One demands, Give me the best beer you’ve got! The other asks, Give me the second-best beer you’ve got. The bartender pours the beers and states, You can have them both for free if you can tell me why this one is better than that one…
Quality metrics were invented to quantify the ineffable, such as the taste of a fine lager or IPA. I see that my neighborhood pub now lists “International Bitterness Units” (IBU) for all its beers. I wonder if this has helped me gauge which pint I should choose? At least it gives me something to talk about while enjoying the beer.
Just as listing the IBU is new in beers, metrics did not always exist in medicine. The moment we really got serious about quality is often cited as Caper’s 1988 article “Defining quality in medical care”. Even as medicine invented quality in the 1980’s, Caper pointed to some misgivings about the terminology. His Health Affairs article suggests abandoning the word “quality” and instead using three terms that correlate to desirable medical outcomes: efficacy, appropriateness, and the caring function. We know that certain interventions are efficacious in certain conditions; we can measure that. We know that certain interventions are appropriate and inappropriate in the sense of utilization; we can measure this. And we know that patients want “caring providers”… We likely cannot measure this very well, but it may be the most important of all the factors. But, the “quality” of care is more than all of these factors and perhaps quite different entirely.
Despite the prescient warning, we have not abandoned “quality” and its continued use has created an entire jargon: quality, measurement, and value. Quality creates value. We are all preoccupied with creating value now. The term is rarely defined but often used: creating value to insurers, for payers, for health systems, even occasionally for patients. It appears to have a vague but unacknowledged relation to quality.
No one used to ask whether they got value when they went to the doctor’s office. We might have discussed whether we had a good doctor, but never whether the experience was valuable. When I buy a car, I sometimes wonder whether I got a good deal and whether the exchange had “value”. But when I sit with my friends for a beer at the pub I have never asked whether I got a good value out of the experience. The use of value reflects an economic creep of the mission of medicine and a subtle deterioration of the relational aspect of “my doctor”.
Those things that are most important to us, and in some sense are valuable, we never ask if they “provide value.” Nor do I ask whether my evening at the pub was “quality time”, and rarely whether I just drank a “quality” beer. Remember “quality time” spent with our loved ones? Once we started asking this about the time with our children, it already represented an unacknowledged loss of the inherent relational component of life. Just so, once we started using “quality” and “value” in medicine, we had already lost its primary relational component. Although not stated in the original Health Affairs article, the discomfort with the term “quality” reflects a disquiet with conflating efficacy, appropriateness and caring with the much more subtle concept of quality.
Quality itself relates to the humanistic function of medicine, and not to its scientific trappings. As such it is describable but not measurable. As an individual patient, whether my A1C is less than 9% correlates only tangentially with the quality of the care my physician provides. I might do better to have a lower A1C, but the factors involved in lowering my A1C, and how I perceive the care I have received, are not measured by the A1C itself. Presumably the A1C captures the “efficacy” of the care received. It is a gross injustice to label this as “quality”. Substituting “quality” for “efficacy” defines patients as lifeless objects rather than in accordance with their characteristics as human beings.
Pay-for-performance takes medical quality metrics to the next level by using them economically. Yet in our medical system they are not working to improve care; why? Because the metric does not incentivize doctors to be more human. Instead it rewards treating patients as commodities and lifeless objects. Doctors resent this incentive because commodification is dehumanizing. As incentives push doctors into becoming more mechanistic, we then invent new metrics such as “satisfaction surveys” to desperately attempt to pull them back towards a humanistic ideal. Satisfaction itself is now a commodity and subject to the rules of the market – massive, absurd inflation everywhere!
However, what does not work on an individual level, can work on a group or institutional level. Some payors, government and private insurance, reimburse hospitals more or less depending on how they perform on various metrics. With some exceptions, this tactic appears to overall have improved medical care in America. Companies should be held responsible, or rewarded, for the quality of their products. Corporations have always responded well to financial incentives; it’s why capitalism works!
The fallacy in pay-for-performance resides in the jargon: quality, value and now “aligning incentives”. This innocuous phrase glosses over the distinction between corporations, which thrive because they transcend individual people, and doctors, who thrive because they are humans providing care to other humans. Be careful with your jargon, and be wary of individual metrics.