How Do You Know if Your Doctor Is Doing a Good Job?

我们在这个博客中花了很多笔墨来讨论衡量美国各种医疗保健系统的质量是多么困难. 衡量质量的一项大规模努力是“基于绩效的医疗保险激励支付系统”,” or MIPS. MIPS is a big deal for health systems. Quality isn’t just for professional pride. The MIPS program has a significant impact on the reimbursement received by U.S. physicians.

毫无疑问，过去几年你在医生办公室里必须回答的一些调查或问题，无疑与他们为提高MIPS分数所做的努力有关. MIPS rates physicians based on measures in four categories:

1. Quality (30% weight), mostly in terms of clinical outcomes and patient experience. 医生可能会根据血压得到控制的高血压患者的百分比或对他们的护理表示高度满意的患者的百分比进行评分.
2. Promoting interoperability (25% weight)医生如何利用技术来提高他们的护理质量和效率. 此类别中的度量可能包括使用电子健康记录(EHR)门户的患者百分比或以电子方式发送到药房的处方数量.
3. Improvement activities (15% weight), 医生通过诸如质量改进项目等活动来改进其实践的效果如何.
4. Cost (30% weight), how much a physician’s care costs compared to his peers. Think: the number of seemingly unnecessary tests and procedures ordered.

Because the work that, say, a psychiatrist does is so different from the work a urologist does, 参加MIPS的医生可以从257项绩效指标中选择6项进行报告, only one of which must be an “outcome measure,” such as hospital admission for a particular illness. The others can be “process measures” like rates of cancer screening. Docs are given a composite MIPS score between zero and 100. To avoid a “negative payment adjustment,” (that is, a reduced fee) physicians must score >75, which seems high to me unless I frame it as a solid “C” grade. Also, 86% of the docs in the sample achieved at least that score, 表明他们要么擅长游戏系统，要么得分并不难达到.

In spite of the massive effort put into MIPS by regulators, docs, and health systems, 目前还不清楚MIPS项目是否真的反映了参与项目的医生提供的护理质量. To investigate, investigators analyzed 3.2019年，80246名初级保健医生使用医疗保险数据集治疗了400万名患者 (paywall). 他们特别关注了五项“过程测量”，比如糖尿病眼科检查和乳腺癌筛查的比率，以及全因住院和急诊就诊的“患者结果”.

They found that physicians with low MIPS scores (<30) had worse performance on three of the five process measures compared to those with high (>75) MIPS scores. Specifically, the low-scoring docs had lower rates of diabetic eye exams, HbA1c screening for diabetes, and mammography for breast cancer screening. However, the lower-performing docs had better rates of flu vaccination and tobacco screening. In the “patient outcomes,与MIPS评分没有一致的关联:急诊科就诊率较低(e.g.MIPS评分较低的患者，其全因住院率更高(更差)。.

Overall, 这些不一致的发现表明，MIPS计划可能不是衡量和激励美国教师质量改进的有效方法.S. physicians. The “patient outcomes,” which I think most of us would be most interested in, showed no clear association with MIPS scores. In addition, 研究发现，一些MIPS评分较低的医生有很好的综合结果, while others with high MIPS scores had poor outcomes. Like every correlative study, there were outliers. This suggests that there may be other, more nuanced, MIPS计划没有捕捉到的影响医生表现的因素.

这项研究是最近的，我们还没有同行评议的批评或正规澳门赌场appMIPS失败的潜在机制的假设. But a blog post from Cornell 这样说:“……对于那些照顾更复杂的医学和社会弱势患者的医生来说，风险调整不足, 独立的初级保健实践用于质量报告的资源较少, leading to low MIPS scores.“因此，病情较重的患者去较小的独立诊所可能会拖累结果. Put another, more frank, way from Dr. Amy Bond in the same blog post, “MIPS分数可能更多地反映了医生跟上MIPS文书工作的能力，而不是他们的临床表现.对于我们人力资源部的同志来说，我怀疑这种批评尤其正确.