CON: Should Hospitals Get Reimbursements Based on Quality Performance?


If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

  • What standards of quality are we going to use?
  • Do these metrics truly translate into “quality”?
  • Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
  • Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

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