We all know its coming. Pay for Performance. MIPS/MACRA. Outcomes-Based Care. Call it whatever you want. Lots of names for lots of proposed methods. The bottom line to this is that medical providers are going to be evaluated on their outcomes. As a doctor, I don’t have a problem being evaluated – and even potentially paid – on my outcomes. I do, though, have a concern with just how we will actually be evaluated. And therein, friends, lies the crux of the problem.

No aspect of patient care is simple, whether treating a foot, a heart, a kidney, a mind or any other area of the human patient. People are highly complex organisms and not simple machines. And if patients are complicated, then how would measuring success in treating those complicated people be a simple process?

Obviously, it’s not. Take a look at how complicated the Merit-based Incentive Payment System (MIPS) is. In order to earn the adjusted payment by Medicare, a physician has to demonstrate that they “provided high quality, efficient care supported by technology.¹ That is a short sentence leading to a lot of work. A physician has to report on six quality measures from a specific list, including one outcome measure. They have to demonstrate completion of four improvement activities for a minimum of 90 days (with another list to look up the options), then report on advancing care information with one of two options. Starting in 2018, they will also have to report on cost reductions. Within each of these categories, there are other details important to know depending on your practice circumstances. I’m dizzy just thinking about all of this.

Now, imagine being a sole practitioner. You’re busy seeing patients and running your business. Along comes all this nonsense to “prove” you’re doing a good job. It’s no wonder the small private practice is disappearing in place of large groups. Who’d want to deal with this?

Then there’s the “simple” issue of human variability. For example, I practice in an area with a lower socioeconomic status with a high-risk heavily diabetic population. The high prevalence of peripheral arterial disease will make treating disorders like neuropathic foot ulcers much more difficult than, say, someone with a heavily Caucasian or Asian populace. When I do an elective bunionectomy, it’s rarely on a 20-year-old healthy patient. I recently saw a patient in their mid-60s on hemodialysis with a painful bunion that has not responded to nonsurgical care and needs surgery. Definitely not a low risk procedure!

Similarly, my geographic area has a shortage of quality vascular specialists, and my ischemic patients often have to wait weeks to get an appointment. This problem, completely out of my control, will negatively affect my outcomes. Am I supposed to be responsible for revascularizing my own patients now? Oh, that’s right. That’s out of a podiatrist’s scope of practice. But somehow, I’m responsible for these outcomes.

Of course, this discussion hadn’t yet included the patients themselves. We can’t forget that patients have a significant role to play in the disease process and its treatment. Let’s go back to that bunion surgery again. I can do the best bunionectomy in the world, but if the patient falls all over it postoperatively, then they might have a poor outcome. How about those sick patients with Charcot arthropathy who need reconstructions? They are classically noncompliant with instructions, beside the compromised physiology.

Additionally, it has been shown from cognitive psychological work by experts such as Daniel Kahneman (I highly suggest reading his most excellent book Thinking Fast and Slow) that people are very poor at accurately determining risk and understanding statistical concepts. Tell diabetic patients that their risk of limb loss drastically increases once they’ve sustained a foot ulcer. Use numbers and watch their eyes fog up.

Putting all this aside, the other problem I have with these “quality measurement” schemes is they’re putting the onus entirely on healthcare providers with no participation from the rest of society. Until it is accepted that quality measurement in medicine is highly complicated, and perhaps impossible, any proposed scheme is likely to come up short and to the detriment of the entire medical system. Perhaps there should be a quality measurement system for the quality measurement system?