It hasn't happened yet but there is insight to be had from CMS' handling of nursing homes. They just published a list of their Special Focus Facilities. The public list is restricted to facilities that have persistent deficiencies for several consecutive months.
The background paper on the CMS web site describes the following:
Most nursing homes have some deficiencies, with the average being 6-7 deficiencies per survey. Most nursing homes correct their problems within a reasonable time period. However, we have found that a minority of nursing homes have more problems than other nursing homes (about twice the average number of deficiencies), have more serious problems than most other nursing homes, and continue to have serious problems over a long period of time. Although such nursing homes periodically instituted enough improvements in the presenting problems that they would be in substantial compliance on one survey, they would be determined as providing substandard quality of care on the next. Such facilities with a “yo-yo” compliance history rarely addressed underlying systemic problems that were giving rise to repeated cycles of serious deficiencies. To address this problem CMS created the “Special Focus Facility” (SFF) initiative.Physicians are rightly concerned about the replication of such quality assurance activities in their offices and practices. But it strikes me that, with nursing homes at least, the process was slow, deliberate, reasonable and pretty much fair.
There is a considerable amount of information and data available on the nursing home certification and compliance website. There was considerable push-back about the details of the criteria but it is difficult to argue against basic process and structural requirements for delivering decent care. There are over 16,000 nursing homes in the US, of whom 120 are currently on the SFF list and 54 names were named because they repeatedly failed to make improvements. That's a very small proportion of nursing homes, at the far tail end of the bell curve. There are about 120,000 physicians in the country, so that represents about 400 recalcitrant physicians in the entire country.
Physicians tend to focus on the content of care, not the structure surrounding it, and so tend to dismiss P4P as "pay for process" or worse. Moreover, one must acknowledge that some physicians are in control of the processes in their offices. The growing majority do not; they can scarcely influence procedures in their large and faceless corporate employers. The quality of physicians probably falls on a bell curve, but then, so does the quality of management. Hopefully, the folks at CMS know that they should only publish the names of the organizations, and not the individual doctors, for poor performance on process measures they cannot always affect.
Also, there is loud opposition comes from conservatives of libertarian ilk (like the folks at the Cato Insitute and my frequent fencing partners at InsureBlog), who do not believe that government can do anything right.
It seems that government is capable of getting it right sometimes. This, despite the fact that government frequently is responsible for the most infuriating and ridiculous attempts at controlling forces and markets where they have no business. The devil, as always, is in the details of implementation. There are forces that would publish poor performance by physicians prematurely.
But then, this discussion is premature. P4P has scarcely gotten off the ground. It is growing and moving towards some sort of public reporting of physician quality based on these process measures. I suggest physicians prepare themselves, work on streamlining their practices and, above all, wake up their lobbies.
I stumbled upon this article on The Wired for Health Care Quality Act. I apologize for having completely missed the fact that this legislation had even been considered, it is an unforgivable oversight. Well, I had heard grumblings that Congress was considering mandating the use of Quality Data, but I had no idea it had gotten as far as this. I guess I can't read everything, you know...
In short, Sen. Kennedy and 12 cosponsors are putting forward a bill to improve the health information infrastructure of the country. Title 3 directs DHHS to develop and review quality measures.
So, this is happening, it is happening now (and if not now, someone else will propose a similar bill as the political winds change), the lobbies are already involved, the information will become public in due course and we will all be competing against each other on the basis of a type of quality we (physicians) don't even recognize as relevant.
At least it looks like they won't be using billing data as the basis of the quality measures. That would be catastrophic to all concerned.