How Would You Define Performance?

Posted in Across the Nation, Cancer Care, Healthcare Reform by ACCCBuzz on May 1, 2012

by Dale E. Fuller, MD, FACR, ACCC Editorial Committee

Pay for performance. Now here’s an excellent example of a term that sounds good, but absent a definition of the second “P” has no meaning at all. I haven’t heard anyone address performance in a way that can be understood and accepted by patients, physicians, hospitals, and insurance companies–all parties at interest and all, may I say bluntly, proverbial blind men describing the elephant of performance.

Perhaps instead of “evidence-based medicine,” we could look at developing the concept of “goals-based medicine.” Yogi Berra is credited with the thought, “If you don’t know where you’re going, any road will get you there.” If the second “P” stands for performance, the question is begged, “Whose performance?”

The assumption is that the party doing the performing is the physician, I suppose. If that is the case, how is performance to be measured?

  • Patient satisfaction? This is pretty subjective.
  • Compliance with some set of guidelines? If so, whose guidelines?
  • Restoration of health of the patient? Now, here’s an interesting idea that sounds pretty good, but must take into account the state of health being experienced by the patient before the current illness began.
  • Quality of life? Who defines that?
  • Relief of symptoms? Pretty easy to assess, but different patients will define the severity of symptoms differently, and nobody else’s definition really matters to each one of them. People “suffer” differently, and some of their suffering is culturally derived.
  • Extension of some number of life-years? Quality adjusted, or just more years? Who can tell?

Almost never in the initial transaction between a physician and a patient and family is there any conversation about the goals or expectations to be accomplished within the experience the “system participants” are entering into and sharing. I would suggest that such an interaction might be the place to begin to define “performance.” Were the expectations set and then met? If they were, we have done our job. If they were not met, there is either more work to be done in the current relationship between physician and patient, or there is a need for the formation of a new relationship between the patient and a new physician.

Left unsaid is that such a discussion of goals and expectations, if held as early as possible in the relationship, may be the time for the physician to share with the patient what is capable of being accomplished, in contrast to what is expected to be accomplished.

“Performance” can be adequately measured only when the metrics of performance are defined and understood by all parties.

If “P4P” becomes the way services are valued, it is the only rational process through which the transaction can result in fair compensation. Bureaucrats sitting in offices faraway cannot do this; only those directly involved in any clinical situation can. And, to makes matters more difficult, every clinical situation will differ from every other clinical situation in one way or another.

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