Edushyster asks the inevitable question: what is the one sure way to improve medicine? The Obama administration has found it: pay for performance!
It hasn’t worked in education, but that’s no reason not to try it in medicine.
What happened: totally unexpected side effects:
“Here’s where our story takes a completely unexpected and yet astonishingly familiar turn. Intended to reward *high quality health care,* the Obama administration’s introduction of pay for performance for doctors and hospitals has ended up punishing those that treat *large numbers of poor people.* Also, also the payment policies are *unintentionally worsening disparities* between rich and poor by shifting money away from doctors and hospitals that care for disadvantaged patients. Also, also, also providers with a disproportionate share of disadvantaged patients appear to *provide lower quality care* than they actually do.”
What lessons can be learned? Read the link.
Diane Ravitch's blog 
Perhaps if we just introduce more rigor and grit into hospitals and fire all those bad doctors, waistlines will shrink, HDLs will rise to match Singapore, and everyone can bench 220lbs and finish triathlons.
LikeLike
Edushyster, you had me at “also, also, also.” 😉
LikeLike
I guess I am lucky I have insurance. It is Tricare, which is military, due to my husband’s death when I was 25. In fact, in order to have insurance, I was told by two lawyers that I should never remarry, so I didn’t. At the time of my husband’s death, I had an 8 month old child and had just completed radiation treatment for Hodgkin’s. So, I didn’t have much choice. I ended up with breast cancer (probably due to the radiation) in my late 40s. Now in my 60s, I have digestive problems. I sometimes have to wait weeks to get an appointment. If my digestive problem is severe, I end up going to an immediate care facility, because I can’t get in to see my Dr. In the early 80’s when I first went to this Dr., I would get in as soon as possible to see him. Now, if I tell the receptionist that I have had severe digestive problems for a week (it actually debilitates me for a week), I’m told the soonest he can see me is a month or so later. I think our health care system had to be rehauled, because so many people didn’t even have insurance. However, we are not there yet. Kind of like education. We have made things worse with charters, testing, etc. Hopefully, one of these years, we will begin to improve education for all–not just those of wealth. (Since it is Memorial weekend–RIP Scott.)
LikeLike
Dottie,
Walk into the office, let them know you are there and that your health problem can’t wait a couple of weeks. Stay until you are seen and satisfied.
Had to do that a couple of months ago, and I was seen.
LikeLike
Thanks for the advice, Duane. I may eventually have to do so. I just had an endoscopy, and they found a hiatal hernia. It was the immediate care PA that recommended I see a GI guy. However, now they have me on hold for the return visit. Just when I thought things were improving, I’m back to waiting until the end of June for the follow-up. By the way, my friends in England think they have great health care.
LikeLike
The lesson that the Obama administration probably learned was they should have had a standardized bubble tests for the patients of doctors and when patients score poorly on that test, you take away the doctor’s license to practice medicine and throw them in prison for malpractice (a private sector prison preferably so a corporation could profit from those incarcerations).
What would be on that bubble test? Well, they could save money and just use the Pearson test that’s being used with the Common Core Standardized testing and the patients wouldn’t be given any medical care until they paid the fee to Pearson to take the test.
LikeLike
The parallel logic in two lines of work serving large groups of peope is bound to have this result. Boutique medical practice is big here, sold as 7/24/365 hour access to an MD, ends up meaning you access a phone bank (think private version of 911). The boutique practice is built on reputations. These are underminded as patients who have paid an annual upfront fee for acess find out there is little or no there–for care.
LikeLike
Nationalized healthcare, as Canada and France do it (and that is, admittedly on a spectrum of coverage, availablity, cost, etc.) is the ONLY civilized way to deliver care. What we had before the ACA and what we have now are pure, unmitigated garbage. . . . . pure dung at best.
Healthcare is a birthright, a human right, and a civil right.
But what does D.C. care? Most senators and congressional reps have excellent coverage for themselves and their families.
The ACA is a gift to the insurance companies.
We Americans will have to learn things the very hard way, but that’s okay in my book because haed lessons are often the ones that produce the most change.
Just ask Picketty . . . . . . .
LikeLike
How sad I feel for what the Obama administration has done/not done. I remember so well election night, 2008. I was at our local Democratic headquarters, and actually burst into tears when Obama’s election was announced. I thought “It’s finally over.” I actually believed the BS that was spewed during the campaign. All his election has taught me was to be careful what you wish for, and that whenever you think it can’t get worse, it always does.
LikeLike
From my reading and understanding of current American medical practice, doctors benefit financially for every test they order. New health care directives seek to prevent that, in ways to numerous to list here.
As in any system, reliance on data and tests lead to Campbell’s law.
We in education have to use these tests carefully. But few in D.C. are listening.
LikeLike
Propaganda that everyone speaks but nobody believes, crazy rubrics that define what is excellent or the best that a few select may fit “squarely” into while the rest of the “round” folk quietly look askance at… invasion of this forced “belief” system in all components of society.. education… medicine.. government… etc… What does this resemble??? To me it is scarily a bit like the Nazi propaganda machine. The high ranking “officials” are the one percent who control the roll out of policies in this artificial ” belief system” because they are either rich/powerful or have a mandate by the rich/powerful and can.. (or in the case of WW II Germany.. they happen not to be Jewish and happen to have blonde hair and blue eyes). And yes there are one percent who are not driving these reforms but who quietly live out their rich lives without speaking out and see their wealth as freedom from the nonsense.
The foot soldiers carry out orders dutifully even if they do not believe in them. They want their family members to live through the dark times and are like today’s teachers who resort to cheating so their student test scores remain high or the teachers who reduce classroom learning to “teaching to the test” to ensure they maximize test scores.. and their principals who dutifully enforce high stakes testing, data obsession and endless pseudo accountability mired in wasteful paper work… they are also foot soldiers ensuring that the pseudo “belief system” – “ed reform” stays in place as do their high salaried jobs. Nobody wants to be unemployed in these times.
And then there are those who capitalize on the absurdity of the times. Those who amass power, take pleasure in being part of the suffering because “they can” … those in power select them because of their “traits” and catapult them into powerful positions… these are absurd times.. they were the one’s under Nazi Germany who gleefully organized or carried out orders which enabled gas showers to exterminate large numbers of humans or happily loved making systems to select those who lived or who died. Today’s education version of one of these types might be Michele Rhee… Who could possibly want to fire a teacher on national tv?
While we might not be inhumanely slaughtering people, we are definitely destroying the educational lives of students, putting a wrecking ball to democracy, metaphorically sending teachers into the gas chambers etc… How many Germans performed the “heil Hitler” mechanically because their lives depended on it… not believing in it for one minute. Fast forward to today’s America… a pseudo belief system” was not okay when it effectively enabled the theft of the pensions of many hard working people.. anyone forget about Enron yet?? The spotlight was put on Maidoff so that thousands of other like individuals could scurry like ants into hiding spots.. in effect escaping responsibility for their equally heinous actions.
Are there not scores of “leaders and/or enforcers” under this ruinous regime who are living out their lives (maybe not in Argentina) but right under our noses unpunished. How many predatory lenders under the real estate and mortgage fraud are still living out their lives unblemished while scores of people buying into the “everyone can have credit” myth lost their homes and livelihoods?
Scores of educators are being publicly vilified and metaphorically slaughtered under yet another “false belief” system – corporate “ed reform” while their students suffer lifelong consequences. The catch word is “accountability”. And those shouting “you must be accountable” have no spotlight on them. Arne Duncan vilifies teachers yet creates policy that is highly damaging to our nation’s youth and he has no “accountability” for this.
And now it is medicine’s turn. Like title one teachers (who teach for the passion of it), doctors who believe in the hippocratic oath and treating the poor will be vilified because in our profit driven times POVERTY is given lip-service but is totally ignored.
If we read the definition of Facism as defined by the New Oxford Dictionary:
“The term Fascism was first used of the totalitarian right-wing nationalist regime of Mussolini in Italy (1922–43), and the regimes of the Nazis in Germany and Franco in Spain were also fascist. Fascism tends to include a belief in the supremacy of one national or ethnic group, a contempt for democracy, an insistence on obedience to a powerful leader, and a strong demagogic approach…”
Belief in supremacy … of the monied group (our students are referred to as human capital)
Contempt for Democracy … (think of recent McCutcheon decision)
Insistence on obedience to a powerful leader… (pick your choice of mega-billionaires who buy policy that people of this nation must follow)
Demagoguery … belief in one way in anything (David Coleman’s common core…. Charlotte Danielson’s evaluation framework are two good examples in education…)
Some might find it crazy to make parallels with Facism and the rise of the Nazis… but in this current climate, our democracy is at risk… Enron, banking/real estate crisis, “ed reform movement”, Supreme Court campaign finance reform rulings.. are all symptoms of a disease infecting our nation. And the literal infection is now taking place as attentions are turned to “reforming” the medicine.
LikeLike
George Orwell wrote an essay titled “What Is Fascism?” His conclusion, as I recall it, was that it was no longer clear, because “fascism” had become a term that was indiscriminately applied to almost anything that the speaker thought was “bad.” That was around 1945.
LikeLike
I apologize in advance for those that find this an overly long posting. However, the thinking behind this posting promotes worst business practices that are customarily touted by their proponents as the latest and the greatest but that have a long history of proven failures.
For example, even a little knowledge gives the lie to the plea by the leaders of the self-styled “education reform” movement that they just need a little more time to “perfect” and “tweak” and “improve” their sacred source of metrics, i.e., scores from standardized tests. Banesh Hoffman in his 1962 THE TYRANNY OF TESTING (original edition) was already working off (literally) decades) of eviscerating critiques. It is more than 50 years later, and their Sacred EduMetrics are not only far from perfection, they seem to be even worse than ever and used for ever more inappropriate and destructive purposes.
See a recent posting on this blog regarding teacher evaluations and VAM: https://dianeravitch.net/2014/05/23/teacher-in-palm-beach-county-how-i-am-evaluated/
Also refer to the recent scandal involving gaming the system of metrics of the Veteran’s Administration, all to the detriment of our nation’s veterans.
I give excerpts below from W. Edwards Deming [please google and note his exceptionally strong numbers/stats background] from THE ESSENTIAL DEMING: LEADERSHIP PRINCIPLES FROM THE FATHER OF QUALITY (2013, pp. 27-28, 173, and 55-57, respectively).
From an article entitled THE MERIT SYSTEM: THE ANNUAL APPRAISAL: DESTROYER OF PEOPLE:
[start quote]
The aim of this paper is elaboration of the third disease—the merit rating… On the basis of this rating, employees are ranked for raises—for example, outstanding high, outstanding, etc., on down to unsatisfactory. Management by fear would be a better name. … The basic fault of the annual appraisal is that it penalizes people for normal variation of a system. …
The merit rating rewards people that conform to the system. It does not reward attempts to improve the system. Don’t rock the boat.
Moreover, a merit rating is meaningless as a predictor of performance…
Traditional appraisal systems increase the variability of performance of people. The trouble lies in the implied preciseness of rating schemes.
[end]
From an interview in 1991:
[start quote]
Annual individual performance ratings, as I’ve said time and time again, represent a major obstacle. In most rating systems, somebody has to get a low rating. No account is taken of the fact that most of the differences between people come from the system itself. Getting a low rating can make you feel despondent, especially if you had a good rating the year before. If people understood that it’s all just a lottery, they would merely feel unlucky.
The idea of a merit rating is alluring. The sound of the words captivates the imagination: pay for what you get; get what you pay for; motivate people to do their best. The effect is exactly opposite of what the words promise. Everyone propels himself forward, or tries to, for his own good, on his own life preservers. In the end, the organization is the loser.
[end quote]
But numbers? C’mon, as “Dr.” Steve Perry says, channeling rapper Jay-Z, “Men lie and women lie but numbers don’t.” Sure, like in VAManiacal schemes and waiting lists at VA facilities.
[start quote]
Numerical goals
A numerical goal is a number drawn out of the sky. A numerical goal outside the control limit cannot be accomplished without changing the system. A numerical goal accomplishes nothing. What counts is by what method. Three words. If you can accomplish a goal without a method, then why weren’t you doing it last year? There’s only one possible answer: you were goofing off. May the numerical goal be achieved? Yes. We can make almost anything happen. But at what cost? What about the loss? Anybody can achieve almost anything by distortion and faking, redefinition of terms, running up costs. …
The worst example of numerical goals came out of our own Department of Education. We did it. On the 18th of April, 1991: Numerical goals. No method. No method suggested. Just numerical goals drawn out of the sky. Such nonsense in high places. Think of the harm done by those numerical goals put out by our Department of Education. Unwitting, innocent people read them and do not understand what is wrong. The harm done cannot be measured. The high school graduation rate will increase to 90 percent. Why stop at 90? If you don’t have to have a method, why not make it 95? 98?
Every school free of drugs. We should hope so, but where’s the method?
And we decided that American schools were expected to produce extraordinary gains in student learning. …
[end quote]
*W. Edwards Deming lived 1900-1993.*
Consider just one part of the above: if you “draw a numerical goal out of the sky” [e.g., test scores for VAM that determine whether or not you have a job, or the waiting times for the VA] and make people’s livelihoods and reputations heavily depend on those figures, how is this not providing very very high-stakes incentives for gaming the system by “distortion and faking, redefinition of terms, running up costs”?
Again, please excuse the overly long comment.
😎
LikeLike
Well worth the length, KTA. No apologies necessary.
LikeLike
It is ok KTA, some flies need to be hit with a sledge hammer. Thank you for the great information!
LikeLike