Almost two years ago to this very day, I wrote a couple of largely hypothetical pieces that toyed with the idea of performance pay for physicians, similar to what's being forced on educators. The first hammered out some specific proposals for doctors, such as the use of a few fundamental metrics, like BMI, cholesterol, and blood pressure, to evaluate doctors and hospitals . I doubled down the second time by suggesting that our health care workforce is failing and that our continued decline in overall wellness is ruining our economic competitiveness. If you follow the education reform debate, you'll read suspiciously similar sounding aspersions cast against our public schools and its teachers.
The New York Times published a piece in January of this year about a new program in New York City attaching quality of care to physician income. We would have, at long last, a health care system accountable to patients. From the article:
The proposal represents a broad national push away from the traditional model of rewarding doctors for the volume of services they order, a system that has been criticized for promoting unnecessary treatment [... ]the public hospital system has come up with 13 performance indicators. Among them are how well patients say their doctors communicate with them, how many patients with heart failure and pneumonia are readmitted within 30 days, how quickly emergency room patients go from triage to beds, whether doctors get to the operating room on time and how quickly patients are discharged.
Doctors, unsurprisingly, do not seem too thrilled about this proposal. Of the reasons cited in the article, they could be docked for conditions outside their control. Some physicians would simply game the system by, for instance, "refusing the sickest and poorest patients, who tend to have the worst outcomes and be the least satisfied." Or, doctors could measure something frequently and report the lowest number.
The union stance is predictably oppositional. They suggest increasing the number of indicators from 13 to 20 -- including "bonuses for going to community meetings, giving lectures, getting training during work hours, screening patients for obesity and counseling them to stop smoking." Physicians groups also recommended excluding certain patients from performance evaluations, "like developmentally disabled patients, homeless people who have no place to go."
So much of this discussion on performance pay for physicians is similar and different than the one for educators. It looks like, according to the proposal, public hospitals specifically and their physicians are in greater trouble. They do not have the luxury of choosing patients and are likely to receive the most difficult cases. From prior experiments with merit pay for doctors, there are concerns that patient care isn't really increasing at all: "they learned very quickly to 'teach to the test'." Despite the controversy, physicians are just going to have to accept this new proposal; ultimately, "physicians are here because they are attracted to that very mission of serving everybody equally."
To all my educators out there: is this starting to sound familiar? It should, but with some small differences. Notice how much control the doctors are having over the debate, at least in this article about this particular proposal. Also, performance-pay proposals for doctors might include at least 13 indicators and, if the union succeeds, up to 20. Educators have what, a handful? Considering many teacher evaluation proposals weigh test scores as much as 50 percent, then it's really only a single indicator since test scores trump all.
In the words of an anonymous physicians' union official, "to say we'll stick a carrot in front of you and therefore you're going to be a better doctor is a little disingenuous." Couldn't you say the same thing about educators? For that matter, this entire New York Times piece could be re-written for educators with only a few word changes. Dr. David Himmelstein, a professor of public health who is frequently quoted, found in a few studies of doctor merit pay that "things that were not measured... appeared to have gotten a bit worse." For example, if speed is valued instead of bedside manner, then efficiency will come at the expense of getting to know patients.
Himmelstein also acknowledges that "The consequences in a complex system like a hospital for giving an incentive for one little piece of behavior are virtually impossible to foresee." Perhaps this is why prominent reform-celebrities like Michelle Rhee are completely and totally stunned that merit bonuses incentivized some teachers to cheat under her watch. Or, that the pursuit of high test scores in only math and reading might contribute to a precipitous decline in, among other things, the low civic awareness of young persons. Folks always bemoan the results, but rarely make the connection.
So, Godspeed to all the unmeasured and neglected health quality indicators out there, and to all the science, social studies, art and music, physical education, and media literacy that used to be taught in our public schools. For now, it looks like we have performance to measure, or at least someone's version of performance.
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