The Tyranny of Metrics

As of 2015, about three-quarters of the reporting hospitals were penalized by Medicare. Tellingly, major teaching hospitals—which tend to see more difficult patients—were disproportionately affected. 34 So were hospitals in poverty-stricken areas, where patients were less likely to be well taken care of (or to take care of themselves) after their initial discharge from the hospital. 35 Attaining the goal of reduced admissions depends not only on the steps that the hospital takes to educate the patient and provide necessary medications, but also on many factors over which the hospital has little control: the patient’s underlying physical and mental health, social support system, and behavior. Such factors point to another recurrent issue with medical metrics: hospitals serve very different patient populations, some of whom are more prone to illness and less able to take care of themselves once discharged. Pay-for-performance schemes try to compensate for this by what is known as “risk adjustment.” But calculations of the degree of risk are at least as prone to mismeasurement and manipulation as other metrics. In the end, hospitals that serve the most challenging patient population are most likely to be penalized. 36 As in the case of schools punished for the poor performance of their students on standardized tests, by penalizing the least successful hospitals, performance metrics may end up exacerbating inequalities in the distribution of resources—