CMS Quality Measures - Where are measures of diagnostic performance?

Jackson, Brian brian.jackson at ARUPLAB.COM
Wed Nov 23 17:06:46 UTC 2016


I totally agree that CMS's and similar quality measurement programs severely shortchange diagnosis.  But they severely shortchange everything else as well.  So I don't think balance is actually the right goal here.  

Here's the thing -- if it were possible to add up all the different processes and outcomes in healthcare that are relevant to quality, it would be many orders of magnitude higher than 97.  So essentially, the CMS measures are ignoring something like 99.9% of therapeutic medicine, and 99.99% of diagnostic medicine.  (Or more likely, 99.99% and 99.999% respectively.)

The consequence is that quality measures in their current form (tied to reimbursement, accreditation, etc.) create perverse incentives.  It's always going to be more cost-effective in the short run for a hospital to optimize its processes to achieve high scores on the things that are measured, rather than put those same resources toward more global improvements in hopes that the measured things will improve as well.  More insidiously, the former approach often degrades performance of unmeasured things.

Tim Harford, a British economist and writer, has a new book out entitled "Messy" that has a great chapter on the problems of incentives.  He uses the example of the NHS emergency transport services where they had an 8 minute target time  to get to the patient (if I remember the story correctly).  In practice this led to ambulance services moving teams and ambulances from rural areas (where the measure wasn't applied) to urban areas (where it was), thus potentially misallocating lifesaving resources.  It meant switching teams from ambulances to 2-wheeled vehicles, thus arriving faster but without ability to transport the patient when necessary to the hospital.  And so on.  There was also a highly politically charged quality target for doctor offices to offer patients appointments within a short time window.  Access is clearly important, but one way to game this measure is to bottleneck the telephone line when the practice is busy, so that patients can't get through to request appointments.  And this turned out to be widespread.

Harford isn't arguing to take away quality measurement, but rather saying that it should be similar to exams in college, where you don't get to see the exam questions in advance.

--Brian Jackson

-----Original Message-----
From: Mark Graber [mailto:graber.mark at GMAIL.COM] 
Sent: Wednesday, November 23, 2016 8:50 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: [IMPROVEDX] CMS Quality Measures - Where are measures of diagnostic performance?


CMS has announced its proposed list of 97 quality measures, based on the goals set in the National Quality Strategy:
(Attached, and at the CMS website):
https://blog.cms.gov/2016/11/22/cms-finalizes-its-measures-under-consideration-list-for-pre-rulemaking/

Of the 97 measures, only 7 directly target appropriate diagnosis:  Measures to encourage screening for frailty, malnutrition, alcohol, tobacco, and opioid use.
Another 9 support improved diagnostic performance by encouraging appropriate transfer of information at transitions of care.

All of the other measures target treatment and management issues.  The imbalance of measures relating to management vs diagnosis is striking in the CMS inventory, as it is in every other performance measurement system, for example The Joint Commission’s.  If diagnosis is half of medical practice, shouldn’t there be a better balance?

Mark

Mark L Graber MD FACP
President, Society to Improve Diagnosis in Medicine


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