track and monitor these indicators. Thanks to ObamaCare, Medicare and Medicaid are taking a system that’s already riddled with unnecessary costs and making it even more riddled with unnecessary costs.

Skeptical Scalpel said...

Cynthia, thanks for commenting. You make some good points. As I said above, I agree that these measures have little to do with quality or outcomes. Based on the recent Time magazine article, I agree that costs are totally out of control and also that armies of clipboard-wielding nurses and administrators have added little to the goal of improved quality.

Anonymous said...

By the time a patient gets to use hospital resources, the real expenses have been locked in, and only nickel-and-diming options of little utility kick in.

To take a few obvious examples:
Coronary angiography (and the almost-certain stenting to follow) has been shown of little value in chronic cardiac disease, both in terms of mortality or quality of life. Yet interventional cardiology is the most profitable area for most hospitals. Yes, PCI saves lives for *acute MI or coronary syndromes*. But, since you can't have very highly paid docs/nurses/techs and expensive equipment just stand around for the occasional MI, most of the interventions are instead used for medically dubious reasons.
The preponderance of evidence is that screening for prostate CA does more harm than good, but it goes on. A significant number will (of course) be positive and the patients go on to very expensive interventions.

Attempts to limit useless (maybe harmful) therapies have been demonized as government/insurance interference with the sacred doctor/patient relationship.

At the more local level, I have always been puzzled by the inability of hospitals to have their physicians show up on time for their elective 7:30 morning starts. Both the hospital administration and surgical staff leadership seldom take the usual miscreants aside; instead, they post monthly on-time figures. Of course, the offenders continue to show up 30 minutes late while the OR staff hangs around costing the hospital big bucks.

Even in hospitals where the physicians are employees, some surgeons (and a few anesthesiologists) just routinely show up late. Short of firing them, there seems to be no answer.

Will said...

Love your blog! I've been doing a lot of research into alcohol rehab and addiction and your article along with the above comments have really helped, thank you!

Anonymous said...

Quality to me (as a surgeon) would be ie rate of infection, complication rates, operative times, and LOS; NOT whether someone likes my bedside manner or my appearance.

Regarding OR start times it is the age-old question of who is responsible for late starts? The patient wasn't down in time or anesthesia didn't see them or surgeon late? It is usually multifactorial and if the room and anesthesia don't get things going before 8 for a 7:30 start, then after awhile the surgeon will start showing up later and later; then get blamed on those rare days when everything is ready at 7:30.

Anonymous said...

I think thats the issue. What quality measures really serve the patient? What quality measures are common to all doctors? I feel there aren't many, and the measures you mentioned put the onus on EM, IM, and Surgery. Certainly a Radiologist doesn't have to communicate much, while a Psychiatrist must communicate alot. Should they be judged by the same standard?

Skeptical Scalpel said...

Thanks for the comments.

Getting the OR to start on time is a vexing issue. As I said, I was unable to solve it in 3 different hospitals. The comments above mention the multiple factors involved.

One of my surgeons who was chronically late had to take his kids to school. So why give him a 7:30 start time? If there were no other takers and he had a long list, he got the time.

I agree with the comments about what is real quality, but in this world, whether the patients like you is going to count for something.

artiger said...

I'm not sure how it is out of my little corner of the planet, but I have noticed here that length of stay and operating time are largely physician dependent. I see it regularly; patient should be going home, but it's a weekend, and the rounding physician doesn't want to fool with the discharge summary, the medcation reconcilliation, it's just easy to let the patient sit around until Monday, when his/her regular attending doc will come around to take care of the patient. Just add 48 hours of hospitalization to even 10% of admissions, and I bet the costs would be staggering. Another thing I see, especially with an older surgical colleague (no offense, Scalpel), is a clinging to outdated it still necessary to go through the progression of clear liquid, full liquid, soft diet, regular diet, with each change taking 24 hours? Again, these days add up over time.

As for patients liking us, well, just treat them like you'd want your Mother treated, or at least your best friend, and the survey results should take care of themselves.

Skeptical Scalpel said...

Artiger, thanks for being a loyal reader.

I'm sorry to have to tell you this, but in the last place I worked, I was the only surgeon who did not order full liquids or soft diet.

The problem with the surveys (see other blogs of mine) is that the "n" is way too low to base somehing like payments on.

Anonymous said...

Interesting comments.

The major money saved is at the level of deciding to screen for cancer, or to cath everyone. The savings after that is trivial in comparison.

About OR starts, yes patients show up late, or anesthesia wants more evaluation, etc. But, some surgeons routinely show up late because they want to sleep, or they have to take their kids to school. The major reason for late OR starts is because surgeons show up late. Period.

Skeptical Scalpel said...

Anonymous, thanks for commenting. I'm not sure where you obtained your information that screening for cancer and caths are the major components of healthcare spending.

You must be an OR nurse because of your absolute certainty that surgeons are the major reason that ORs start late. I disagree. There are many factors that result in late OR starts--surgeons, anesthesia, OR staff, transport of patients, floor nurses and more.

Libby said...

In my corner of the world (Alberta) by way of an official inquiry or some other very expensive evaluation, it was discovered that discharges are held up because of a lack of continuing care/nursing home/assisted living/mental health/rehab beds so the doctors are not at fault because they have to wait for someone to die or be rehabilitated before a bed on a inpatient floor is available for the patient down in the emergency department who needs to be hospitalized.

I'd like to be a fly on the wall of the people who have to sort through all the physician communication opinions. I'm going out on a limb & say that it is quite possible that one doctor could end up with 50% that say the dude(tte) walks on water & explains everything and 50% compare him/her to the spawn of satan & barely spoke never mind explain anything clearly. (I did some dubious research on to come up with my theory along with teaching First Aid/CPR for 15yrs. & reading my evaluations).

I was with anon. about the skill in the OR--infection rate then I thought: hmmm what if the sterilization tech did a poor job? or the patient didn't do wound care? so that doesn't work either.

How about using a grid system, compensation is based years of training, experience, continuing ed. hours...or the such?

Anonymous said...

Hi, I am very wary of basing any sort of compensation or rating on patient feedback. When you do this you are letting patient biases (and there are plenty) impact doctors and hospitals significantly. For example, I've read on numerous online rating websites patients complaining about doctors with accents. I don't think this is a fair complaint.
Ultimately, tort reform is the best answer. I know it's difficult to take on lawyers. But all this effort trying to pinch pennies in other places, collectively directed towards tort reform could finally make a difference.

artiger said...

Scalpel, about the above, you strike me as more progressive despite your seniority. Still, we surgeons, as a group, tend to cling to the past no matter what our age (you and I are the exceptions, of course).

Unknown said...

Where is the evidence that sny of these indicators has anything to do with "quality" of care? To debate the efficacy each indicator suggests that they have validity. Things such as NSQIP which involve accurate and reproducible data collection are light years away from the "touchy feely" evaluations being propagated by bureocrats and payors who can establish unproven standards under the guise of cost containment. The VA has documented the total lack of validity of "prevetable complications" which we are now blessed with. for example.

Skeptical Scalpel said...

Good comments everyone. Thanks.

Libby, as you point out, there are many flaws in this plan.

Anon, "doctors with accents"? I hadn't heard that before. How does one correct that, I wonder?

Artiger, There are only a few of us around.

Charles, I agree that these and many other indicators have nothing to do with quality. People are finding that quality is hard to measure.

Anonymous said...

Re: doctors with accents. The US is not a homogeneous society. I don'think this is a problem that needs correcting (provided they are comprehensible, and I've never run into a doctor who wasn't). My larger point is that people have all sort of unfair biases and these lace patient ratings (especially since there is no real incentive for a patient to keep their biases in check). And for this reason alone, patient ratings are inherently useless.

Skeptical Scalpel said...

Thanks for clarifying. I agree. I also think there is a segment of the population who will never be pleased no matter what one does.

artiger said...

And conversely, there are plenty of patients who unknowingly get crappy care but think their physician is God's gift to the world.

Skeptical Scalpel said...

That is very true.

Anonymous said...

Sometimes I wish I could be a fly on the wall at some of these administration meetings where the standards of payment and patient care are determined by non MD or academic MD leaders.

Press Ganey scores linked to performance... one of the best ENTs I know has the worst bedside manner: that's what his patients tell you. But none of them will allow anyone else to operate on them.

Communication... I don't speak Russian, German, Mandarin. On cable they write subtitles for americans from New Orleans.

Readmission after 30 days... what about the COPDers who leave the ICU to go smoke.

I wonder when instead of the multiple hats doctors are expected to wear we could finally just focus on practising medicine

Skeptical Scalpel said...

I agree with your comments. Thanks.

Anonymous said...

I'm not trying to be contentious. I'm a current med student, so I want to understand these issues more thoroughly. When you say "get crappy care" do you mean receiving below the standard of care or receiving care that isn't as good as the care you provide?

artiger said...

Both. I'm not bragging about the care I provide here, but I do all right. When you get out into the world, depending on what kind of location you choose for your practice, you'll probably see some care that you'll consider less than stellar. Just don't go tell the patient about it.

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