Measuring Quality for ED Doc pay

[thegenius]

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Another question about ED doc pay.

Any of you guys and gals at your work have, as part of your compensation package, a component tied into the nebulous concept of "quality"?

It can come via any number of mechanisms, some fair and some not fair (i'm just tossing some out there)
- press gainey scores
- door-to-doc time
- 48 hr return rate
- CT scans ordered
- narcotics given
- Narcotic Rx given
- patient satisfaction

I know some of these are not based on quality. I'm just trying to get a sense of how other groups define and measure quality of physician work, and then pay based on that. There are lot of changes going on at our place and we are trying to define this aspect of our pay.

 

[Alvarez13]

No.

 

[GeneralVeers]

Mods can we delete this thread? Don't want CMG execs, hospital CEOS, or Medicare administrators getting any bright ideas.

 

[cyanide12345678]

One of the places I looked at had a 10/hr bonus given quarterly if a minimum patient satisfaction score was met for each quarter. According to the recruiter, most people met that score, but who knows. I never went too much into the details for that job.

 

[southerndoc]

This is in place at numerous CMG's and even SDG's (two that I know of). PG rates are rarely enforced, but some things are (i.e., if you have a huge complaint that is vetted, etc.). Most are determined by local medical directors, but I know of one large CMG that the one of the C-suite people at corporate in the upper US will enforce it without even telling the doc. It happened to a friend of mine. She took a 20% cut in pay and ended up leaving.

 

[GonnaBeADoc2222]

I would like to see modifiers for "quality" of physician work conditions such as:

-IPH (interruptions per hour)
-number of times basic equipment non functional or not present
-consultant committing emtala violation by refusing to evaluate
-hospitalist refuses to admit
-patient yells/threatens/bites/spits
-family obstructs or dumps patient
-48 hour returns (I told you no narcotics/antibiotics the first time)

 

[Birdstrike]

Any of you guys and gals at your work have, as part of your compensation package, a component tied into the nebulous concept of "quality"?
- press gainey scores
- door-to-doc time
- 48 hr return rate
- CT scans ordered
- narcotics given
- Narcotic Rx given
- patient satisfaction

I know some of these are not based on quality...

If you were to pick a doctor, based on your perception of the quality of their care, would you look at the metrics you've listed?
I wouldn't and neither would any of the people claiming we need these "quality measures" which don't measure quality.

No way in hell I'd pick my doctor based on his Press-Ganey scores, which are probably high because he gives inappropriate antibiotics and opiates, and smiles inappropriately.

No way in hell I'd pick my doc based on the lowest door-to-doctor times, because he places impressing business and poly-sci majors with his corner cutting speed, over careful, quality Medicine.

No way in hell I'd pick my doc based on return rates, because he has upped his needless admission rate, to game the 48-hr admission number to please people that didn't go to medical school.

No way in hell I'd pick my doc based on a "CT scans ordered" number. I don't want him ordering too many, or too few, to achieve a "metric." I want him ordering one when I need one and not needlessly irradiating me when I don't, to game a number.

No way in hell I'd pick my doc based on a "narcotics given" ranking. I don't want someone over-prescribing them to me or anyone else to bump his Press Ganey scores, nor do I want my doctor to deprive me of a short term, justified narcotic for my agonizing broken bone or surgical pain because some jerk somewhere else is abusing the system, to game narcotics-given number.

And the administrators, insurance people and politicians wanting these metrics don't pick their doctors based on this s**t either. That's the sick truth. The people forcing these numbers upon us to measure "quality" don't use these metrics themselves to choose their own doctors. They go by name, reputation and the recommendation of someone they trust. No one, I repeat no one, uses these metrics to decide who's the best doctor for them, and it's therefore insane to build these false, inaccurate and misleading metrics into our system, and everybody knows it.

Yet here we are.

 

[thegenius]

No I wouldn't look at any of that stuff. I would look at stuff that is largely un-measurable. Which means that it's very hard to measure quality.

Just curious if some groups have found a way to measure stuff like that.

For instance, ordering CTs is individualized, but there are probably regional or nationwide data on the percentage chance one orders a CT on a patient. In our group this data exists...although I can't remember off the top of my head what it is. Its something like 40% chance you get a CT. So if there is a doctor whose number is 75%, averaged out over a year and thousands of patients in the same ER, that can't be good. Hard to argue that person is practicing good medicine.

I think MIPS / PQRS is trying to pay doctors based on quality, like not giving antibiotics for acute sinusitis, only treating strep with a + culture or swab, stuff like that.


How would I pick a doctor? Outside of the ED that is? I want a doctor that practices evidence based medicine. And I want him to be nice. Unfortunately probably like 80% of the decisions we make - we don't have EBM to guide us. Very hard to measure quality

 

[thegenius]

Bumping this thread I started a while ago which didn't go too far.

Tying physician quality or bonuses to testing (like CT utilization, MRI utilization), is that prima facie bad thing? What about if you are in court and a lawyer says "Dr. Dohickey, do you get compensation for not ordering tests?" "Well..yes a small percentage of my pay comes from a quality bonus that measures CT utilization." "Dr. Dohickey, by not ordering that CT Dissection study and missing my plantiff's dissection, which obviously killed him, did you receive that part of the quality bonus and make money?"

Wondering if anybody has ever heard of successful litigation against a physician tying not ordering a test to compensation or bonuses.

 

[southerndoc]

No, because it's not tied to an individual patient. Nobody tells you to not order a CT dissection protocol or a head CT. They tell you to use your judgement and try overall to reduce your CT's. This can be done by applying NEXUS criteria, Canadian criteria, etc. More use of D-dimers instead of going straight to CT (when appropriate).

 

[TheSingularity]

No, because it's not tied to an individual patient. Nobody tells you to not order a CT dissection protocol or a head CT. They tell you to use your judgement and try overall to reduce your CT's. This can be done by applying NEXUS criteria, Canadian criteria, etc. More use of D-dimers instead of going straight to CT (when appropriate).

Ya until you miss one then you're ****ed

Sent from my Pixel 3 using SDN mobile

 

[ShockIndex]

When I worked for EMP (now USACS) 10 years ago, they went through a couple permutations of incentive based compensation models. All incorporated PG in the compensation scheme.

The most malignant version of this concept tied the monthly productivity bonus to PG. Each site had a target RVU /hr that most of the docs would exceed. For every 0.1 RVU/hr over target, you got an added 1$/hr. So, someone producing 9 RVU/hr would make an extra $30/hr if the target was 6 RVU/hr. The kicker was that you had to be in the top 10% on your PG for that month to collect the full amount. You got half the amount if you were 50th-90th% and none of if under 50th%.

Needless to say, physicians did some pretty crazy stuff to make people happy or keep angry patients from getting surveys. This included rampant overprescribing, unnecessary admissions, and even changing disposition records to AMA once the patient left so that they wouldn’t get a survey.

Like I said in another thread, I’d rather do prostate exams and hernia checks on Guantanamo detainees for a career than spend a single shift doing that bulli**** again.

 

[GeneralVeers]

When I worked for EMP (now USACS) 10 years ago, they went through a couple permutations of incentive based compensation models. All incorporated PG in the compensation scheme.

The most malignant version of this concept tied the monthly productivity bonus to PG. Each site had a target RVU /hr that most of the docs would exceed. For every 0.1 RVU/hr over target, you got an added 1$/hr. So, someone producing 9 RVU/hr would make an extra $30/hr if the target was 6 RVU/hr. The kicker was that you had to be in the top 10% on your PG for that month to collect the full amount. You got half the amount if you were 50th-90th% and none of if under 50th%.

Needless to say, physicians did some pretty crazy stuff to make people happy or keep angry patients from getting surveys. This included rampant overprescribing, unnecessary admissions, and even changing disposition records to AMA once the patient left so that they wouldn’t get a survey.

Like I said in another thread, I’d rather do prostate exams and hernia checks on Guantanamo detainees for a career than spend a single shift doing that bulli**** again.

You worked with them at the same time I did. The PG ganey bonus was incredibly stupid. We'd be bonused often with N=1 surveys. They were then averaged over 3 months, and if you got one bad survey EVER you potentially missed out on the bonus every month due to low number of respondents.

 

[ShockIndex]

You worked with them at the same time I did. The PG ganey bonus was incredibly stupid. We'd be bonused often with N=1 surveys. They were then averaged over 3 months, and if you got one bad survey EVER you potentially missed out on the bonus every month due to low number of respondents.

I thought they had to have 30 surveys which didn’t happen until several months of employment, but I could be misremembering that. However, you are very correct that it was easy to get into deep, deep hole that took several months to climb out since they used a rolling average of the last 30 surveys. Just a couple of bad surveys meant no bonuses for at least 2 or 3 months and docs would suddenly slow down or log every second in the ED to make up for the lost income.

Prior to that system which was implemented in 2009ish, they had a compensation scheme where the partners competed for an hourly rate based largely on productivity, but also factored in PG and “citizenship” in the compensation scheme.

The problem with all of these schemes is that they incentivize doctors to meet expectations that are unrealistic or unhealthy rather than improving outcomes. Trying to have an frank and honest conversation with the company leadership about these unintended consequences was a waste of time.

 

[GeneralVeers]

I thought they had to have 30 surveys which didn’t happen until several months of employment, but I could be misremembering that. However, you are very correct that it was easy to get into deep, deep hole that took several months to climb out since they used a rolling average of the last 30 surveys. Just a couple of bad surveys meant no bonuses for at least 2 or 3 months and docs would suddenly slow down or log every second in the ED to make up for the lost income.

Prior to that system which was implemented in 2009ish, they had a compensation scheme where the partners competed for an hourly rate based largely on productivity, but also factored in PG and “citizenship” in the compensation scheme.

The problem with all of these schemes is that they incentivize doctors to meet expectations that are unrealistic or unhealthy rather than improving outcomes. Trying to have an frank and honest conversation with the company leadership about these unintended consequences was a waste of time.

You are correct. It was the rotating 30 survey average. With an N typically of under 6 per month, it took a LONG LONG time for a bad survey to rotate off the list. Considering I don't give out narcs or other patient satisfiers I almost never got the bonus.

I also loved the "citizenship" incentive, as if USACS was some sovereign nation and holding their passport meant a damn