Peers, Professionalism, and Improvement — Reframing the Quality Question

“As [health economist Jonathan] Kolstad explained, much of the insurance–industrial complex is built on the assumption that profit-seeking physicians will always consume excess resources unless barriers are put in their way. Formularies and prior authorizations, for example, create adversarial relationships between insurers and physicians, who may bristle at having nonphysicians dictate what’s best for their patients.

Contributing to this tension is our dependence on randomized, controlled trials to tell us the “right” way to treat any one patient on the basis of average treatment effects in large study populations. The resultant technocratic approach to quality often fails to account for patients’ heterogeneous needs and preferences. To Kolstad, a quality-improvement (QI) model giving physicians more real-time feedback on patient outcomes (including quality of life) and decoupling performance data from compensation would better suit both physicians’ psychology and care complexity. [..]

Economically speaking, administrators are responding rationally to payer incentives and to policies premised on the aspiration that health systems and clinicians will deliver better care at lower cost if we just dangle enough money in front of them. Yet this theory ignores the complexity of human motivation.

As Harvard’s J. Michael McWilliams notes, use of financial incentives to improve quality assumes that quality lapses reflect deficient physician motivation. If the current state of quality reflects the limit of what physicians can achieve by means of concern for patients, then the seemingly obvious solution is to turn to financial rewards — physicians, like most humans, are motivated by profits. But most physicians also remain deeply motivated to take good care of patients, and when people pursue their work because it’s inherently gratifying, attaching a reward or punishment can actually reduce their interest in the work, render it less meaningful, and lower its quality. Why, then, do we cling to this outmoded approach to influencing physician behavior?

Partly because it’s easier that way. As Alfie Kohn, the author of Punished by Rewards, explained to me, using financial rewards or penalties to promote certain behaviors absolves us of having to think deeply about root causes of complex problems. When discussing the prevention of, say, heart-failure admissions, proponents of value-based payment designs often defend extrinsic financial incentives with some version of, “If I gave you x dollars, you would figure out how to keep patients with heart failure out of the hospital.” Sure, that approach might work if x dollars could solve every social ill, make all beneficial medications accessible and affordable, and cure all the coexisting conditions that make heart-failure management challenging. But when such reimbursement approaches fall short, the default response is often to try to optimize, rather than scrap, the financial rewards. To Kohn, the problems with rewards, financial or otherwise, can’t be fixed by adjusting the design or implementation of a particular plan. “Rewards, like punishments, are based on a fatally flawed set of assumptions about human motivation,” he says. “They focus only on behavior, rather than on why people act the way they do.” That’s why rewards might induce temporary compliance but, as Kohn says, “are counterproductive in the long run, because people don’t respond well to being manipulated.”

To the extent that financial incentives strip physicians of agency, measurement itself may play an equally pernicious role. Even Donald Berwick, who for some time bought into the mantra “If you can’t measure it, you can’t manage it,” now recognizes the dangers of this mindset. “That idea murders spirit. It dumbs down meaningful improvement,” Berwick said in 2019, reflecting on the evolution of his thinking about quality. Noting that “measurement casts a shadow over meaning,” Berwick suggests that metrics can work only when they are contextualized using qualitative tools: stories, conversations, contemplation. “We are the masters, not the servants, of the numbers,” he says. [..]

Late in his life, the QI pioneer Avedis Donabedian, emphasizing that health care is a sacred mission rather than a commercial one, alluded to this symbiosis between meaningful work and quality.7 Ultimately, he noted, “the secret to quality is love. You have to love your patient. You have to love your profession. You have to love your God.” As QI has become subsumed by forces of commercialization while physician burnout accelerates, Donabedian’s wisdom seems as critical as it does quaint. Quality, like so much in medicine now, is a business; love, in its essence, doesn’t scale. [..]

So what’s the answer? A few aspects seem obvious: using fewer metrics, allowing efforts to originate from within rather than above, and abandoning pay for performance. But these modifications seem far removed from where true quality begins. That most clinicians know good care when we see it doesn’t mean we know how to consistently ensure its provision. It may be frustrating to admit, but solving the problem of quality requires a willingness to recognize the problems we cannot easily solve. How to do better, then, may be less a finite question we need to answer than a spirit of inquiry we must create and sustain. [..]

If the quality movement has gone too far in blaming the system for our failures, the correction isn’t to start blaming individuals, but to better support clinicians in taking responsibility when we can. The more requirements we pile on in the pursuit of being better, the less room clinicians have to determine — with their patients — what “better” really means. It will always be easiest to keep counting; only sometimes will the measures reveal the meaning we seek.”

Full article, L Rosenbaum, New England Journal of Medicine, 2022.4.27 [This is the third article in the journal’s series: Medicine and Society – The Quality Movement. Here are my summaries of Rosenbaum’s initial and second articles.]