Metrics

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
rcordova said:
mortality
Click to expand...
Our tertiary center acuity is too high for that.

OP, make them things that maybe matter that you can somewhat control.
Your hospital is largely responsible for left without being seen and ED length of stay, but you can control things like time from physician sign up to orders entered and physician sign up to disposition in EMR. Or make something about following appropriate risk stratification for PE or chest pain discharges.
 
The most important metric for pay SHOULD be RVU/hr IMO. How much money do you generate an hour in professional services. Nothing else should compare when it comes to determining your salary. If you are generating a ton of money for a place you should make a ton of money. If you are doing nothing, you shouldn't probably be making very much.
 
gamerEMdoc said:
The most important metric for pay SHOULD be RVU/hr IMO. How much money do you generate an hour in professional services. Nothing else should compare when it comes to determining your salary. If you are generating a ton of money for a place you should make a ton of money. If you are doing nothing, you shouldn't probably be making very much.
Click to expand...
Surely this can't be all that there is to it. Generation of money for a place has no direct correlation with the quality of the service you provide. You can order lots of useless tests that make your employer rich, but if your patients have poor outcomes, then you should not be compensated well. NPs are a classic example of this. I have worked with several individuals who BLAZE through patients but discharge patients to the street when they should be admitted, or they order a CT scan on a patient when they don't need one and can go home with routine follow up. In an RVU based model they would be making a killing, but I don't know if that's the way it should be.

If I paint 10 houses in 1 week, and the next week, all the paint starts chipping off, should I be paid more than the person who paints 2 houses in a week but does a great job?

The fact of the matter remains that in this day and age quality based outcomes are not the driving incentive. While I have never worked for a CMG, I will take a guess that they don't care as much about how well the patients do as they care about the bottom line.
 
I agree that quality should matter in an ideal world, but it doesn’t really in reality and would be near impossible to implement consistently. So in the current way we bill for our care, I think the most fair way we should be compensated for should be based on how productive we are. You can take amazing care of one person per shift, but no matter how great of care you took of that person, you can only generate up to a 99215 code (unless there’s procedures or CCT). So you may have been wonderful to them, got them snacks every 30 min, called their family and their pastor, watched a movie with them, and really bonded. But in the end, you billed for 200 bucks at most during the entire shift where you took the greatest care of one patient ever.

Yes quality should matter, I do agree in spirit, but I’d be afraid how insurances or the govt would want to use that against us. We already have seen some of this used against billing, where complications like a UTI from a foley basically negate further charges, etc.

Its easier to define patients/rvus per hour. Quality is a lot harder to define. Its not universal. You may think its quality to spend a ton of time with people and see 1.0/hr, and you are right, that is quality for those patients. But the patients that have to wait 6 hrs to be seen because of high wait times from things getting backed up aren’t receiving quality care. So should that then be held against you?

You get my point. Quality is too relative.
 
Backpack234 said:
Metrics suck, hands down. But if you were able to pick the metrics that affected your pay and you HAD to choose one or two, which metrics would be best?
Click to expand...
CEO to termination rate
 
gamerEMdoc said:
I agree that quality should matter in an ideal world, but it doesn’t really in reality and would be near impossible to implement consistently. So in the current way we bill for our care, I think the most fair way we should be compensated for should be based on how productive we are. You can take amazing care of one person per shift, but no matter how great of care you took of that person, you can only generate up to a 99215 code (unless there’s procedures or CCT). So you may have been wonderful to them, got them snacks every 30 min, called their family and their pastor, watched a movie with them, and really bonded. But in the end, you billed for 200 bucks at most during the entire shift where you took the greatest care of one patient ever.

Yes quality should matter, I do agree in spirit, but I’d be afraid how insurances or the govt would want to use that against us. We already have seen some of this used against billing, where complications like a UTI from a foley basically negate further charges, etc.

Its easier to define patients/rvus per hour. Quality is a lot harder to define. Its not universal. You may think its quality to spend a ton of time with people and see 1.0/hr, and you are right, that is quality for those patients. But the patients that have to wait 6 hrs to be seen because of high wait times from things getting backed up aren’t receiving quality care. So should that then be held against you?

You get my point. Quality is too relative.
Click to expand...
Quality does not always have to equal more time. While you are talking about spending more time with the patient, bring them food etc., these are not patient centered outcomes, especially if you have a patient in the waiting room who dies because you are not seeing patients fast enough.

Speed is important, no question. But speed at the expense of a meaningful outcome is also not beneficial. Similarly, as you pointed out, being slow because you are so concerned about getting a meaningful outcome is detrimental as well.

I agree with you, quality is virtually impossible to define. We shouldn't ding EM docs because they couldn't save a crashing patient who had way too many comorbidities.

But if I could create some sort of index that took into account the complexity of the patient's presentation, tied in with whatever physiological derangement they had when they presented to the ED relative to the status of that derangement when they left the ED, combined with resource utilization and ordering of tests, and compensate people based on all these factors, I think that would incentivize ED docs to provide the best possible care.

I don't think it's possible to come up with such a metric, but I think this thread is in many ways just an exercise in coming up with a "perfect world" scenario.
 
gamerEMdoc said:
The most important metric for pay SHOULD be RVU/hr IMO. How much money do you generate an hour in professional services. Nothing else should compare when it comes to determining your salary. If you are generating a ton of money for a place you should make a ton of money. If you are doing nothing, you shouldn't probably be making very much.
Click to expand...

I think it's fine to say that RVU/hr is the most important metric for pay, but lets not confuse productivity with quality. You are paying for productivity in this case.

Measuring quality seems to be an impossible thing in medicine, the holy grail. Even these MIPS measures can be gamed to achieve what you want. I posted a similar question 1-2 weeks ago and had many similar responses.

If I were to design a way to measure quality, I would want an ER physician to practice EBM and deliver efficient, compassionate care.

ER Doc A: Sees 500 chest pain patients a year, admits 25%, rules out PE with CT 5% time, out of those discharged, 1 returns with MI within 30 days
ER Doc B: Sees 500 chest pain patients a year, admits 40%, rules out PE with CT 20% of the time, out of those discharged 0 return with MI within 30 days.

Which ER doc delivered higher quality care above?
 
thegenius said:
I think it's fine to say that RVU/hr is the most important metric for pay, but lets not confuse productivity with quality. You are paying for productivity in this case.

Measuring quality seems to be an impossible thing in medicine, the holy grail. Even these MIPS measures can be gamed to achieve what you want. I posted a similar question 1-2 weeks ago and had many similar responses.

If I were to design a way to measure quality, I would want an ER physician to practice EBM and deliver efficient, compassionate care.

ER Doc A: Sees 500 chest pain patients a year, admits 25%, rules out PE with CT 5% time, out of those discharged, 1 returns with MI within 30 days
ER Doc B: Sees 500 chest pain patients a year, admits 40%, rules out PE with CT 20% of the time, out of those discharged 0 return with MI within 30 days.

Which ER doc delivered higher quality care above?
Click to expand...

Depends on the patients each doctor sees...
 
Although quality is nebulous we all know good doctors and bad doctors. I wish your quality rating could be generated by a random (blinded) set of physicians in same-specialty reviewing and rating a statistically significant # of your charts.
 
Highly disagree that quality care is some nebulous concept that can't be measured.

For example at my residency all the attendings got annual reports of the # of CT head scans ordered including the number of positive findings and number of positive findings requiring acute neurosurgical intervention. So if you have x attending who orders 300 CT head scans with 10 positive scans and 4 requiring intervention and y attending who orders 150 CT head scans with 15 positive scans and 6 requiring intervention everyone knows who's providing better quality care. You could also do the same for any other imaging study performed in the emergency department.
 
alpinism said:
Highly disagree that quality care is some nebulous concept that can't be measured.

For example at my residency all the attendings got annual reports of the # of CT head scans ordered including the number of positive findings and number of positive findings requiring acute neurosurgical intervention. So if you have x attending who orders 300 CT head scans with 10 positive scans and 4 requiring intervention and y attending who orders 150 CT head scans with 15 positive scans and 6 requiring intervention everyone knows who's providing better quality care. You could also do the same for any other imaging study performed in the emergency department.
Click to expand...

Love when hospitals toss out these stats as a "quality" measure, when really it's a "how much money did the hospital / insurer have to spend" measure.

If we had tort reform in the majority of states, imaging and testing rates would plummet.

Don't punish physicians because of the financial motivations of hospitals, insurers and plaintiffs attorneys.
 
Remember, hospitals don't want us discharging patients. They make money on admissions, not on ER pts. Sure, the ER isn't a colossal money loser (sometimes), but they really care about the things that make money. One admission earns more than 5-10 ER pts. One ICU admission can earn as much as 100 ER pts.
Think about that one for awhile.
 
thegenius said:
I think it's fine to say that RVU/hr is the most important metric for pay, but lets not confuse productivity with quality. You are paying for productivity in this case.

Measuring quality seems to be an impossible thing in medicine, the holy grail. Even these MIPS measures can be gamed to achieve what you want. I posted a similar question 1-2 weeks ago and had many similar responses.

If I were to design a way to measure quality, I would want an ER physician to practice EBM and deliver efficient, compassionate care.

ER Doc A: Sees 500 chest pain patients a year, admits 25%, rules out PE with CT 5% time, out of those discharged, 1 returns with MI within 30 days
ER Doc B: Sees 500 chest pain patients a year, admits 40%, rules out PE with CT 20% of the time, out of those discharged 0 return with MI within 30 days.

Which ER doc delivered higher quality care above?
Click to expand...

I don't know about quality of care but the quality of life for Doc B would be much better and this is what is important in our environment.

Once Doc A is sued a couple of times for the Missed MI, Doc A will eventually become Doc B. Doc B is rewarded for not having to spend 2-3 yrs working through a med/mal case
 
alpinism said:
Highly disagree that quality care is some nebulous concept that can't be measured.

For example at my residency all the attendings got annual reports of the # of CT head scans ordered including the number of positive findings and number of positive findings requiring acute neurosurgical intervention. So if you have x attending who orders 300 CT head scans with 10 positive scans and 4 requiring intervention and y attending who orders 150 CT head scans with 15 positive scans and 6 requiring intervention everyone knows who's providing better quality care. You could also do the same for any other imaging study performed in the emergency department.
Click to expand...

But who has the better patient satisfaction? Pure outcome numbers is only part of the story.
Attending X ordered more CTs, patients are happier b/c many times they requested them, great sat scores
Attending Y ordered only when he thinks is necessary, patients are pissed b/c they came for a CT, Poor Sat scores.

Now attending Y has to go through patient satisfaction metrics training.

I would say Attending X would be praised in our current system.

In all the hospitals I have worked at, we have NEVER been scored on our lab/rad utilization. But we sure are on all of the patient sat metrics

Don't kid yourself that hospitals care about how much test you order. They are happy that you do as they can bill more.

Attending X - CT/labs = Level 5 and high facility charge
Attending Y - No Labs/No CT = Level 3 and low facility charge
 
alpinism said:
Highly disagree that quality care is some nebulous concept that can't be measured.

For example at my residency all the attendings got annual reports of the # of CT head scans ordered including the number of positive findings and number of positive findings requiring acute neurosurgical intervention. So if you have x attending who orders 300 CT head scans with 10 positive scans and 4 requiring intervention and y attending who orders 150 CT head scans with 15 positive scans and 6 requiring intervention everyone knows who's providing better quality care. You could also do the same for any other imaging study performed in the emergency department.
Click to expand...


You are oversimplifying things though. What if attending Y who has the “better ct metric” also regularly kills 1 patient every 4 years by missing something horrible while attending X does not? That would be missed by your simple metric - and who is providing better quality then?
 
doctalaughs said:
You are oversimplifying things though. What if attending Y who has the “better ct metric” also regularly kills 1 patient every 4 years by missing something horrible while attending X does not? That would be missed by your simple metric - and who is providing better quality then?
Click to expand...

That can be answered by comparing the NNH (and quantifying that harm) for the extra scans X is doing vs the NNH of missing whatever disease process is killing Y's patients once per 4 years.
 
doctalaughs said:
You are oversimplifying things though. What if attending Y who has the “better ct metric” also regularly kills 1 patient every 4 years by missing something horrible while attending X does not? That would be missed by your simple metric - and who is providing better quality then?
Click to expand...

This is the problem, I think the "Efficiency" of care is not much consolation to the family of a patient seen by 'Attending Y' who had a missed head bleed that could have been intervenable and then dies or is neurologically devastated.

This might upset some of the tender-hearted residents on this forum, but in the current climate, all the incentives point towards more testing. It results in more patient satisfaction, more RVUs per hour, more facility charges and collections, fewer misses, fewer lawsuits.

As a physician you do not personally reap the loss of "wasted" dollars on overtesting, and the downsides of 'over diagnosis' or 'radiation exposure' do not currently blowback on the ordering physicians.

All of these things could change in the next few years, but CURRENTLY the incentives favor heavy testing and conservative dispositioning. If and when that changes, my practice will likely change as well. I am but a small cog in this machine and my behavior is directed by forces outside of my control.
 
Tenk said:
Doctors should rate patients and have their insurance premiums tied into it.
Click to expand...

Why not? Insurance companies would love to have a reason to increase people's premiums.
 
RoyBasch said:
This is the problem, I think the "Efficiency" of care is not much consolation to the family of a patient seen by 'Attending Y' who had a missed head bleed that could have been intervenable and then dies or is neurologically devastated.

This might upset some of the tender-hearted residents on this forum, but in the current climate, all the incentives point towards more testing. It results in more patient satisfaction, more RVUs per hour, more facility charges and collections, fewer misses, fewer lawsuits.

As a physician you do not personally reap the loss of "wasted" dollars on overtesting, and the downsides of 'over diagnosis' or 'radiation exposure' do not currently blowback on the ordering physicians.

All of these things could change in the next few years, but CURRENTLY the incentives favor heavy testing and conservative dispositioning. If and when that changes, my practice will likely change as well. I am but a small cog in this machine and my behavior is directed by forces outside of my control.
Click to expand...

Agreed. It's so "in vogue" to minimize testing and optimize TATs to some ridiculous number that makes you wonder whether someone actually had time to lay hands on the pt to examine them. The irony is that this kind of revolution in culture within the ED is fueled by all the groups interested in minimizing costs and optimizing efficiency for the bottom dollar. Hospitals, hospital management, CMGs, insurance carriers, etc... The message gets pushed into all the latest EBM journals quoting studies to lull physicians into a sense of complacency and false security thinking "well if nobody else is ordering this stuff, then I won't either..." I mean, think about it... who's going to publish a study showing that decreased TATs correlates with increased misses or increases in bad outcomes? Who's going to publish a study showing that increased testing reduces bounce backs and re-hospitalization within 30 days? Nobody wants to publish that stuff. I'm not even saying that much of the literature isn't valid but I'm a firm believer it needs to be taken in context. There's a tremendous push to publish "only" literature that supports the overarching goals in reduction in medical cost expenditure and anything that increases productivity and operational efficiency in an already overwhelmed system. That results in a clear reporting and publication bias.

Within our CMG, we get this monthly report showing CT utilization among all the physicians. Nobody is actually telling you NOT to order CTs, but it's a psychological tool to make physicians think that ordering CTs is a bad thing. I often hear some of the newer graduated docs muttering to themselves "man, I hate ordering this CT, it's going to make my numbers look terrible this month" and I can't help but cringe. I keep thinking to myself "Don't you get it man?...None of these scorecards or outside pressures matter in the end. Nobody is going to fire you for ordering too many CTs. Do what you think is right. Go with your gut. You think that 65 y/o with belly pain needs a CT? Order it. Numbers be damned. Do what you think the pt needs and tune out all the outside noise from forces upon high trying to subconsciously influence how you practice medicine." Anyway, I'll get off my soap box but your post resonated. Because, let's face it... until we have some sort of massive tort reform, defensive medicine is here to stay. It's oftentimes better for the patient and it's sure as hell better for the doctor.
 
You should always do what you think is right for the patient and what you're comfortable with.

The issue with metrics is misleading. Yes, everybody would love to have a top performer. However, as with anything you have to take it in context with your peers. Evaluating a doc and comparing him/her nationally doesn't give me any information. Comparing him/her to peers gives me a lot of information. If someone's patient satisfaction scores are in the toilet, you can compare it with other docs at the same location. You can generalize an individual's performance with their peers as they are generally seeing the same type of patients, acuity, etc. unless they are working all nights, only certain areas of the ER (high/low acuity), etc.

Regarding CT's per 100 patients, the goal isn't to get as low as you can. The goal is to not be more than 1 standard deviation from your peers. If your peers are ordering 45 CT's per 100 patients, SD is 5 CT's, and you're averaging 97 CT's per 100 patients, then you have a problem that needs addressing. You can look at your average acuity and admissions, but it's highly doubtful it justifies that many CT's. Likewise, someone performing more than 1 standard deviation lower than their peers (i.e., ordering too few CT's) is likely missing things if they are seeing the same type of patients.

In the era of DRG's (diagnosis related groups), many insurers pay a hospital $x amount of dollars for a given diagnosis for ER visit all the way to discharge. If you order a CT, CXR, labs every day or if you just order a CXR and labs on admission, the hospital gets the same reimbursement. The bottom line is that the more you order, the less profit margin for the hospital. Even non-profit hospitals must make a profit or at least break even to survive.

The real metric that needs attention by all providers is MIPS (Merit-based Incentive Payment System). Your performance will follow you around. So if you do poorly on MIPS this year and your reimbursement is reduced in subsequent years, if you change employers then your new employer will suffer by your poor performance with reduced Medicare reimbursement. It is likely -- particularly in small groups -- that MIPS data will become part of your pre-screening for employment as groups will be affected by your reimbursement. Larger groups will be more likely to buffer reduced payments, but I would imagine in the near future reduced payments to a group will result in reduced salaries for the providers with lower performance.
 
southerndoc said:
You should always do what you think is right for the patient and what you're comfortable with.

The issue with metrics is misleading. Yes, everybody would love to have a top performer. However, as with anything you have to take it in context with your peers. Evaluating a doc and comparing him/her nationally doesn't give me any information. Comparing him/her to peers gives me a lot of information. If someone's patient satisfaction scores are in the toilet, you can compare it with other docs at the same location. You can generalize an individual's performance with their peers as they are generally seeing the same type of patients, acuity, etc. unless they are working all nights, only certain areas of the ER (high/low acuity), etc.

Regarding CT's per 100 patients, the goal isn't to get as low as you can. The goal is to not be more than 1 standard deviation from your peers. If your peers are ordering 45 CT's per 100 patients, SD is 5 CT's, and you're averaging 97 CT's per 100 patients, then you have a problem that needs addressing. You can look at your average acuity and admissions, but it's highly doubtful it justifies that many CT's. Likewise, someone performing more than 1 standard deviation lower than their peers (i.e., ordering too few CT's) is likely missing things if they are seeing the same type of patients.

In the era of DRG's (diagnosis related groups), many insurers pay a hospital $x amount of dollars for a given diagnosis for ER visit all the way to discharge. If you order a CT, CXR, labs every day or if you just order a CXR and labs on admission, the hospital gets the same reimbursement. The bottom line is that the more you order, the less profit margin for the hospital. Even non-profit hospitals must make a profit or at least break even to survive.

The real metric that needs attention by all providers is MIPS (Merit-based Incentive Payment System). Your performance will follow you around. So if you do poorly on MIPS this year and your reimbursement is reduced in subsequent years, if you change employers then your new employer will suffer by your poor performance with reduced Medicare reimbursement. It is likely -- particularly in small groups -- that MIPS data will become part of your pre-screening for employment as groups will be affected by your reimbursement. Larger groups will be more likely to buffer reduced payments, but I would imagine in the near future reduced payments to a group will result in reduced salaries for the providers with lower performance.
Click to expand...

I agree with much of what you're saying from the perspective of administration.

No one is arguing that metrics aren't valuable from an administration standpoint, but what's the utility in broadcasting out this information to all the docs on a monthly or quarterly basis? How is this useful to them other than fostering an air of competition and insecurity? I'm speaking somewhat as a devil's advocate because if I was an administrator, sending out a scorecard is exactly what I would do. It's simple psychology. People start comparing themselves to others and don't want to be at the bottom of the list, therefore providing incentive for enhanced and optimized performance. That's a great thing from an administrative point of view and from the perspective of CMG top brass. It's brilliantly effective. I'm not so sure it's always in the patient's best interest though. However, do we really need extra upon extra layers of enhanced performance incentives for a group of individuals who are the quintessential overachievers of society? Do we really need to "educate" an emergency physician on when they are ordering too many CT scans compared to their peers? I'm not saying there aren't exceptions but what's the chance someone who graduated an RRC approved EM residency program made it all the way through without knowing when or when not it is appropriate to order a CT scan of all things? How many times have you seen someone so egregiously outside the norm of CT utilization that you've had to schedule a meeting specifically to talk with them about excessive use of radiation in their patients? I would bet the number is very small.

As for MIPS...while I agree with you in the importance of adhering to whatever quality or performance guidelines happen to be in place during one's career...do we really expect MIPS to be here 5 or 10 years from now? During my tenure at my current CMG, we've gone from scorecards for hospital core measures to PQRS and now to MIPS. With all the published problems with MIPS, I have no reason to believe this won't change in the near future. If not replaced, then heavily modified.

Welcome to the new era of emergency medicine with brilliantly executed processes in place by CMS, CMGs, hospitals, etc.. to directly influence how physician's practice medicine. As if to imply that left to our own devices, we would horribly mismanage patients and prove incorrigible and incompetent in how to appropriately utilize health care resources available to us! LOL

Now, let me get back to my 30cc/kg fluid bolus in my 200 kilo CHF'er so I don't get dinged for a sepsis fallout and get peer reviewed on it.
 
Of course they do it to try to instill competition among physicians. I've heard them actually say it. News flash, if I'm not rvu, this will have no effect on me.
 
Patient satisfaction......our pay has a small bonus attached. I don't even waste my time looking at my scores. I would have to vastly change my practice style if I wanted to get better patient satisfaction, and it would leave me being less productive, as well as possibly doing unethical practices.
 
You must log in or register to reply here.

Similar threads

thegenius
Random ER Metrics Thread
2
Replies
84
Views
5K
VA Hopeful Dr
VA Hopeful Dr
sylvanthus
Metric BS
Replies
44
Views
6K
RoyBasch
R
Birdstrike
Physician Satisfaction Score: A New Metric for Balance
Replies
3
Views
1K
Sushirolls
Sushirolls
I
Metrics Massaging
Replies
5
Views
2K
TooMuchResearch
T
Groove
Metric Mania
Replies
16
Views
2K
deleted245139
D
Top