Quality Measurement, Outcomes, and Incentives

Quality Measurement, Outcomes, and Incentives

John V. Cox

Sep 11, 2010

Modern business principles have convinced jillions of us that the road to quality improvement lies in managing processes within our practice/business. Certainly medicine and policy makers have taken this to heart, developing multiple ‘measures’ that focus on the processes of care. CMS’s PQRI measures (voluntary, soon to be mandated) require us to submit one of several answers to CMS to acknowledge our completion of each process measure. They offer an incentive payment to drive our adherence to the program (no comment on the true $ cost/value here).

A ‘definition’ of quality in medicine is adhering to these measures.

Yet, to an outside observer (read = your patient) these ‘steps’ of care likely have little meaning. And, though patients may be persuaded by the rankings in the local newspaper of their local hospital, when they dive into the data, I suspect they don’t choose their providers on this basis.

The Holy Grail of quality would be a true system of outcome measurement. What’s needed is an incentive system that ‘gets it right’—that is, really acknowledges quality, good care—and discriminates from lesser care.

This was really driven home to me driving to work on September 10—listening to Morning Edition/NPR. “How do you stop sea captains from killing their passengers?” is a wonderful piece looking at the transport of felons in the 1700s to the penal colony of Australia. Roughly a third of the prisoners died in transport. All of England wished to be rid of the felons, but were also upset by the deaths. Much hue and cry drove many governmental efforts to identify and change the processes that were at fault—all to no effect. Ultimately, a simple and elegant solution was determined, one that produced a survival rate of 99%. It was an economic solution—providing the captains a proper incentive. Instead of prospectively paying the captain for the number of prisoners transported, the government offered payment only on the basis of the outcome: the delivery of a live prisoner to Australia.

What of medicine? What transformation would come to our system if we (collectively) were paid for health outcomes in our communities? Say, simply on the basis of long term survival of colon cancer patients in Dallas. A bottom line measure = survival.  It would be difficult to argue with the measurement. What would happen to screening rates in our community? Or the education of surgeons and pathologists for accurate documentation of staging and adequate node sampling? Or of the adherence to best practices in adjuvant therapy?  Or the application of fourth-line therapies for patients with terminal disease?

What kind of conversations would begin to drive collaboration of community institutions rather than discrimination of services?

More survivors of colon cancer?

PQRI program information and links:


Two papers in JOP that have addressed quality issues in colorectal cancer by Abernethy, et al and Jacobsen et al:




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