A couple of weeks ago, each pediatrician in CHOP's primary care network received the data on how successful each provider had been in getting two year olds under their care up to date on their vaccinations. For the record, CHOP's goal is greater than 95 percent. My own number was 94 percent. I "got dinged" because one patient had missed a couple of appointments after 15 months and by his second birthday, the metric window closed for the patient. "DING!"
If an individual provider misses too many vaccinations and it pulls them under the 95 percent threshold for the year, the possibility of missing out on quality incentive pay exists. Ou$h.
Yes, if you ask my partner. (Absurd is one of his favorite words, but he says it "abzurd").
"Why," he asks "are we getting penalized because somebody doesn't show up? Is it my job to go get them and drive them to the office? I do my best to immunize and I want them to get their vaccines but I think it's ridiculous that I'm held accountable if they are not here when it's the parent's job to be the parent. It's abzurd."
I agree. And yet...
Physicians, especially pediatricians, are generally people who want to do "good." We want to provide our patients with qualtiy care, offer them support and guidance to prevent illness, and help them regain their health when it falters. For the majority of us who believe that vaccinations are an important part of the care we provide, we strive to keep our kids up to date.
If that's our thought process when we walk into the office in the morning, why do we need to be hit over the head with these metrics?
Because individual human beings can do extraordinary things, but as groups, we tend to revert to the mean. We may wake up in the morning with the best of individual intentions, but unless there is a larger, unifying standard at work, good intentions will not translate to meaningful improvements at the margins.
Not everyone can be the late, great C. Everett Koop. Group standards encourage each of us to try a little harder and push a little further. Humans respond to standards and the statistics associated with those standards. Pediatricians, who wake up desiring to do good, will also respond and try to do better.
In our practice, before dollars were connected to metrics, our vaccination rates were 91 percent for the under two year old population. Peer pressure, coupled with financial incentives, has seen our practice rates climb to 96 percent. Same intentions, better execution.
What's the point? What's the difference if the rate is 91 or 94 or 96 percent? The point is herd immunity. We all know that this number varies from disease to disease, but we don't know how many individuals in a given community have either opted out of vaccines or in how many the given vaccines did not take. The extra couple of percentage points in our known practice numbers may nudge the vaccine rate for the community above the herd immunity threshold.
Take a different metric; say the number of persistent asthmatics who are currently NOT on a controller medication. What difference does it make? The difference is emergency department utilization and the associated costs. Fewer ED visits means fewer co-pays for patients, fewer hospitalizations, and less money spent by all of us by way of our health insurance premiums.
Higher quality care, across a population, has an impact on a population of patients. It can also affect an individual patient - your patient, my patient. Well designed, thoughtful, and meaningful metrics can measure better care. Poorly designed metrics can drive us crazy. But if a metric has been created with practical, clinical insight it can also take our good intentions and encourage us to practice better medicine.
By the way, CHOP didn't come up with the linking of financial incentives to performance on quality metrics. A growing collection of insurance companies and government payers is making this a connection a reality.
Sometimes better medicine involves doing something BEFORE we walk into the room. For those practices with an EHR, extracting data on who is behind on vaccines at a given time and giving those patients a call can be a few mouse clicks away. For those without an EHR, have someone in the office (anybody in the office have a high school aged child?) create a spreadsheet that lists each new baby in the practice, their birthdates, and the date when they turn two years (or the time when a given insurance program says that their metric must be met). Once a month, key on that column, check to see that the patient is up to date and if not, call them and get them scheduled for an appointment. BAM - good care has been linked with a financial reward.
The reality is that paying for quality is becoming the standard. Quality metrics can make us better pediatricians. We can wake up in the morning with the intention of doing good and have the means to do well. If the intention and design of the metric leads to higher immunization rates or lower emergency department utilization rates, then patients benefit. If meeting these metrics can help pediatricians' bottom lines then pediatricians benefit.
It sounds like a win-win to me.