The Metrics Say His Pediatrician is Failing. But they are and have always been wrong!!

Let me tell you about two kids with asthma.

Both are 8 years old. Both have moderate persistent asthma. Both have primary care pediatricians who care deeply about them.

But one lives in a low-income housing complex in the city. The other lives in a wealthy suburban neighborhood with tree-lined streets and manicured lawns.

Only one of their doctors will be rewarded for “delivering high-quality care.” And it has nothing to do with effort.

In Low-Income Housing: Barriers on Top of Barriers

The child in low-income housing wakes up coughing most mornings. The apartment has mold. The air conditioning barely works. Cigarette smoke leaks in from the unit next door. The child sleeps on a mattress directly on the floor, right next to a dusty vent.

Her mom works two jobs. She wants to stay on top of the asthma care plan, but life gets in the way. The inhaler refill was ready last week, but the local pharmacy closed before she could get there. She didn’t have bus fare. The next closest pharmacy is 15 minutes away on foot—past high-traffic roads and blocks where she doesn’t feel safe walking with her child. She could take a bus, but its 20 stops away.

The child went to the ER two weeks ago—her third visit this year. No one from her clinic called to follow up. Not because they didn’t care, but because they never got a notification. The data systems don’t talk. The hospital doesn’t share. The pediatrician found out when the mom brought it up at the next visit—weeks later.

That pediatrician? She’s trying her best. She prescribed controller medications. She gave the mom an asthma action plan. She offered referrals to housing assistance. But none of that shows up in her “quality metrics.”

Unless the medication is filled—and filled in the right ratio compared to rescue meds—her Asthma Medication Ratio (AMR) score stays low.

So she’s marked as underperforming. No bonus. No praise. Just another clinic at the bottom of the rankings.

In the Suburbs: Smooth Sailing

Now imagine the other child.

He lives in a quiet, suburban neighborhood. The house is spotless. The air is filtered. There’s a full-time parent at home. The other is a healthcare executive. They picked up the controller inhaler through a mail-order pharmacy last month—automatically refilled, no need to remember. The child’s school nurse has an inhaler on file. He has a quarterly visit scheduled. They’ve laminated the asthma action plan and posted it on the fridge.

This child had one minor flare, but it didn’t require an ER visit. His medications are filled. His controller usage is consistent. His family logs symptoms on an app. They’ve got it under control.

His pediatrician? They’re also caring and competent. But they didn’t have to chase down missed refills or track down school records. They didn’t have to fight with housing authorities or wait on hold with Medicaid.

Still, their AMR score is high. Their performance ranking is in the top 10%. Their clinic is considered a "quality leader." They get the bonus.

The System Says: One Is Succeeding. The Other Is Failing.

Except that’s not the truth. Not the real truth.

Both pediatricians care. Both kids matter. But one is living in a system designed to reward stability, not effort.

What HEDIS Doesn’t Measure

The HEDIS Asthma Medication Ratio (AMR) asks one question:

Of all the asthma medications filled, how many were controller meds rather than rescue inhalers?

It sounds fair. Until you realize what it doesn’t account for:

• Whether the child actually used the medication

• Whether the pharmacy was accessible

• Whether the caregiver understood the instructions

• Whether housing conditions were triggering the asthma

• Whether the pediatrician made heroic efforts behind the scenes

HEDIS doesn’t measure that. It measures fills. It measures what’s easy to track, not what’s meaningful.

And That’s the Problem.

If you serve affluent families with reliable transportation, calendar alerts, and digital access, you’ll probably do great on your HEDIS scores—even if your patients would have done fine without much intervention.

If you serve families navigating poverty, housing insecurity, transportation gaps, job shifts, or trauma—you’re penalized. Not because you’re a bad doctor. But because your patients don’t fill prescriptions on time. Or don’t understand the directions. Or don’t show up when life falls apart.

And here’s the kicker: you may be doing more work, with greater need, and higher stakes—and still be told you’re failing.

What HEDIS Rewards Is Proximity to Privilege

Want to win at HEDIS? Want to get the bonus? Want to be ranked a "high-quality" provider?

Here’s the secret: Don’t serve the sickest kids. Don’t open a clinic in low-income housing. Don’t take on Medicaid-heavy panels. Don’t lean into neighborhoods with poor infrastructure, bad air, and old buildings.

Instead: Choose the kids whose parents already have care organized. Build your practice where it’s easy to follow through. Let someone else manage the chaos.

If That Sounds Backwards… It Is.

Because the doctors who serve the most at-risk kids should be getting more support, more funding, and more recognition—not less.

They should be celebrated for keeping kids out of the hospital when they’re surrounded by every reason to be there.

Instead, they’re working overtime, making calls, coordinating care, offering samples—and being told their AMR score is too low to qualify for a performance bonus.

So What Should We Measure Instead?

We don’t need to abandon accountability. But we do need to redefine it.

Try measuring:

• Reduction in ER visits year over year

• Improvement in ACT scores for high-risk patients

• Completion of action plans in underserved families

• Medication delivery to housing complexes

• Symptom-free school days

• Actual adherence, not just filled prescriptions

And most importantly—adjust for the social complexity of a provider’s panel.

Don’t compare a pediatrician in public housing to one in a private school suburb and pretend they’re playing the same game.

Let’s Be Honest About What’s Broken

The child in low-income housing isn’t failing. Her family isn’t failing. Her doctor isn’t failing.

The system is failing—by rewarding what’s easy to count, not what’s hard to deliver.

We’ve built a performance structure that encourages providers to avoid risk, avoid poverty, avoid mess. That’s not health equity. That’s just inequity dressed up in spreadsheets.

If This Matters to You

If you're a payer, a policymaker, or a provider, here’s what you can do:

• Push for risk-adjusted metrics in P4P models.

• Include qualitative impact in bonus structures.

• Support care models that account for social drivers.

• Invest in pharmacy access, community delivery, and real-time alerts.

• Stop judging pediatricians by what their patients can’t control.

We don’t need more perfect metrics. We need just systems.

Because the kids with the greatest needs don’t live in the suburbs. They live in the places metrics forget. And the doctors who serve them deserve more than a failing grade