9 MEDICINE
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informational and diagnostic: the process of keeping track of various methods and procedures, and then comparing the outcomes,
Note:UN RUOLO
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transparency to consumers, and a basis for comparison and competition among providers.
Note:SECONDO RUOLO
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pay-for-performance,
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TERZO
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contain costs.
Note:QUARTO
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THE FINANCIAL PUSH TO CONTROL COSTS
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“luxury good”—
Note:XCHÈ I COSTI IMPAZZISCONO...PIÙ RICCHI PIÙ SI SPENDE
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the baby boom generation ages,
Note:FATTORE ESOGENO
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availability of more specialty drugs
Note:FATTORE...UNA TAC E UNO SPECIALISTA NN SI NEGA A NESSUNO
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put pressure on doctors and hospitals to lower reimbursement
Note:PRESSIONE DAL GOV.
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reliable evidence that doctors and hospitals are providing services
Note:QUANDO PAGA N TERZO
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RANKING THE AMERICAN MEDICAL SYSTEM
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World Health Organization’s “World Health Report 2000,”
Note:LA CLASSIFICA
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“It is hard to ignore that … the United States was number 1 in terms of healthcare spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy.”
Note:LA CLASSIFICA CHE HA FATTO SCOPPIARE UN CASO
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Scott W. Atlas,
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more than a little misleading.
Note:MA....FUORVIANTE
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“health distribution,”
Note:COSA PREMIA IN REALTÀ LA CLASSIFICA
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The criterion, in short, was ideological.
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influenced in large part by factors outside the medical system,
Note:SPERANZA DI VITA MORTALITÀ ECCETERA
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Obesity
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Cigarette
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United States is an ethnically heterogeneous country,
Note:AFROAMEROCANI E MORTALITÀ INFANTILE
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When it comes to diagnosing and treating disease, Atlas notes, American medicine is among the best in the world.
Note:LA REALTÀ
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METRICS AS SOLUTION
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Michael E. Porter of the Harvard
Note:SPONSOR
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provide a powerful incentive for improving performance.
Note:LA FEDE NEI NUMERI
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THREE TALES OF SUCCESS
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Cleveland Clinic as a pioneer
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The clinic annually publishes fourteen “outcome books”
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Cleveland Clinic attracts patients from around the world.
Note:ESITO DELLA TRASPARENZA
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Geisinger Health System,
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ALTRO CASO
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integrated team of physicians
Note:METTERE IN RETE I DATI
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Rather than parceling out treatment
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Geisinger employs a more holistic approach.
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use of performance measures to reduce hospital-induced infections acquired from “central lines.”
Note:UN SUCCESSONE...INFEZIONI DA CATETERE
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82,000 blood infections
Note:NEL 2001 NEGLI USA
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from $12,000 to $56,000.
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32,000 people died.
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dropped dramatically, thanks in no small part to the efforts of Peter J. Pronovost,
Note:DA ALLORA
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he developed a program based on a checklist of five standard
Note:CHECKLIST
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blood stream infections dropped by 66 percent,
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This is an instance of diagnostic metrics.
Note:FUNZIONE DELLA METRICA IN QS CASO
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incentives in the form of peer pressure.
Note:INCENTIVI
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WHAT SHOULD WE CONCLUDE FROM THESE SUCCESSES?
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Is the success of the Cleveland Clinic a function of the fact that the Clinic publishes its outcomes? Or is the Clinic eager to publicize its outcomes precisely because they are so impressive?
Note:È LA CULTURA...NON IL NUMERO
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one of the world’s great medical institutions before the rise of performance metrics,
Note:CLEVELAND
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fallacy of post hoc ergo propter hoc.
Note:NESSO INVERSO
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metrics of performance, therefore, are neither imposed nor evaluated from above
Note:GEISINGER
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pathways were effective because they were led by physicians,
Note:I PROTAGONISTI
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improvement in medical outcomes was brought about primarily by “a shift in clinicians’ belief—
Note:L INTERPRET DI PRONOVOST
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begin penalizing hospitals with higher infection rates
Note:MA IL GOVERNO HA INTERPRETATO DIVERSAMENTE
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THE BROADER PICTURE: METRICS, PAY-FOR-PERFORMANCE, RANKINGS, AND REPORT CARDS
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professionals who write about medical metrics have a vested interest
Note:CONFLITTO D INTERESSE
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end with a plea for more data, more studies,
Note:ANCHE CHI NON CONFERMA
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Patients will act as consumers, comparing the cost of care with relative success rates.
Note:UNA FUNZIONE PROBLEMATICA DELLA METRICA
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to see how widely accessible information on research
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there was no lasting effect on patient outcomes.
Note:UN VERDETTO RICORRENTE
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patients with multiple medical problems.
Note:IL PAZIENTE REALE HA UNA RELAZIONE NN CLIENTELARE CON IL SUO MEDICO
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the effect of the tested intervention often disappears.
Note:LA COSA INVALIDA GLI EFFETTI AUSPICATI DALLA TRASP
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does not necessarily lead to improved outcomes.
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Nor, according to the Dutch experts, did the publication of metrics affect patient behavior in choosing a provider or hospital.
Note:ALTRI FALLIMENTI DELLA TRASP
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pay-for-performance (P4P)
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Another prominent form of medical metrics is the public ranking of doctors and hospitals
Note:CLASSIFICHE
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“medical report cards.”
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doctors and hospitals will have an incentive to perform better
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What is quite astonishing is how often these techniques—so obviously effective according to economic theory—have no discernable effect on outcomes.
Note:AMPIA LEYTERATURA SUL P4P E RANKING
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public reporting of mortality rates has had no impact on patient outcomes.
Note:ES MEDICARE 2009
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dubious criteria,
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examined process and intermediate outcomes rather than final outcomes,
Note:IL DIFETTO DEL P4P
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do affect outcomes, it is often in ways that are unintended and counterproductive.
Note:RANK E P4P
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goal diversion.
Note:PRINCIPALE PROB
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less holistic care and inappropriate concentration of the doctor’s gaze on what can be measured rather than what is important.”
Note:TIPI CO ESITO
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lower quality
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cardiac surgeons became less willing to operate on severely ill patients
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patients who the surgeons declined to operate
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overly aggressive care to meet metric targets.
Note:C È ANCHE IL PROB OPPOSTO
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Patients whose operations are not successful may be kept alive for the requisite thirty days
Note:I TRENTA GG
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costly and inhumane.
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can point out very poor performers,
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the tendency here, as with so many performance metrics, is to glean the low-hanging fruit, and then expect a continuingly bountiful harvest.
Note:ANCHE SE L ELUSIONE È SEMPRE POSSIB
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marginal costs exceed the marginal benefits.
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incalculable opportunity costs of what doctors and other clinicians might have done with the time
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time invested is largely uncalculated and uncompensated.
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burdensome and redundant
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“Pay for performance” reduces intrinsic motivation.
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rancorous debates about compensation, fees, and reimbursement that so occupy the time of health care leaders
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A TEST CASE: REDUCING READMISSIONS
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readmissions to hospitals within thirty days of discharge,
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a result of inadequate patient care,
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penalties on hospitals with higher than average rates.
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instead of formally admitting returning patients, hospitals placed them on “observation status,”
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Alternatively, the returning patients were treated in the emergency room.
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metrics of readmission thus improved, but not necessarily the quality of patient care.
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major teaching hospitals—which tend to see more difficult patients—were disproportionately affected.
Note:GLI OSPEDALI PENALIZZATI DALLA METRICA
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hospitals in poverty-stricken areas,
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what is known as “risk adjustment.”
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performance metrics may end up exacerbating inequalities
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A BALANCE SHEET
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enhance the safety and efficacy of their medical care.
Note:DA SALVARE
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controlled by and within the organization’s medical system,
Note:LA METRICA CHE FUNZIONA...QUELLA CHE APPLICO A ME
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