Pay for Performance: Here to Stay-for the Time Being

Improving health care quality is absolutely the right thing to do for our patients, and different approaches are being used by the various organizations involved in health care. For example, the member boards of the American Board of Medical Specialties are developing specialty-specific maintenance of certification (MOC) programs that are based primarily on a quality improvement approach, with a final exam at the end of the 10-year MOC cycle. In the waning days of the last legislative session, the Congress passed legislation expanding pay-for-performance to Medicare physician payments following the lead of private payers. Pay-for-performance intuitively sounds like a good idea and is consistent with our capitalist system in the United States. Furthermore, it certainly appears that pay-for-performance is here to stay for the foreseeable future, so we might as well get used to this approach. However, there are issues that must be addressed if pay-for-performance will achieve what is hoped.

How Should Quality Be Measured?

Perhaps the foremost challenge is a reliable, valid means of evaluating the quality of a physician’s practice. The thoracic surgeons have developed a system that measures the outcome of coronary artery bypass graft procedures, which is frequently held up as the gold standard for quality measurement programs. Indeed, it is a very good system that many believe has improved the quality of care in that specialty. However, thoracic surgeons perform a limited number of procedures and have very small ambulatory practices, which makes measurement of coronary artery bypass graft procedures a relatively easy and manageable approach for them.

Otolaryngologists, on the other hand, perform a wide variety of surgical procedures, but even these make up a small part of our practice, as most of our activity occurs in the ambulatory setting. Furthermore, many of our operations are performed in ambulatory surgical centers or even in some offices, which makes a thoracic surgery-like system difficult to apply to our specialty. Therefore, measuring quality in otolaryngology will be difficult, but it must be achieved and will likely require not only an in-hospital approach as in other surgical specialties, but also ambulatory measures like our nonsurgical specialty colleagues.

Also important in any system that measures outcomes of patient care is risk adjustment. An otherwise healthy patient who presents to the doctor with a given condition is more likely to have a good response to therapy than one who has a host of other medical problems, including diabetes, congestive heart failure, and other comorbidities that contribute to the patient’s overall well-being. This factor is particularly important for conditions requiring complex surgery, such as major head and neck resections with substantial reconstruction with flaps. Without taking comorbidities into consideration, a surgeon with a head and neck practice involving very sick patients will not look as good as one who performs smaller head and neck resections on otherwise healthy patients. The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP), which has been used successfully in the Veterans Administration hospital system to improve quality of care, takes comorbidities into consideration and could serve as a model, with modification, for the surgical subspecialties.