Why my obsession over “quality” matters


Category : Medical Rants

California physicians sue over quality ratings

Physician ratings process needs transparency

The lawsuit is the most recent complaint organized medicine has made about health insurers' quality and cost rating, tiering and quality designation programs. Published studies have shown that research has supported physicians' assertions that these programs are inaccurate and potentially misleading, though the plans say they are based on firm, solid evidence.

The CMA says the Blue Ribbon program, which premiered June 1, is based on faulty data and doesn't accurately represent the quality of physicians' care.

"While Blue Shield of California has touted its Blue Ribbon Recognition Program as identifying physicians in California supposedly providing superior medical care to Blue Shield of California enrollees, in reality, it is an economic profiling scheme that inaccurately and unfairly rates [physicians] through the use of inherently flawed methodology," the lawsuit says.

There are many reasons to object to "quality reporting".  First, they are not measuring quality but rather pieces of quality.  The pieces usually refer to measures on the management of some common diseases (e.g., diabetes mellitus, CHF, hypertension).  Second, the measures come from administrative data rather than from evaluating actually patient care.  The measures often ignore patient characteristics, yet patient characteristics make a difference.  Third, the measures are statistically unstable. 

The "quality" movement represents a desire to measure physicians, a desire that reflects an unhealthy obsession in our society.  I suggest these older rants:

More on performance measures

Our obsession with measurement

This issue should rank in the top 3 problems of medical practice today.  The "train that has left the station" is a wreck.  I will not stop my campaign against this lunacy. 

Bravo to the California Medical Association.  I hope that this trial will slow down the train and perhaps even derail it.  They are not measuring quality, they are measuring something and they claim:

The AMA and state medical societies, including California, have called for insurers to publicly document the accuracy of their physician cost profiling.

Insurers, which have generally defended quality ratings as imperfect but better than nothing, said they want to work with physicians to improve rating programs.

In April 2008, Blue Shield was among the health plans that signed on to a Patient Charter for Physician Performance Measurement, Reporting and Tiering, drafted by the Consumer-Purchaser Disclosure Project, a group of businesses and consumers who advocate for transparency and meaningful quality information. The insurers pledged to use agreed-upon, evidence-based standard quality measures rather than cost data to rate physicians.


Major health plans and America's Health Insurance Plans, the plans' trade organization, have responded to that letter by saying that their programs are carefully established, that they believe in getting accurate results, and that they are qualified by National Committee for Quality Assurance's Physician-Hospital Quality Program, which certifies physician-profiling programs. However, the fact remains that RAND and others have found significant errors in multiple studies. A transparent system would resolve the matter concretely.

It's in everyone's interests that the ratings be correct. Instead, independent research has revealed problems, and the rating process largely remains a mystery — hardly a confidence-building profile of a system that presumes to give guidance to patients and pass judgment on doctors.

I opine that they are all on a fool's mission.  Quit trying to take shortcuts.  We cannot measure quality through proxies.  Evaluating quality is very complex, and not an actuarial task.

Comments (5)

 The AMA is committed to empowering patients to make informed health care decisions regarding their choice of physicians, but flawed information just leads to flawed decisions.

A series of studies recently conducted by researchers at RAND Corporation confirm the AMA’s longstanding contention that serious flaws exist in health insurer programs that attempt to rate individual physicians based on economic criteria.  Go to: http://www.rand.org/pubs/research_briefs/RB9523/
One RAND study shows that physician ratings conducted by health insurers can be wrong up to two-thirds of the time for some groups of physicians. Under the best circumstances, insurers misclassified one-fourth of all physicians. This and the other studies call into question the use of cost-profiling tools to control health care spending and provide the public with information.
Patients need to know that physician evaluations based on cost criteria have a high risk of error. The AMA has called on health insurers to publicly document the risk of error in their physician evaluations. Patients can then decide for themselves if the information is worth considering when choosing a doctor.

It might be possible one day to reliably evaluate the work of individual physicians against cost criteria, until then, insurers shouldn't keep fooling patients by pretending to provide accurate information.

Cecil B. Wilson, M.D.
President, American Medical Association

Insurers have proven that they cannot process claims correctly, verify coverage, or provide reliable formulary information.  Who in the world would think that they could "measure quality" (based on claims submitted) with any degree of accuracy?

Cherry-picking individual measures from various chronic diseases, and lumping them together can hardly be called a “quality program”, especially if a single patient can have more than one of the conditions being measured. IANAD, but this is yet another case of minimum wage clerks telling you how to practice medicine.

What we are seeing is various entities trying to fill a vacuum. It is not a major part of physician culture to track how we are doing. We lament that absurd metrics are foisted upon us but all of this would be moot if we are the drivers of defining quality metrics. 
I agree that it is madness as presently pushed since we are being held accountable to metrics that we believe are irrelevant. Patients and physicians (as well as other health care providers) need to be in the forefront of defining what is important and develop tools which can measure them. This is an integral part of being a doctor. Defaulting on this responsibility means someone else will do it.

[…] seems we have a tough time determining what we should be measuring. What numbers really matter? Hospitals report metrics – but often disagree with the metrics or […]

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