Comments on: Quality measurement – a delusion

By: Michael Kirsch, M.D.

Michael Kirsch, M.D. — Sun, 10 May 2009 20:43:55 +0000

Every player in the game advocates for increased medical quality. How do you define medical quality and how do you measure it? You can’t. How can you assess how thorough a physician’s medical history is? How do you measure and compare a physician’s skill in examining patients? Is there a rubric that can measure a doctor’s medical judgment? These are true quality determinants in medical care. Instead, the government and others will be measuring data that has little to do with medical quality. They will measure what is easy to count because there is no way to measure what truly matters.

Michael Kirsch, M.D.
wwwMDWhistleblower.blogspot.com

By: Jan Krouwer

Jan Krouwer — Tue, 28 Apr 2009 11:25:29 +0000

Nevertheless, quality tools (which include quality measures) can be useful. A recent example is preventing infections in central lines (NEJM 2006;355:2725-32). Here, an infection rate was observed (the quality measure), it was studied, steps were taken, and the infection rate decreased. The quality tool relies on measuring an error rate. There are other examples such as improvement in reducing errors in anesthesiology in the late 70s and 80s.

By: pcb

pcb — Mon, 27 Apr 2009 13:27:45 +0000

Docs who work in more affluent areas, on average, will have higher P4P scores.

Docs who mislead patients, exaggerate benefits, and encourage treatments/meds based on simplistic number goals will have higher P4P scores.

Docs who refuse to consider whether the patient in front of them appropriately fits the guidelines being measured will have higher P4P scores.

Docs who avoid shared decision making (what if the patient’s informed decision goes against what’s good for my scores?) will have higher scores.

Docs who try to avoid or refer out difficult patients or those with difficult disease will have higher scores.

So if you want to encourage docs to flock to areas with the healthiest patients, avoid those who need the most help and are often the hardest to treat, mislead patients to achieve simplistic number goals that may or not be appropriate on an individual level, and discourage patients from being involved in their own care decisions, P4P is the way to go!

By: docanon

docanon — Mon, 27 Apr 2009 13:26:41 +0000

Could you please provide us with a list of the “performance czars”? It doesn’t have to be a complete list. Just name the first few that come to mind.

I wonder if they really hold the beliefs you attribute to them. Maybe you could consider asking. Or maybe baseless accusation is more fun.

Your take on this whole subject smacks a bit of Glenn Beck, and your level of paranoia is deeply concerning. In fact, I feel it necessary to take the specific step of pointing out that nobody is–or has been–threatening you.

By: cory

cory — Mon, 27 Apr 2009 13:10:00 +0000

I would amend your point just a little.
Quality, from any scientific management perspective, is quit easy to define.
Quality is conformance to predefined standards.
The problem we have, as your commentators have noted, is not defining quality but defining standards. Many, if not most, if not all the standards currently used are flawed in some way. Our job is to “unflaw” them as it were, admittedly not an easy task.

“Doing the right thing is easy. Knowing what the right thing to do is the hard part.”
– Lyndon Johnson

By: James Gaulte

James Gaulte — Mon, 27 Apr 2009 13:01:37 +0000

Onora O’Neill’s comment that quality indicators are chosen for ease of measurement and control and do not measure accurately what the quality of performance is ranks as a great insight but I think even more fundamental to the issue is Goodhart’s law.This states that when a measurement becomes a target it no longer is a valid measure. This is largely true because people respond to incentives.

By: country solo doctor

country solo doctor — Mon, 27 Apr 2009 12:12:50 +0000

As a solo doctor, I tried quality measurements with Medicare on LDL cholesterol, A1C, and BP on diabetics. It became a hassle to report each of these on patients for a massive 2% bonus on office fees, only on the reported patients and only after meeting a certain percentage of reporting. I figued a third of my Medicare patients have diabetes and an average office visit of 4 times a year each. The bonus was going to be around $900 a year, which equates to a 6 day work week and 3-9 Medicare patients/day of less than $2 a day or less than 50 cents a patient. It was not worth my time.
So far, none of the private plans have based my fees on quality, but three of my national plans are tracking quality, such as mammograms, pap smears, LDL cholesterol, A1C, urine microalbumin, etc. I went from 70% average on labs to over 90% average, when I started doing the labs in my office. At least 20% of my patients were not doing the ordered labs. Many of patient refused to do colonoscopies for cancer screening at age 50 or older, as they have $1,000-$5,000 deductibles. Other patients have ob/gyns, yet I get dinged when a mammogram or pap/thin prep is not done. Finally, I can start with a new patietn with an A1C of 12-14, severely uncontrolled diabetes, and get that A1C down within 6 months to a year to 7-8 range, yet that person is still considered uncontrolled diabetes by quality ranking. Ditto if a patient as an LDL cholesterol of 150 with diabetes, high chol, and HTN, and I get it down with meds/diet/ex to 110, that patient still has not med national guidelines. Quality if vague across the plans.
One other thought, a physician who does too many referalls or tests in Medicare Complete gets up to a 10% ding on his/her fees while receiving monthly capitation payments regardless of seeing patients. Capitation encourages physicians not to see the patients by financial incentives. Quality with Medicare complete and most capitated plans is simply being an efficient doctor.

By: Topics about Laughter | Quality measurement - a delusion

Topics about Laughter | Quality measurement - a delusion — Mon, 27 Apr 2009 02:57:47 +0000

[...] DB’s Medical Rants added an interesting post on Quality measurement – a delusionHere’s a small excerptEveryone wants to insure quality. Quality is job #1. Who can be against quality? We should measure quality, report it, reward it, and publicize it. But what is quality medical care? Can we measure it easily? Many argue that we can measure quality. My friend and colleague, Bob Wachter, argues for quality measurement – On Quality Measurement, Babies, and Bathwater . As for me, I’ll keep critiquing bad measures and pointing out when new science emerges that changes how we should thi [...]

By: brian

brian — Mon, 27 Apr 2009 01:55:53 +0000

fact is: PQRI and quality measures are thinly veiled attempts by Medicare and insurance to have another excuse to either cut payments or NOT pay at all.

it is a joke to think it has anything to do with improving quality of care.

cookbook medicine has never worked and it is a sad day when we treat ALL patients the SAME. based on a protocol.