Episode Details

Here's the context, friends: As you may have noticed over the past few episodes, we have been digging into value-based care here at Relentless Health Value corporate work-from-home headquarters. Many lessons have been learned, and it's important that we sit back and think hard every now and then about how we are going to use these learnings to improve.

While this show tackles the Hospital Readmissions Reduction Program (HRRP)—and wow, I was glued to my seat during this interview—the show is really about more than that, which I'll get into in 30 seconds.

But let's start here: HRRP was originally part of the Affordable Care Act in 2010. In 2012, HRRP began imposing penalties on hospitals with higher-than-expected 30-day readmission rates for three conditions: heart failure, myocardial infarction, and pneumonia. Spoiler alert: More recently, CABG, THA/TKA, and COPD were added to the list.

So basically, if a patient is in the hospital for any of these six things and then is readmitted to the hospital for any reason within 30 days, penalties can happen.

Today's guest is Rishi Wadhera, MD, MPP. Dr. Wadhera authored a retrospective analysis in the BMJ about the HRRP, which we will talk about in this health care podcast. His findings are fascinating and relevant on a number of levels.

Dr. Wadhera is a cardiologist at Beth Israel Deaconess Medical Center. He also has a master's in public policy at the Harvard Kennedy School of Government and also a master's in public health from the University of Cambridge. Dr. Wadhera works on policy at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

But here's the larger epiphany that pertains to all value-based care and all quality metrics which Dr. Wadhera brings up in this health care podcast and which my nerd heart could not love more: Goodhart's Law. This law is the root of so very many problems. Goodhart's Law is this (which I learned from Dr. Wadhera): "When a measure becomes a target, it ceases to be a good measure." In other words, when we set a goal, people will try to take a shortcut to the goal, regardless of the consequences. And sometimes the consequences, paradoxically, are to do worse at the goal. For example, teaching to the test may not actually lead to students who deeply understand a subject.

Here's another example, and Rebecca Etz, PhD, talks about this in EP295: If you want PCPs to do an amazing job managing diabetes, for example, the best measures are ones that quantify the doctor's relationship with the patient and the amount of trust between them. The second you start using their panel's average A1C as the performance metric, A1Cs at best don't improve. Why? Bean counters and admins and maybe even goal-oriented clinicians themselves will go right to the end goal, inadvertently skipping a whole bunch of (it turns out) rate-critical steps. It doesn't go well. It's like salespeople who try to close before they build a relationship. Time to goal counterintuitively is slower, and performance is poorer.

Anyone building value-based care or quality programs might really want to include Goodhart's Law in their thinking. And anyone trying to achieve value-based care success, improve quality, form collaborations, or make sales might want to remember that old proverb, "Sometimes the shortest way home is the long way around."