How Do You Measure Health Care Quality?

[McCamy Taylor]

We all want to make sure that we are getting quality for our money. But how do you measure intangibles like customer satisfaction, when people can get their friends to go online and post glowing reviews of their businesses and harsh criticism of their opponents? How can you regulate a profession like the medical one, when a Medical Board member ( a pain specialist) can have her husband anonymously "turn in" all her competitors in order to strip them of their licenses and leave her as the only pain doctor in her town (this really truly happened in Texas with the State Board and is the reason they no longer accept anonymous complaints).

http://www.aapsonline.org/newsoftheday/004

The lawsuit specifically points out misconduct by Roberta Kalafut, the Board president. The law suit claims that Kalafut “arranged for her husband to file anonymous complaints again other physicians, including her competitors in Abilene…”

She then “…worked inside the TMB, with other defendants, to discipline doctors based on anonymous complaints filed by her physician husband.”

http://www.anh-usa.org/texas-medical-board-as-out-of-control-as-ever/

There were eleven hours of hearings before the Texas House of Representatives. The suit spurred the resignation of TMB president Roberta Kalafut, whose tenure, according to the AAPS, “was marked by unjust disciplinary actions, particularly against her competitors, and stonewalling by the TMB and Governor Rick Perry.”

As Alan Moore (re)said in The Watchmen, "Who watches the watchmen?" We do, the people, the consumer. But how can we judge the effectiveness of a certain health care system or provider before we put our lives or the lives of our family members in their hands?

You can implement "metrics", measures of variables that relate to the quality of service or care. The problem with these metrics--they can be manipulated. And, it is often easier to treat the metrics than the underlying problem. For instance, if your state issues a score card of how many heart patients die after surgery, no surgeon will want to do surgery on a really sick patient--even if the patient will definitely die without the care. If the patient dies because no surgeon wanted to risk his or her own "score card", the quality of health care for the community declines. It becomes a a health care system that serves only the healthy and which fails the truly needy.

http://www.nytimes.com/2015/07/22/opinion/giving-doctors-grades.html?_r=1

Another example---Medicare's latest attempt to make sure that its beneficiaries get quality care, "pay for performance." Sounds good on paper. Doctors get more money if their patients achieve better diabetes control, get their mammograms, take their medications. The problem with this system--it is easier to select only healthy, wealthy compliant patients in your practice than to achieve miracles in patients who are poor(unable to comply), have mental illness or substance abuse issues (unwilling to comply), or have so many co morbidities that no matter how much they comply with treatment they will never get their diabetes under control. Doctors are free to set up their practices where they will--in affluent neighborhoods, away from bus lines--and if an undesirable slips in the door anyway, they can always "fire" the patient for non compliance because he can not keep an appointment (no ride). Or refuse to treat his pain. Or declare that his case is too complicated and referring him to someone else. Meaning, once again, that a metric which is supposed to help people choose the best health care actually deprives the needy of necessary care.

This can happen even in public health systems for the uninsured. The public health clinic where I used to work had two locations in the same suburb. One was run by one medical school, another by another one. When patients at clinic A would complain, they would immediately be transferred to the care of doctors at clinic B, supposedly as a way to improve patient satisfaction. But, when Clinic A lost the complainers, they then tossed out the complaints. Since the patients were no longer patients of clinic A, their complaints did not count against clinic A, right?

Why go to all the bother to falsify a metric like number of complaints? Clinic A's doctors trying to take over all the clinics within the system. And so, after a year of this, the medical director of the entire clinic system announced that Clinic A had received no patient complaints, making them better doctors and better qualified to run all the clinics.

Those of us who worked at clinic B knew that Clinic A could not possibly have received no complaints--we were seeing the patients who were transferred to us because they had complained about their care at Clinic A. But by then, the deal was sealed. All Clinic A had to do was get rid of those pesky complaining patients in order to fix their metrics so that they would look stellar on paper. Who cares which medical school runs a public health clinic? Probably no one except the poor, uninsured people who use that clinic. However, what would you think if you found out that your doctor had no qualms about turfing the sickest, neediest patients somewhere else in order to cheat on a metric test for personal gain? Would it make you wonder which was more important to the doctor, your health or his business? Sure it would. But again, these are uninsured folks, and beggars can not be choosers, meaning that even if the public knew what was going on behind the scenes, no one would care.

Sadly, the use of metrics can have a negative impact even on so called "hard working" Americans who have health insurance. For example, people living in suburbs tend to be younger and healthier. So, you can treat bronchitis in a suburb easily and quickly as a doctor, giving you more revenue (better patient flow), making your look more efficient, cutting down the number of tests you need to order to treat an illness. Your colleague in the city is likely seeing older patients, people with more chronic illnesses. There is a huge difference between a healthy 30 year old who takes no medication and who gets a mild skin infection and a chronically ill 70 year old on methotrexate (chemotherapy for arthritis) and coumadin (blood thinners) and a huge list of other medications who comes in for a mild skin infection. Much more time must be spent with the second patient, more tests must be ordered, more care must be taking with the selection of treatment (medication interactions) more warnings must be given, there must be closer follow up. And yet, anyone looking just at he diagnosis would say that the suburban doctor was able to treat the diagnosis of skin infection more quickly and economically and with a better outcome than the urban doctor--making the suburban doctor a better doctor by several widely used metrics. Oh, and the suburban doctor is making more money, too, since he sees more people and he gets to charge them more than Medicare rates.

The result? Cities are losing doctors and hospitals to the suburbs. Urban dwellers face increased barriers to care. For example, from a study of New Jersey hospitals in 2005

http://www.hschange.com/CONTENT/769/

Hospital systems are expanding and upgrading facilities in suburban areas of northern New Jersey, while smaller hospitals serving urban areas are struggling. The area’s two largest hospital systems—St. Barnabas Health Care System and Atlantic Health System—are competing aggressively for market share in the wealthy, suburban areas of the market where most of the area’s population growth is occurring. Meanwhile, smaller community hospitals that serve the aging urban communities surrounding the city of Newark confront declining admissions, growing charity care burdens and deteriorating financial performance, resulting in several hospital closures in recent years. A third group of facilities, comprised of safety net hospitals that serve inner-city Newark, remain viable sources of care for underserved populations, but financial constraints limit their ability to upgrade facilities. These developments raise the prospect of widening disparities in care among the three groups of hospitals and the patients they serve.

Providing health insurance for all is supposed to eliminate or at least decrease the disparities in care. However, even if all patients are insured, if those living in cities are older and sicker than those living in the suburbs, there will still be a tendency for clinics and hospitals to be built in the suburb---because the profit margin is higher, the liability is lower. If we rely only on the so called free market to shape our health care system, those who need care the least will get it the most. If we rely upon easily manipulated metrics to judge our providers, we will reward those most willing to treat the numbers rather than the patients.

Unfortunately, our current system--private insurance for some, public for others--is designed to perpetuate this problem. Insurers want healthy patients. They can no longer cherry pick healthy patients, but they can cherry pick the providers who treat healthy patients. Meaning they can enroll lots of doctors and hospitals in the suburbs and enroll too few in the cities or in minority areas. They can provide free yoga classes and have only one oncologist for a huge area. They can put pressure on hospital systems to move into the suburbs and leave urban areas to public clinics. They can design payments so that there is no increase in reimbursement for extra time and tests spent caring for the sickest. Under the current system, urban hospital emergency rooms are swamped with people seeking care for minor illnesses--those without insurance can not afford to see a doctor and those with insurance can not find a doctor nearby to see them. Everyone puts off care, because who wants to wait in an ER five or six hours. Or, they try to get inappropriate care in a Minute Clinic set up for ear infections. "What do you mean you can't treat my chest pain for sixty bucks? I don't have the money or time to go to the ER and wait!" This generates complaints against urban providers who fail to meet patient expectations, which in turn drives providers out of the city into the suburbs, where it is easier to get high marks and glowing reviews.

Yes, in a perfect world, a perfect health care system could be entirely free market. But that would assume that everyone has the same health issues and the same insurance. Even if we all get the same insurance---cradle to grave, single payer, the only one proven to cut costs and improve life expectancy---if we rely upon the so called "free market" to make public health decisions, we will face continuing health care disparities. Universal single payer health insurance is not an end in itself. Whoever is in charge of the nation's public health needs to make an effort to improve access to care in the cities and in currently under served areas. We need to increase the rewards for providers who serve the under served, rather than stigmatizing them as "over utilizers who achieve bad outcomes". We need to acknowledge that when it comes to disease, we are not all created equal and some of us need and deserve a little more care.

[Hoyt]

1. I agree that those who treat the poor and sickest among us should get paid better. In fact,

I would support penalties for those physicians and other providers who will not take Medicaid patients, the penalties going to help pay Medicaid providers better.

I do think there are quality measurement systems that are better than doing nothing.

Good post.

[RichGirl]

2. So many doctors these days are basically...

...drug dealers. Seriously, it's unbelievable how many prescription drugs people take! It's fine if you have diabetes or a condition that requires them. But, drugs should never replace taking of yourself.

A friend went to her doctor because she was feeling a lot of anxiety and asked him to give her something. He said...my prescription is to join a gym. She isn't overweight at all but he explained that aerobic exercise is the best thing you can do for your physical and emotional health. THAT is a good doctor.