PQRI: ‘We’re from the Government, and We’re Here to Help’

These results are surprising only until you realize that P4P (as well as PQRI) does not report quality. PQRI reports processes. Just because you give someone having an AMI an aspirin, this doesn’t mean you’ve delivered quality care. It means you’ve followed the cookbook formula to get your bonus. Conversely, just because you didn’t give an AMI patient an aspirin, this doesn’t mean you didn’t deliver high-quality care. It may mean that as a physician, you feel that giving aspirin to this particular AMI patient may not be in the patient’s best interest.

The Value of Autonomy

What do cochlear implants, the Epley maneuver, antibiotic therapy for peptic ulcers, and laparoscopic cholecystectomy have in common? These are just a few examples of deviations from clinical practice norms that resulted in major innovations and improvements in medical care. Although the above examples are well accepted in current medical practice, when they were introduced they were all initially rejected-and in some cases labeled malpractice by conventional medicine. One cannot deny the impact such practice deviations have had on the evolution of medical care to date. PQRI will enhance practice conformity at the expense of any deviation from practice norms that would result in similar innovations in the future. This is probably the worst and most insidious part of PQRI because we will never know what innovations would have occurred if not for such intrusion into the work of professionals.

Which brings me to the word professional. Part of the identity of a professional is the capacity for autonomous judgment and decision-making. If we are following a cookbook protocol, can we call ourselves professionals? And why should anyone pay for our services as professionals? Why not hire a technician who can follow the book as well as anyone else?

Voluntary?

Although the PQRI is a voluntary program, many see it as inevitably becoming mandatory at some point in the future. Consequently, they may ask, Why whine and complain about it? Although I, too, suspect that CMS plans to expand PQRI and probably make it mandatory, I do not see it as inevitable that all physicians should participate. Particularly, if physicians understand that (1) it will not result in improved payment, (2) it will not result in improved quality of care, and (3) it will result in the cookbooking of medical care, then aren’t we ethically required to reject it? CMS requires physician participation and acceptance of this program to make it work.