你怎么知道你的医生是否做得很好?

We’ve spent a lot of ink in this blog discussing how difficult it is to measure quality in the various US healthcare systems. One large-scale effort to measure quality is the “Medicare Merit-based Incentive Payment System,或MIPS. MIPS对卫生系统来说是一件大事. 质量不仅仅是为了职业荣誉. MIPS计划对美国学生收到的报销有重大影响.S. 医生.

Some of the surveys or questions you’ve undoubtedly had to answer in doctors’ offices the last few years are undoubtedly tied to their efforts to improve their MIPS score. MIPS对医生的评价基于以下四个方面:

1. 质量(30%重量)，主要是在临床结果和患者体验方面. Doctors might be scored on the percentage of hypertensive patients who have their blood pressure controlled or the percentage of their patients who report a high level of satisfaction with their care.
2. 促进互操作性(25%权重), how well a physician uses technology to improve the quality and efficiency of their care. Measures in this category might include the percentage of patients using the electronic health record (EHR) portal or how many prescriptions are sent to the pharmacy electronically.
3. 改进活动(15%权重); how well a physician is working to improve her practice through activities like quality improvement programs.
4. 成本(30%重量)与同行相比，医生的护理费用是多少. 想想:看似不必要的测试和程序的数量.

因为我的工作, 说, 精神科医生的工作和泌尿科医生的工作是完全不同的, doctors who participate in MIPS may choose six of a possible 257 performance measures to report, 其中只有一个必须是“结果度量”,比如因为某种特殊疾病而入院. 其他的可以是“过程测量”，比如癌症筛查率. 医生的综合MIPS得分在0到100之间. 以避免“负支付调整”,(也就是说, a reduced fee) 医生 must score >75, 这在我看来是很高的，除非我把它定义为" C. 也, 样本中86%的医生至少达到了这个分数, indicating that they either are good at gaming the system or that the score isn’t terribly difficult to achieve.

尽管监管机构在MIPS上付出了巨大努力, 文档, 以及卫生系统, it’s unclear whether the MIPS program really reflects the quality of care provided by participating 医生. 进行调查, 调查人员分析 3.4 million patients treated in 2019 by 80,246 primary care 医生 using Medicare datasets (收费). They looked specifically at five “process measures” like rates of diabetic eye examinations and breast cancer screens and the “patient outcomes” of all-cause hospitalizations and emergency department visits.

They found that 医生 with low MIPS scores (<30) had worse performance on three of the five process measures compared to those with high (>75) MIPS scores. 具体地说, 得分较低的医生进行糖尿病眼科检查的比率较低, 糖化血红蛋白筛查糖尿病, 以及用于乳腺癌筛查的乳房x光检查. 然而，表现较差的医生有 更好的 流感疫苗接种率和烟草筛检率. 在"病人结果"中,” there was no consistent association with MIPS scores: emergency department visits were lower (e.g., 更好的) for those with low MIPS scores, while all-cause hospitalizations were higher (worse).

整体, these inconsistent findings suggest that the MIPS program may not be an effective way of measuring and incentivizing quality improvement among U.S. 医生. 病人的治疗结果,我想我们大多数人都会对此最感兴趣, 与MIPS评分无明显关联. 除了, the study found that some 医生 with low MIPS scores had very good composite outcomes, 而那些MIPS得分高的人则结果不佳. 与所有相关研究一样，也存在异常值. 这表明可能还有其他原因, 更微妙的, factors at play that are not captured by the MIPS program that influence a physician’s performance.

The study is recent enough that we don’t have peer-reviewed criticism or hypothesizing yet about the potential mechanism of MIPS failure. 但是一个 康奈尔大学的博客文章 puts it this way: “…there is inadequate risk adjustment for 医生 who care for more medically complex and socially vulnerable patients and that smaller, independent primary care practices have fewer resources to dedicate to quality reporting, 导致较低的MIPS分数.” So, sicker patients going to smaller, independent practices may drag down results. 换句话说，更坦率地说，从Dr. 艾米·邦德在同一篇博文中, “MIPS scores may reflect doctors’ ability to keep up with MIPS paperwork more than it reflects their clinical performance.” For our comrades in Human 资源, I suspect this criticism rings especially true.