Mismanagement by Metrics – Peter S. Kibbe, MD FHM

Some years ago when I practiced in a rural hospital I was asked to admit a man who had sustained fractures to both knees.  I balked because I knew that the only orthopedic surgeon at the hospital was out of town and the man needed surgery on both knees. Aside from the fractures, he had no medical issues preventing surgery.  Conventional medical wisdom teaches that the faster this sort of injury is fixed, the better the outcome for the patient.  The hospital administrators pressured me to keep the patient “for a few days” until the orthopedic surgeon returned.  Their incentive was clear.  They wanted to capture the operative/financial billing.  My incentive was to get the patient the care he required.  Discussions that ensued between the administrators and me were not pretty.

At times financial and outcomes metrics push in an opposite directions.

I recently came across an interesting article of investigative journalism by Pulitzer Prize writer David Phillips in the New York Times. Phillips describes the complaints of physicians at a small VA hospital in rural Roseburg Oregon. They claim that the hospital administrators frequently denied care to patients who were very ill, sending them home or off to other facilities, in order to make their overall medical care outcomes look better.  If the patients were not admitted, they were off the radar in terms of data analysis.  Any negative outcome of their illness would occur at home or at another hospital.

He describes a set of ‘metrics’ used throughout the VA system to grade hospitals and their associated clinics.  Patients who are very sick and die lower the grade as well as anyone requiring admission for congestive heart failure (the diagnosis implies poor system outpatient management).  Also bringing down the score are patients readmitted within thirty days, hospital acquired infections and so forth.  Phillips reports that there are about one hundred of these metrics that are used to grade facilities.

Curiously, Phillips finds, since the metrics grading system was implemented across the VA system, many facilities have improved their scores.  He interviews doctors who claim this has happened not because of improved medical care but due to the fact that administrators game the numbers by avoiding the treatment of patients who might have poor outcomes.  About half of the beds at the Roseburg VA, he reports, remain empty.

The community of Roseburg is rural and poor.  The unemployment rate is high.  The Roseburg VA Health System, he states, is understaffed and he reports that many of their primary care physician positions are empty, making ongoing care of patients in the system problematic.  The hospital itself has no intensive care unit.  But Phillips interviewed emergency and hospital physicians there who claim they are forced by administrators to turn patients away who could be cared for there in order to play the metrics game. They claim that the administrators want to keep patients with poor prognoses “off the books.” He describes a cachectic veteran in his eighties who presented with dehydration, falls and fractured ribs whom the doctors wanted to admit.  The administrators refused and sent him home.

Given the fact that the community is rural and poor one would expect the disease burden of the veteran population in Roseburg to be high.  So, given the poor staffing, the population, the location, and the demographics, why would distant administrators impose what sound like unattainable metrics on a group of health care workers struggling to provide veterans with care?

And, if you were the local administrator and the administrators above you would reward you if your scores improved and punish you if they did not, would you not manipulate everything you could to make your performance look better? Phillips reveals that administrator’s bonuses go upward with better scores.

This issue of avoidance of ill persons by medical professionals is not at all new.

The problem with evaluations at play in systems such as this is the failure of leadership (administrators) to embrace the reality of the workplace.  From what Phillips reports, Roseburg’s VA facility’s principal and overarching problem is lack of staffing. Until administrators attend to that it is hard to imagine the value of imposing grading systems on teams of workers which are skeletal.

It would appear that the grading system under which it struggles represents an administrative failure.  Expecting excellent medical outcomes in attempting to appropriately treat aging, rural veterans with multiple morbidities is a fool’s errand which fails the patients.  The doctors think it is actually diminishing the quality of their care by administrators who do not want physicians  to care for them in the hospital at all. The doctors he interviewed seemed to be saying, “Let us do our jobs and do what we can for these fragile and sick people without sending them many miles away from their families.  Some of them might die because some of them have fatal illnesses, but metrics should not be part of the decision to care for them here or transfer them out.”

In my experience I have found that physicians generally, in keeping a patient at their facility or seeking a transfer to a higher level of care, do so with the best interest of the patient in mind. The questions involved include whether the patient would benefit from care not available at his/her present facility, and whether the patient wishes to experience that higher level of care.  Hospital administrators can push and pull that decision in both directions depending upon their incentives.  I would argue that the decision should be medical.

Administrators, in most of these decisions, lack the license, the agency and the ultimate responsibility for these decisions.