Defining and accurately measuring quality will be a serious problem. In the post you quoted from above, I gave the example of a patient with end-stage renal failure, advanced COPD, and hypotension. I keep getting letters from Humana complaining that I did not treat him with ACE inhibitors and beta-blockers for diabetes and heart disease. He had elevated sugars intermittently when on high dose steroids when hospitalized with respiratory failure, and his major cardiac problem was hypotension requiring vasopressors during his last hospitalization. Their recommendations not only were not indicated but would have been harmful.

Even more routine cases present difficulties in measuring quality. I also read EKG’s at the hospital and I continuously get quality reports which include not only my patients but include the patients I have only read EKG’s on. I obviously have no control over whether a diabetic I read an EKG on is being treated properly.

The quality measures used by many insurance companies are based upon their reimbursements but I’ve often found this to be inaccurate. I’ve seen quality reports saying that diabetics have not had measurements of HgbA1c when the same insurance company had paid for many of them. Even worse, often they require submitting information on what has been done. Medical care is busy enough as it is. Any system which requires physicians to enter multiple parameters in order to receive credit for having done something is not going to work.

With the high deductibles, I have about 20 percent of my patients who refuse to get labs or health screening tests by age, such as fasting lipid panels, colonoscopies, etc. I then get dinged on my quality reports for patients who have not gotten their diabetic labs, liver enzymes while on statins, annual eye exams, etc. Currently Medicare is the only plan that rewards quality, but may change. The primary care doctor will have to decide what to do with patients who bring down the quality ratings.
Other patients on the list include ones who have lost their insurance/jobs, moved out of the area, and recently one who had died of colon cancer but was listed as needing a statin. The quality measure reporting and tracking are time consuming and highly inaccurate. I even have patients who have ob/gyns for their wwe, but then I get listed as not having mammograms or thin prep/pap smears done annually on these patients who have established care with their ob/gyns and where reports from them are in my chart.
Currently insurance companies are trying to reduce reimbursement or only raise it by 1-2% if quality measures are met. Until primary care fees are paid at realistic rates, quality measures will be just another burden that does not benefit the patient and sucks time from my date for less than 50 cents a patient.

IBM is a premier employer. When they start saying “we’re not getting a good value for our dollar, we want to pay primary care doctors more” I think the primary care sector of the profession needs to perk up!

An employer has leverage over its employees in ways that a government program does not. Employees can be rewarded for changing without encountering quite the same expectations of equity and fairness that a government program will generate. The population in this group will not be totally represenative of the nation because they are or have been employed, so results might be better than you’d expect on the whole. Still I’m sure this group, being American, is full of overweight folks who could be doing more.

When I read this story I saw hope for reform that I think will be difficult to effect in the government arena. Don’t tell me why this isn’t good for the profession. Tell me what you would design as the quality measures and how you’d work around some of the drawbacks mentioned above.

The medical home pilots that have been done so far have been successful and have saved money. Here is an example:

http://www.annfammed.org/cgi/reprint/6/4/361?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=dobson&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

There is some confusion out there between the medical home & disease management programs (e.g., the Humana anecdote above). Stand alone disease management doesn’t work as many of us who have had similar letters from Human, UnitedHealthcare, etc. can attest. One of the keys to the North Carolina approach and other Medical Home successes is the collaboration between the payors and the physicians. BC/BS has just had a successful pilot in Iowa and is expanding it into Nebraska because it works & saves money. Due to my past experience with United Healthcare, I’m not sure they are capable of any meaningful collaboration, but IBM (google Paul Grundy, MD, MPH, one of IBM’s medical directors) has been working at this for several years because they know it saves money & provides better care.

“One of the keys…is the collaboration between the payors and the physicians.”

Yes, it is conceivable that a real program involving collaboration (as opposed to insurance companies sending out instructions from afar) could produce benefits. The problem many of us fear is when they try to base reimbursement upon measurements of quality which are not valid. It is not the collaboration we are concerned about but changes in reimbursement based upon inaccurate criteria.

“There is some confusion out there between the medical home & disease management programs (e.g., the Humana anecdote above.”

Note that we really have two different discussions going on (not confusion). The Humana letter got drawn into this as the post quotes from a post I wrote which wasn’t on Medical Home or IBM’s ideas. It is a somewhat different topic, but the issues raised in that post still have some application to any third parties trying to measure quality.

Further up country solo doctor mentions the problem of patients having Gynecologists but being graded based upon whether pap smears and Mammograms are completed. As an internist I’m in a similar situation. I do the paps on many of my patients. In other cases they go to Gynecologists, and some have a GP they see for such procedures and other routine things. This shows both the benefits of tracking and problems with using this for reimbursement. Now that tracking has recently begun I’m finding that some of my patients who I have listed as receiving their pap smears from Gynecology are a year or more behind. This is fine if only used for patient tracking as it allows me to either have the patient follow up with their Gynecologist or I do the pap. It would be a problem if payers actually used this information putatively if a patient failed to follow up with their Gynecologist.