The Ironic Conundrum of the Preference Sensitive Measures, P4P and HEDIS Criteria

The Disease Management Care Blog received this posting from a primary care physician who prefers to remain anonymous. It speaks to the good intentions of applying HEDIS measures in the real world of primary care practice involving real physicians and real patients:

Most readers are familiar with the Oracles of Dartmouth and their numerous reports touting the opportunities from reducing variation around preference sensitive care. In the ideal world of measurement around the average, it all seems so logical and even warm and fuzzy. However, practitioners in the real primary care world are having a tough time fulfilling its promises in day to day practice. Is the problem the art and science of medicine, or is the problem with the logic underlying the measurement methods?

As a family doctor I am constantly being measured by HEDIS criteria and compared to my peers' average measures. This is how I am graded by most of the health insurers I contract with and my pay for performance (P4P) dollars are often based upon them. Yet, no matter how much my patients prefer – after careful, physician-delivered full disclosure of why this should be done - not to have a colonoscopy, not to schedule a diabetic eye examination or not to take a statin for coronary artery disease, it is the physician who is penalized for not obtaining one. When charts are reviewed, and documentation is read, informed choice is not a consideration for HEDIS.

In my opinion, HEDIS criteria are unreasonable, static, inflexible and fail to account for patient preferences. It measures physicians by the same unforgiving yardstick that expects all patients to be the same. It fails to account for the degree of patient preference care that’s been described in other care settings in the Dartmouth Atlas.

The only way to incorporate flexibility of choice in the P4P system is through the use of multiple individualized clinical pathways. Yet, each of the multiple clinical pathways are also inflexible and ill-suited to the special circumstances of each patient. Here’s the conundrum: If I am offering flexibility to my patients through multiple inflexible options, how can I properly inform them flexibly?

Good point. The physician points out that the current blunt force approach to HEDIS in managed care networks is based on a) comparing physicians to an ill-suited average measure that fails to capture the uniqueness of each practice setting that has a population of unique individuals, b) doesn't incorporate patient preferences and c) is demoralizing because it fails to give physicians credit for trying. The physician also doubts that health information technology and decision support will ever be up to the task of overcoming the special perspectives of any individual healthcare consumer. Last but not least, the DMCB is fascinated by this portrayal of the flip side of 'patient sensitive care' which, according to the Dartmouth Atlas, is prone to overutilization.

The DMCB doubts managed care medical directors will care much about this point of view, partially because they've been brainwashed by regular attendance at the Church of the Holy HEDIS and partially because their bonuses often depend on it.