Monday, December 7

Common Core: Medical Edition

They say that measurement is the first step towards controlling and improving things, and that “you are what you measure”. Management dogma has long promoted intensive measurement, tracking and reporting as the main driver of desired change.

Unfortunately, as the Common Core debacle has demonstrated, any attempt to apply this theory to practice will see it quickly erode in the face of two inconvenient realities. First, critical and relevant aspects of a situation are often intangible; they simply don't lend themselves to effective and accurate measurement. Second, no matter what you're looking at, there are almost always scores of contributing and/or influential factors, making it almost impossible to measure, aggregate, and report on them in a meaningful way. Considering that some of those factors will be several steps removed from the “main action” and/or intangible, and you've got a clear recipe for frustration!

Why am I rambling at you about this business nonsense? Because it's exactly what came to mind when I read that “non-profit news outlet ProPublica [has created a] never-before-available tool” they're calling an "Adjusted Complication Rate." Long story short, they've developed and launched a scale ranking “Nearly 17,000 doctors performing low-risk, common elective procedures such as gallbladder removal and hip replacements... in the new calculation...derived from government records collected about Medicare patients...” The score looks at post-operative complications “like infections, clots or sepsis” and a handful of risk factors such as “patients' ages, the quality of the hospital where the surgery took place, and other factors.”

The goal is straightforward: provide consumers a tool through which to compare the quality of potential surgeons before scheduling a procedure, and create a highly public venue through which to shame, scare, or (more euphemistically) motivate both doctors and the hospitals for which they work to step up their games, sharpen their skills, and identify and remove roadblocks to top-notch patient care. As a bonus, proponents suggest that these changes will significantly reduce the cost of readmissions related to surgical complications. Considering that such readmissions for Medicare patients cost “taxpayers $645 million” between 2009 and 2013, this is no small benefit.

ProPublica's intentions are clearly noble, and they should be applauded for doing something. After all, you never get anywhere if you don't at least try! That said, I can't help but cringe at what looks alarmingly like the early stages of a repeat of the Common Core disaster in the making. They're right to note that not all doctors or hospitals are created or perform equally. Certainly those doing well should be rewarded, and those at the bottom of the barrel strongly motivated to improve.

But the inconvenient truth is that people are bio-individual, both physically and in terms of their physical, social and familial support systems. For example, as an NTP I can tell you that most people are walking around with all kinds of undiagnosed and unrecognized health issues that are directly relevant to their ability to heal and their likelihood of readmission. My sister the nurse can testify to the kinds of disastrous individuals and relationships patients often rely on for their post-procedure care. These things are not, and cannot consistently or realistically be, accounted for on this index. As a result, just like teachers, doctors will be penalized for things outside their control without recourse to explain or defend themselves. Doctors battling to revamp struggling hospitals, or serving the lowest-income, most at-risk patients will suffer the most in this respect, punished for their faith, elbow grease, and big hearts.

Many doctors will respond by taking the only protective course available to them: refusing to see or work with any patients who don't present as excellent candidates for a quick, clean recovery. Dealing with a messy family situation? Obese? Smoker? Low-income? Cantankerous or absent-minded? Watch how fast you get turned down and punted over to the waiting list for one of the handful of (low ranked) doctors still willing to take you! As it stands, this well-intentioned ranking will most likely have the unintended (if predictable) effect of making losers out of neediest, least-ideal, and highest-risk among the us and those who stubbornly continue to serve them.

I can't help but be deeply saddened to see this kind of thing happening. We need real answers; real initiatives that get at the heart of the problem (like the increasing loss of non-profit hospitals), rather than relying on false metrics and sideways pressure.

What do you think? Am I over-reacting, or does this strike you as terribly counter-productive, too?

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