Comments on: What is quality medical care?

By: Topics about Health, Food and Well being » Archive » What is quality medical Bcare/B?

Thu, 12 Feb 2009 17:06:52 +0000

[...] Healthcare website and Blog placed an interesting blog post on What is quality medical Bcare/B?Here’s a brief overviewUnitedHealth and I.B.M. Test BHealth/B BCare/B Plan … UnitedHealth will try giving doctors more authority and … Will BUnited/B BHealth/B emphasize all… [...]

By: Ron Chusid

Ron Chusid — Tue, 10 Feb 2009 23:13:05 +0000

“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.

By: Bohdan A. Oryshkevich MD, MPH

Bohdan A. Oryshkevich MD, MPH — Tue, 10 Feb 2009 21:55:27 +0000

You make an excellent point.

Context is everything in medicine.

Primary care is personalized care and aggregates do not count.

Primary care is also the art of the possible. Illiterate patients cannot meet the same criteria that educated upper middle class people can.

The first step to quality care in the aggregate is universal insurance so that everyone can be seen. The doctor can and should decide where to spend his time and energy. He has to triage his time. You are clearly doing that.

But how do we get that to filter up to those who design quality standards?

Bohdan A. Oryshkevich, MD, MPH

By: Dr. Bob (FP)

Dr. Bob (FP) — Tue, 10 Feb 2009 16:13:36 +0000

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.

By: TerryS

TerryS — Tue, 10 Feb 2009 15:57:19 +0000

The problem is quality is an inidividual phenomenom. It is not a group measure. Quality care for one patient might be horrible care for the next. For example, I work for the VA. I get report cards of how bad I am doing all the time. I have a large population of schizophrenic patients who just cant understand all the things we need them to do so I can get a good report card. I also have patients with a variety of malignancies and end stage CHF or COPD. I dont screen them for anything as they already are going to die soon of their primary problem. I really dont care what their HGA1C is- they wont develop diabetes complications. I am a bad doctor in my boss’ eyes. I feel I am providing quality care because I am trying to maximize QOL over quality of diseae measures.

Measuring quality in the aggregate will be a failure and lead to gaming the system and patient harm. I wish it would just go away.

By: GingerB

GingerB — Tue, 10 Feb 2009 10:56:20 +0000

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.

By: Bohdan A. Oryshkevich MD, MPH

Bohdan A. Oryshkevich MD, MPH — Tue, 10 Feb 2009 05:18:18 +0000

We all have to work for quality. Doctors within all institutions have to be concerned about quality and have high internal standards and accept external standards that are objcctively derived for the benefit of the patient who is at the center of care-. That stems from what we learn technically, from our integrity and from the ethical challenges that we face. But how you get there is not so easy. I am certain that in countries which surpass us in outcomes, we may find things that do not meet our standards of quality. Standards of care may be imperfect.

I am writing this post not because I am against quality. But United Health Care sponsoring an experiment in quality strikes me as an oxymoron. They recently were caught redhanded in New York State for defrauding their own insured of hundreds of millions of dollars.

Our entities have to practice quality insurance. Otherwise they will not have the moral authority to define quality for us and to reimburse us for their alleged standards.

http://topnews.us/content/22555-united-health-group-pay-350-million-resolve-lawsuits

Bohdan A. Oryshkevich

By: country solo doctor

country solo doctor — Tue, 10 Feb 2009 03:02:47 +0000

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.

By: Ron Chusid

Ron Chusid — Mon, 09 Feb 2009 18:45:23 +0000

Another concern in making payment based more upon quality is how we handle noncompliant patients. We all probably have patients who need insulin but refuse to take it (or refuse to take enough injections per day), and people who are convinced that a statin is the cause of their back pain which actually began ten years before the statin was prescribed, and refuse to take any statins.

The current economy is making matters even worse as I’m seeing more patients refusing to take recommended medications due to cost. (This can lead to a related problem. In some cases we can give them samples, but the insurance companies then believes they are not receiving a medication because they have no record of charges for it).

As long as pay for performance is a trivial part of our reimbursement this doesn’t matter much. We all have numbers under 100% in some measures and it doesn’t really matter.

However if a significant portion of our income was based upon performance as opposed to fee for service, doctors might be tempted to dump patients who lower our numbers. This could apply to both noncompliant patients and to more complex patients. Even if we don’t get patients down to goals due to noncompliance (or intolerance of medications, or inability to afford the medication) our services are frequently still of value and better than no treatment at all.

By: Ron Chusid

Ron Chusid — Mon, 09 Feb 2009 18:23:05 +0000

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.