A Fascinating Audience Vote on Quality and Transparency

At my just-completed annual hospital medicine CME course, we held a fascinating session on the future of quality measurement, transparency, and pay for performance (P4P). The discussants – Andy Auerbach, Peter Lindenauer, and Kaveh Shojania – all emphasized the limits of process measurement, particularly noting the problems of unforeseen consequences, playing for the test, and flawed measures. The panelists see outcome measurement (e.g., mortality, readmissions) making a comeback, something I’m noticing as well.  

But perhaps the most interesting part of the session was a series of audience votes. Using a computerized audience response system, sorta like Regis uses when he polls the audience on Who Wants to Be a Millionaire, I periodically ask the audience to weigh in on key questions.  

So I asked the crowd of about 550 physicians about the impact of transparency on their practice and their institution.

First, I asked what these physicians (four out of five were hospitalists, and thus in the cross-hairs of today’s quality measurement and reporting efforts) think of today’s measures, particularly the Medicare “Core Measures”:

  • 18% thought the measures bore no relationship to their quality of care
  • 63% said that the measures capture a portion of their quality, but perhaps 90% is going unmeasured
  • 18% thought they captured a decent slice of quality
  • 2% thought they accurately captured the quality of their care

Then I asked how much their hospital’s leadership (CEO, Chief Medical Officer, the Board) focuses on the publicly reported measures.

  • 37% said a great deal, as much as they focus on hospital finances (a high bar, indeed!)
  • 47% said a moderate amount, not quite as much as finances but an awful lot
  • 13% said “not much” – people mention it and are embarrassed by bad results, but that’s it
  • 3% said “not at all”

Next, I asked how much their patients were focusing on quality measures; perhaps the C-suite’s focus on the quality measures was coming from patients threatening to vote with their feet:

  • 1% said a great deal (lots of patients choosing hospitals and docs based on results)
  • 6% said that some plugged-in patients were paying attention
  • 43% said not much; patients sometimes mention the results but it rarely influences behavior
  • 50% thought patients were paying absolutely no attention to public reports of quality.

The most damning result came when I posed the following statement: “P4P is really just a CMS (Medicare/Medicaid) scheme to save money, wrapped in the flag of quality.”

  • 79% of the audience agreed with this statement, 21% did not.

Medicare clearly has some work to do if it cares about getting the buy in from docs.

All of this is further proof of the point I made last week: the biggest surprise of the quality revolution is the immense power of transparency, which does not appear to be mediated through consumer-driven pressure. I argued that the pressure generated from public reporting is leading to lots of internal P4P (bonusing based on scorecard results), which may ultimately make payer-generated P4P unnecessary.  

And if you think the reporting is generating action now, just imagine how powerful it will be when patients actually pay attention to the results!

These survey results are also sobering evidence that this group of docs – a group that has been subject to more quality measurement than any other, and, in general, has bought into the quality thing – believes that today’s quality measures don’t really capture much of importance. Moreover, these physicians, by a wide margin, believe that the “quality revolution” may in reality be a big cost-saving scheme by the payers.

The bottom line: everybody’s got a lot of work to do if we’re going to get this thing right.


  1. Joe Miller on October 16, 2007 at 9:05 pm

    Your commentary makes me wonder why patients do not take a more active role in evaluating quality… and more specifically will they ever be informed healthcare consumers?

  2. Bob Wachter on October 18, 2007 at 5:50 am

    Yep, it is pretty extraordinary. Remember Bill Clinton’s experience – he received his CABG from the lowest ranked cardiac surgeon in New York State.

    But perhaps that was then, and this is now? Well, no. I recently asked the members of UCSF’s Epidemiology & Biostat Dept how many ever checked quality measures before making medical decisions for themselves or loved one. Answer: one person (out of about 50). If anybody was going to follow and act on quality data, it would be them!

    When will patients start following these data? When they are much easier to use, when the measures become more meaningful, and when health professionals use the data themselves for decisions and recommendations. Right now, when a family member or friend calls me for a hospital or doctor recommendation, I still mostly base this on reputation, word-of-mouth, and pedigree (ie, medical school, residency). Patients won’t start using quality data until we do it ourselves. Best guess: in 3-5 years.

  3. Brian Clay on October 21, 2007 at 1:14 pm

    With lack of health literacy in the general population being such a prominent problem, it is not surprising that patients are not more proactive in attempting to evaluate the quality or outcomes of their physicians. Surveys in this area repeatedly show that while patients think medical care could be improved, most people feel that their OWN doctor is “one of the good ones.”

    I agree with Bob that a much higher degree of facility of use and the inclusion of hard outcome measures rather than process compliance will move patients in the direction of wanting to know and make use of quality data. I also find it highly unlikely that initiatives such as P4P will result in such a move.

    The ironic thing is that I have the sense from the hospitalist community that we want to generate this data and find the right measures, because we know that we can make the greatest strides toward improving care by accurately measuring the problems we have now. The quality improvement drive in hospital medicine is substantial, and a lot of us are excited to be a part of it. I suspect that there is frustration that our quality improvement work (and what is targeted for improvement) is being at least partially driven by entities such as CMS and The Joint Commission and their regulatory requirements.

    I hope that in 3 to 5 years I see a patient in our emergency room who tells me that they came to our hospital instead of another based on outcomes data that they looked up or read about. Hasn’t happened yet.

    Brian Clay
    Division of Hospital Medicine, UC San Diego

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