The Cost of “Quality”

In case you missed this beautiful little article, it’s worth re-highlighting regarding the paradoxical “cost” of “quality”.

In theory, high-quality care is its own reward. Timely actions and interventions, thoughtful and thorough evaluations, and appropriate guideline adherence when applicable are all goals with reasonable face validity for healthcare delivery. Competing incentives, however, coupled with time pressures, erode some of the natural inclination towards ideal care. Thus, “quality” metrics and goals, created with the best of intentions to nudge clinicians and health systems towards better care.

Unfortunately, the siren song of “quality” has begat a locust horde of metrics from all manner of organizations. Health care expenditures in the U.S. have grown from 9% of GDP to 20% GDP, and administrative costs are estimated to comprise up to 30% of total national health care spending. To add context to these larger estimates, this little article simply looks within their own institution to evaluate the potential contribution of “quality” measures to those larger sums.

The authors identified, by surveying personnel across their institution, 162 quality metrics reported to 7 measuring organizations, totalling 271 reports (as some required reporting to multiple organizations). The bulk (70%) were publicly reported “quality” measures, while another 27% were related to pay-for-performance programs.

Overall, across surveyed personnel, the authors determined approximately 108,000 person-hours were consumed annually on these reports. Based on the annual salaries of the individuals involved and their time commitment, the total annual cost to the institution was estimated at over USD$5 million. The most expensive metrics were those requiring individual chart abstraction, while those metrics requiring merely electronic data capture required a fraction of the cost.

Multiplied by the 4000+ hospitals in the U.S., suddenly we’re obviously talking about tens of billions of dollars of added administrative overhead. Interestingly enough, and relevant to emergency medicine, one of the worst offenders as far as cost is SEP-1 – the CMS sepsis core measure. Not only is this measure onerous and costly to administer on the institutional side, it results in substantial unmeasured additional work for clinical staff – and I suspect many of these “quality” measures have their cost similarly underestimated.

Administrative costs aside, it is as important to consider whether “quality” metrics actually reflect higher-quality care, or whether the changes in care driven by metrics improve value. What is certain, however, is their proliferation has been clearly nightmarish.

“The Volume and Cost of Quality Metric Reporting”
https://jamanetwork.com/journals/jama/article-abstract/2805705