Health policy is an important way of effecting change in society at scale. When acting at scale, it is necessary to make assumptions and generalizations that do not take into account all of the nuances and complexities of a society that is not inherently equal and just. As a consequence, health policy that may seem effective at first glance may actually be complicit in creating inequities that perpetuate society’s injustice.
Today, the care of patients in hospitals and outpatient clinics, like anything else, is a business. Businesses are focused on efficiency and optimization of profits. It therefore follows that almost all metrics in healthcare are designed from an administrative or billing perspective. However, the institutional bias that results from policy, despite being much more subversive, can be addressed by careful design of metrics, separating compensation from outcomes (at least until a more equitable society is formed).
Navathe and Schmidt show one of the pitfalls of using metrics where the perceived rhetorical purpose to outsiders and perhaps even the designers—improving care for all patients—is mismatched to the practical purpose to hospitals and clinics—optimizing profits. In order for metrics to be effective, it is necessary to consider the possible rhetorical uses of the metrics while designing them.
When metrics are used to determine compensation, people will always attempt to game the system. Instead of allowing physicians to be rewarded for treating patients, they are incentivized to treat their “score.” It would be naïve to assume otherwise. Unfortunately, tying healthcare outcomes to compensation is fundamentally flawed in a society where hospitals can “refuse” to see patients in implicit, less obvious ways.
The byproduct of tying outcomes to compensation and using metrics to quantify outcomes results in a situation where hospital administrators limit “unprofitable services like psychiatry wards either by keeping only a small number of spots for patients or by simply not offering a dedicated psychiatry ward at all.” These metrics “create incentives for hospitals to avoid patients from these groups” because patients in minority populations are “economically unattractive to hospitals.” Chronically understaffing preventative care offices has deep repercussions in the form of worse patient care and increased overall costs over a patient’s lifetime.
With each of these types of payment models, the initial intention regarding social justice may be unclear, unknown or even aimed at promoting it. A value-based payment reform model seems as innocent as a daisy and worlds apart from the most overt forms of structural racism, such as segregated transportation or drinking fountains. Yet, far too often, such models share the consequence of systematically disadvantaging some groups, whether as a result of the design of policies or culturally ingrained behavioral patterns.
Amol S. Navathe and Harold Schmidt
With today’s data-focused society, healthcare metrics are indeed critical tools to assess the functioning of our healthcare system. However, it is important to keep in mind that they have limitations and can easily be flawed Ultimately, metrics must be used with extreme care to ensure that these unintended consequences are fully thought through.
Dossier
“Why a Hospital Might Shun a Black Patient,” by Amol Navathe and Harold Schmidt, October 6, 2020. https://www.nytimes.com/2020/10/06/opinion/medical-racism-payment-models.html
“The Tyranny of Metrics,” by Jerry Muller, 2018.