Patients and Quality: A Measured Analysis

Austin Frakt, writing in the New York Times on the role that hospital boards can and should play in improving quality at hospitals, references a 2014 JAMA article on non-profit CEO compensation which concludes by explaining that CEO compensation was “associated with technology and patient satisfaction but not with processes of care, patient outcomes, or community benefit.” The point of course was to suggest that CEO’s can do more to improve care and that one way to do it is to tie quality outcomes to their compensation levels.

Perhaps there is something to this way of thinking when it comes to CEO’s, but the bigger question is whether large systemic quality issues on the institutional level can really be successfully addressed through individual compensation incentives. This of course is the theory behind pay for performance (P4P). Simply put, if we pay the providers differently the care they provide will be different. The theory seems to suggest that the problem at hand is one of doctor motivation.

A doctor, interviewed as part of qualitative analysis of a P4P program in the U.K., seems to object to that underlying theory that providers need to be incentivized or that motivation is the core issue.  The objection is based on a clear idea of professional ethics:

“We’re paid money to do that anyway, why is it that there’s extra money given when you’re given a wage to do it anyway? I don’t know why a carrot should be dangled to a health professional, personally I find it immoral.” (P37, practice nurse, high performer, deprived area).


But, of course, there are other reasons for P4P, such as risk transfer.   One study puts this idea at the center of P4P explaining that “P4P is a method by which risk is transferred from purchasers to providers of health care.” But if our goal is institutional change, then should we be dealing with risk- financial or professional- as a game of hot potato?

One of the challenges of the quality movement in health care is to develop systems for shared responsibility. The New York Times recently assessed the new trend in medicine to use surveys to measure suffering.   “But now, reducing patient suffering — the kind caused not by disease but by medical care itself — has become a medical goal.” Not surprisingly the Press Ganey survey is at the center of this discussion. Will the surveys help institutions change?

A goal of Press Ganey is to measure and quantify the subjective experience of being a patient. In their white paper A New Care Model to Reduce Patient Suffering, Press Ganey explains that their objective is to measure the patients suffering and to eliminate what they call avoidable suffering. They write, “Current measures of patient experience do not directly ask patients to report their level of suffering. However, they do allow us to understand the extent to which a patient views elements of their care as optimal or not. When patients report sub-optimal care or less-than-perfect experiences, those are opportunities to further reduce their suffering.”

The survey tool becomes the quantitative measure of success the institutions use to measure their improvement in reducing patient suffering.

As in other parts of healthcare, this is a financial business/industry. Press Ganey, which is owned by Vestar Capital Partners Inc is reportedly considering an IPO that might be worth as much as $ 1 billion dollars.

There are those who call for compensation- both CEO and provider- to be tied to such survey tools. At this point we can only begin to imagine the consequences both intended and un-intended that this might create. But we are beginning to get a sense of what it feels like not to be only responsible for a patient, but also for a data point.

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