An essay on the topic of death by Michel de Montaigne serves as a reminder about the manner in which the famous ancient Greek playwright Aeschylus met his fateful demise. Warned in a prophesy that he would die after being struck by a falling object, he took to the great outdoors to reduce the likelihood of such an outcome. While he was sitting by the sea, an eagle soaring aloft that had just captured a tortoise committed the error of mistaking the tragedian’s shiny bald pate for a rock. In order to crack the shell of its quarry, the bird unfortunately dropped it on the playwright’s head.
Similarly, health care is a sphere where many examples can be found of actions resulting in outcomes that differ from what originally was anticipated. Long-term efforts to achieve health reform have focused on access, cost, and quality. Three articles published in the April 29, May 5, and May 12, 2022 issues of the New England Journal of Medicine represent a scorecard for assessing how successful various initiatives have been in enhancing health care quality.
A premise is that to improve quality, the system must be fixed. As attractive as that notion may appear, the author indicates that some 30 years later, the fix itself is a massive system. As reimbursement models shift toward value-based payment, quality improvement (QI) no longer is just about being better, but also about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. For example, CMS’s Merit-Based Incentive Payment System (MIPS) for ambulatory care settings found that clinicians and administrators invested about 200 hours per year to meet each physician’s MIPS requirements. That these hours could be spent in countless other ways, especially caring for patients, raises an obvious question: Is the system created to fix the system even working? Moreover, despite innumerable metrics and vast research assessing their worth, it still is not clear that what matters is being measured nor whether the tools to do so exist.
Another example involves CMS’s Hospital Readmissions Reduction Program (HRRP). In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. Hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Ironically, billions of dollars thus are being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced facilities, thereby worsening the disparities policymakers claim to be trying to fix.
Furthermore, a perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. If value is defined as quality divided by cost, then measuring value faces all the same problems as measuring quality—flawed risk adjustment, metric gaming, and omission of the many aspects of quality that defy measurement. A good question is why continue to embrace these flawed constructs, particularly when it is not clear that the current regulatory approach effectively serves patients or clinicians?