Measuring Outcomes: Lessons From the World of Public Education

Abstract

The quality and efficiency of American health care are increasingly measured using clinical and financial data with a goal of improving clinical practice. Proponents believe such efforts can improve outcomes, motivate clinicians, and inform the public about quality. Detractors point to problems with the accuracy of these measures and the risk of creating perverse incentives for both physicians and patients. Drawing on lessons from similar performance management policies in public education, we provide guidance about this trend for primary care physicians and health care policy makers. We argue that public school teacher evaluations that use value-added modeling foretell specific pitfalls for the use of similar models to evaluate physician effectiveness, and that unintended consequences of performance management in both education and health care can include the narrowing of purpose, deprofessionalization, and a loss of local/community control. INTRODUCTIONF or much of the 20th century, the quality of medical care was considered to be an attribute of the person providing the care. Individuals seeking the best care looked for physicians who were board certified, trained in prestigious institutions, and recommended by friends or family members, or some combination thereof. Over the last 2 decades, this concept has eroded in the face of growing evidence of systemic problems with poor quality and uncontrollable costs in American health care.1 Today, as new information technology facilitates electronic data collection, the paradigm of quality as a clinician attribute is being replaced by systems of objective quality measurement and reporting. The notion of determining health care quality by measuring outcomes is based on 3 assumptions: that quality can be accurately measured, that quality can be improved, and that reporting quality measurement data will influence how people use health care and how clinicians practice.2-6 Physicians and hospitals have challenged these assumptions while also expressing concerns about the high cost of implementing quality measurement. [7][8][9][10][11][12][13] Foremost among their concerns is the inability of most outcomes studies to prove causal relationships between the care a patient receives and the outcome of that care, as quality studies rarely use random assignment of patients. Attempts to adjust quality measurements based on case mix complexity and social confounders have not resolved this controversy. In addition, data used to measure quality have generally come from electronic claims and patient satisfaction surveys, and, more recently, from data abstracted from electronic health records. All 3 sources of data have their limitations.Meanwhile, the policy community including health purchasers and health plans has begun to focus on measurement of value. [14][15][16] In this context, value is defined as the health outcomes achieved per dollar spent and potentially represents a way to prioritize health care services. 17Value measurement is a tempting policy target as the he...

Palestinian doctors’ views on patient-centered care in hospitals

“…Findings showed patient-related factors that influence the doctor’s views. The perception on the doctor’s side about his patients can’t be ignored [ 53 ]. Surprisingly, the perception of low levels of health literacy had no significant influence on the doctor’s PCC behaviors.…”

“…(2) Attributes related to the doctor in the workplace such as job satisfaction, job interest, and his tendency to approach patient’s problem either formally or friendly [ 7 , 20 , 48 – 50 ]. (3) Attributes related to the patient include the level of health literacy and tendency to hide relevant information [ 51 – 53 ]. The doctors are asked to score the prevalence of eight contextual factors.…”

Ethics in contemporary health care management and medical education

“…Many quality and outcomes measures fail to show causal relationships between quality of patient care and health care outcomes . The value of economically meaningful surrogate markers—eg, cost and quality—is problematic since the surrogate markers are subjective and open to conscious or unconscious manipulation.…”

In This Issue: Powerful Ideas for Action

“…These consequences of narrowing of purpose, de-professionalization, and loss of local/community control, are most likely to affect the most vulnerable. 24 The article should shock policy makers into reexamining a measurement paradigm that increasingly is oppressing teachers and primary care clinicians, and for many children and patients, results in less effective education and health care. The Saultz paper is a call to action for the education and health care professions to rise up together for support rather than incentives.…”