Professionalism Revealed: Rethinking Quality Improvement in the Wake of a Pandemic

“After 2 decades of efforts relying largely on quality measurement and performance-linked payment incentives, we need new ideas and new conversations. As revealed by health care workers’ response to the Covid-19 pandemic, professionalism in health care may be an underused resource. Reframing quality improvement around the linchpin of care delivery — physician agency — could provide much-needed direction by elucidating strategies that address problems of information or motivation when professionals act as agents on their patients’ behalf.

[..] A central concept in health economics is that the physician acts as an agent for the patient, determining what the patient’s problem is and what should be done about it. While patients desire high-quality care, they may not be sufficiently informed to demand it. Physicians are more informed than patients by virtue of their training and experience, and are expected to be motivated by their intrinsic concern to use that knowledge in their patients’ interest.

[..] Empirical observations that physicians can be misinformed, unaware of evidence, subject to biases, and influenced by financial incentives upended physicians’ long-standing position as unquestioned and self-regulated authorities. With these shortcomings exposed, consensus emerged that physicians could no longer be solely entrusted to know and do what is best for their patients.

[..] In general, quality improvement strategies can be categorized based on their reliance on performance measures and involvement of the payment system [see author’s Figure below].

Quality Improvement Strategies Categorized by Reliance on Performance Measures and Use of Payment Policy

[..] In recent years, we have focused almost exclusively on the box of strategies that combine measurement with payment to make up for weak competition or deficient provider agency by tying financial incentives directly to performance on specific measures. At best, the gains have been spotty and perhaps not surprisingly so. Measure-reliant strategies such as public reporting, pay for performance, or value-based purchasing are constrained by the multidimensional nature of quality and the challenges inherent in measuring and rewarding it.

First, focusing on measurable markers of quality can divert resources from harder-to-measure but equally or more important aspects of care, resulting in unchanged or even worse quality overall. [..] Second, performance measures detect the symptoms of dysfunction, not necessarily the cause. Thus, performance-linked incentives often elicit low-cost responses that improve measured performance (e.g., teaching to the test or gaming) but do not address the underlying disorder. [..] Third, risk adjustment presents a thorny challenge with no satisfying solution, particularly for outcome measures such as functional status or mortality. [..] Fourth, whereas payers can set strong incentives for providers to minimize costs without having to measure provider costs (e.g., via capitation contracts), financial incentives to improve quality as a whole are inherently weaker because quality must first be measured to serve as a basis for payment.

[..] Recognizing the costs, experts agree that the deployment of quality measures needs to be rethought. Yet in the scramble for new directions, the conversation is still dominated by a measure-reliant orientation. Measure enthusiasts offer only incremental suggestions — such as introducing more “skin in the game,” limiting the number of measures, and improving risk adjustment — or inviable aspirations to link strong incentives with fanciful measures that somehow capture all that we care about and are immune to the problems above.

[..] Although often misquoted to the contrary, W. Edwards Deming — a leader in the field of quality improvement — incisively noted: “It is wrong to suppose that if you can’t measure it, you can’t manage it—a costly myth.” Moreover, reliance on scorecards and pay for performance is at odds with the basic economics of market functioning. Economic theory points out that quality improvement does not require quality to be converted into a contractible or manageable quantity. Quality just has to be observable to whoever is motivated to benefit from it.”

Full article, McWilliams JM. New England Journal of Medicine Catalyst: Innovations in Care Delivery 2020.September-October