Sustaining Performance Systems, Keeping Up With Day Care, and the Problem with Readmission Rates

Plus: Patient-ranked doctors and more management news

Thanks very much, B&G readers, for your responses over the last month to our questions about the impact of performance measurement. Two down (here and here); two to go. And when they're all done, we promise you a Governing-exclusive piece giving a sense of what we've heard. Here's the latest question: If the government with which you have been associated has established a results-based performance information system, has it been difficult to sustain? If so, why? Email us about your experience. We look forward to hearing your thoughts.


Sometimes budget cuts go beyond simply reducing the quality or quantity of services. They can actually preclude agencies from following state law — and possibly put public safety at risk. In Illinois, for example, day care facilities are supposed to be inspected annually. But, according to the Chicago Tribune, "55 percent of Illinois day care operations have not been inspected during their current three-year license period." The state's Department of Children and Family Services argues that it's incapable of keeping up with the caseload, thanks to staffing shortages created by budget cuts. Other staff-related problems have cropped up, including a backlog in background checks for people working in day care centers.


If someone who's been released from a hospital has to turn around and check in again, there may well be a systemic problem. That's why hospital readmission rates can be extremely useful performance measures for the provision of health care. But, like many useful performance measures, the devil is in the details.

A new study from the Medical Center at the University of California, San Francisco found that readmission rates can overestimate unplanned readmissions by up to 25 percent. That's because, among other things, readmission rates often don't differentiate between planned readmissions for follow-through and unplanned surgeries that result from unanticipated complications. The first of the two is benign. The second is clearly not. Conflating the two can render the readmission measure far less useful, and potentially even destructive.


While we're talking about health-care measures, here's another thought: Let's consider Medicaid managed care programs whose quality is measured, in part, with customer satisfaction surveys. This makes sense, but there's a potential trap here. When people self-report the quality of their care, mightn't they be inclined to give higher ratings to physicians who give them what they want — even if it's not what they need? A higher dose of painkillers may present future hazards, but it makes a patient a lot happier in the short term. As a result, the physician who provides more medication may look better on paper but may not necessarily be providing better health care.

This seems a lot like student-satisfaction ratings of college professors. They're used quite a lot these days. But we'd argue that the professor who provides a better education is superior to one who can most effectively appeal to the students. We bet some of you disagree with us about this general line of thinking. Let us know if you do, please.


Truth in advertising, and a strong recommendation: Alan Ehrenhalt is the former editor of Governing, a man with whom we've worked for many years, an extraordinarily thoughtful writer and a friend. But we're not going to let that stop us from strongly recommending his brand new book, The Great Inversion and the Future of the American City. Many of you may already be familiar with it from the lengthy excerpt that ran in Governing last month.

Alan has looked at real-world instances of the shifting of populations in and out of cities, and he examines the underlying reasons why those changes are taking place. He also explores how the United States will change as a result. He focuses on places like Chicago, Brooklyn, Cleveland Heights, Phoenix, Philadelphia and others. Ultimately, he writes, "The truth is that we are living at a moment in which the massive outward migration of the affluent that characterized the second half of the twentieth century is coming to an end. And we need to adjust our perceptions of cities, suburbs and urban mobility as a result."


"When the burdens of the presidency seem unusually heavy, I always remind myself it could be worse. I could be a mayor." — President Lyndon B. Johnson


We know we talk a lot about user fees. Just to be perfectly clear, we don't have anything against them, per se. We've simply become convinced that their overuse by state and local government is going to cause a kind of user-fee revolution that could lead to revenue shortfalls in cities and states.

Here's the latest news from the user-fee beat, from the Brennan Center for Justice at New York University: "Increasingly, state and local governments attempt to finance operations by imposing more fees and fines — 'legal financial obligations' — on people charged with crimes. Some of these assessments cover the costs of court operations and related service, but other 'surcharges' finance activities unrelated to the criminal justice system. The result is that people emerge from prison saddled with increasingly large debt loads that impede their reentry back into their home communities."

For more on this topic, take a look at the Brennan Center's 2010 report Criminal Justice Debt: A Barrier to Reentry. According to that report, "In the rush to collect [criminal justice fees], made all the more intense by the fiscal crises in many states, no one is considering the ways in which the resulting debt can undermine reentry prospects, pave the way back to prison or jail, and result in yet more costs to the public."


We've recommended the Wisconsin Legislative Bureau's excellent Tap The Power lists of recommended reading on multiple topics before. In April, it tackled career/technical training and "other technical and job training options such as apprenticeships, private postsecondary schools, community colleges, and the Wisconsin Technical College System." If any of these are an interest, don't miss this great source of information.


A double-edged sword: The federal government requires that states meet certain minimum "level of effort" requirements in order to get funding in areas like Medicaid, TANF and education. In these cases, in order to receive federal funds, states must guarantee they won't reduce their own support of a program.

So far, so good. But as with so many well-intentioned efforts, looking under the rocks can be dispiriting. In April, Oregon's Audits Division took a close look at this topic. Its findings were focused specifically on Oregon, but we're pretty confident that they're true for many other states as well. Among other things, Oregon's auditors found that "Unclear federal guidance [...] complicates the administration of Level of Effort programs. Oregon agency staff reported inconsistent, inflexible and sometimes unrealistic level of effort requirements. They indicated that Level of Effort guidance can be interpreted quite differently by different federal staff and the varying guidance is frustrating." More? "In some programs, the mandates discourage innovation and program efficiencies," the audit report said. "For example, for some programs a one-time investment in a new management information system could raise the state's ongoing level of commitment into the future. Level of Effort can also be insensitive to changes in service populations or short-term economic downturns that leave critical non-level of effort programs subject to greater reductions."


For a while it sure seemed like the transparency movement was an unstoppable force in government. Now, the super-movement may have found its kryptonite, as illustrated by a new piece written by Kathleen Peine in the California Progress Report.

A new law in Pennsylvania, for example, prohibits physicians from explaining the specifics of health problems associated with the natural-gas extraction known as hydraulic fracturing, or fracking. The law, accoring to Peine, "essentially gags physicians when they want to tell their patients what particular chemicals they have been exposed to, should they become ill from exposure to fracking chemicals. The doctors will be required to sign confidentiality agreements in order to find out the components in their quest to treat stricken individuals."

Another example, from the same article: "Kansas and Arizona join each other in the dubious distinction of advancing bills which would essentially allow physicians to withhold or misrepresent prenatal testing results should they think that the mother might have an abortion due to that information."

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