Socialized medicine leads to this exact problem in just a slightly different fashion. Saving and the distribution of dollars becomes King. Suddenly it is business people and managers that call the shots. That is what has been happening as government regulates forcing physicians to work for consolidated businesses and hospitals that pull the strings based upon the evaluation of a CFO instead of an M.D..

Risk adjustment is great, but we are very bad at it and it can be gamed.

You say, ”I would favor trusting the pt and physician make these tough calls unfettered by allegiances to other masters. The beauty of America has been this very ability to offer everyone from the homeless man to the board member the same level of care – we are slowly losing that – and I’m not sure it has to be this way given what we still can and do spend on healthcare overall.” I wholeheartedly agree.

Some don’t recognize that perfection is the enemy of good.

Thanks for a wonderful article.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4793506/

Backing away can give us different frames:

If we had a single payer would public reporting still be useful? (as competition and market share are not particularly relevant here.)

Highly accurate risk adjustment sounds helpful but details could obstruct patient understanding…how far to go in this effort?

Is purpose of public reporting to enhance smart shopping by patient or referring physician? Is there evidence this is happening?

Is purpose to improve provider performance?, save money? Evidence?

Is purpose to remove bad providers? Evidence?

Is public reporting fair to the few subsets of professionals who are singled out? Congress, lawyers, airline pilots, teachers, ad infinitum, are potential subjects for this too.

Is all this record keeping and publicity costing more than the benefit of enhancing provider skill? ..,or whatever we are doing this for.

Its a fallacy to assume that no progress would have occurred without the checklist movement.. The idea of sterile procedure somehow took hold and spread well before there were ACOs. I’m not suggesting we shouldn’t hold doctors and health systems responsible – i’m suggesting the way we’re going about it is mindless. http://www.philly.com/philly/blogs/healthcare/Medical-Errors-The-problem-with-getting-to-zero.html

Good point Matthew. There is a case to be made for rationing.

By all means use data to understand what’s happening, identify safety issues and flag problem doctors. But when you use this kind of reporting data as the underlying unit of knowledge to organize your healthcare system you run into a problem. All data is political.

Fundamentally, this isn’t an accounting problem.

This is a political problem.

And a human problem.

Anish, Princeton’s Uwe Reinhardt wrote in the past that healthcare quality can be defined and summarized by the acronym, POSS. P is for process — following evidence based guidelines and protocols. O is for outcomes, ideally risk-adjusted. The first S is for patient safety — minimizing hospital acquired infections, etc. The second S is for patient satisfaction which can include non-medical criteria like good food, flat screen televisions, valet parking and pleasant nurses. These four criteria would have to be weighted in some appropriate way with outcomes presumably the most important to patients. The risk-adjustment state of the art apparently isn’t where it needs to be yet.

As for the quality / accountability movement, hasn’t there been a meaningful decline in central line and VAP infections and haven’t the use of checklists and timeouts in the OR reduced egregious errors like wrong-site surgery?

As u know, I’m a skeptic of the emerging quality/accountability movement. Quality is measured at the moment by checking a box on the EHR that says I prescribed a statin and performed a depression screen..

Perhaps we should take a hiatus until we can appropriately risk adjust. Why did we even embark on this if we weren’t sureness we could risk adjust?

Who decides what’s reasonable? In this case patient, surgeon, and cardiologist thought it reasonable. Blalock thought it was a reasonable thing to operate on babies who were born blue that were ‘destined’ to die. Worth pointing out that there were a class of folks at the time that thought this was a waste of resources and unethical.

The ability we traditionally have had to offer the best therapy equally to rich and poor is what has made American healthcare
special.

Im an advocate for making patients responsible for the health care equivalent of oil changes- not for catastrophic illnesses.