Quality Measurements: Beware Unintended Consequences

Whenever anything is presented to us by the government, and/or corporations who work closely with the government as progress, we should be very skeptical.

The whole concept of measuring “quality” in medicine and paying doctors for performance is a case in point.  The article below touts a government/big insurance corporation collaboration to rate doctors on quality, so they can pay less to physicians whose patients have worse outcomes.

On the surface, this sounds like a great idea.  We all want to have high quality goods and services.  On some level, it makes sense to demand some kind of measurements in medicine to be sure people, or taxpayers, are getting their money’s worth.  We do need, however to think about unintended consequences.  As the late great Paul Harvey would say, “And now, for the rest of the story…”

There is a problem that arises when insurers base physician payments on so called “quality measures.”  First, they are basing someone’s pay on many factors that are out of that person’s control.   There are many real world examples of why this is an unfair practice.  Personally, I have counseled patients with diabetes that they need to watch their diet, exercise, quit smoking, and take their medications faithfully.  I did all the right things and provided high quality care.  Unfortunately, despite impassioned pleas, they did none of the above.  Their weight, blood pressure, and blood sugars continue to get worse.  I had done all the right things, but my patient did not.  I am penalized for their maladaptive behavior.

If I have done everything I could to improve their health, but they are resistant to change, and I know that I will be losing money from here on out if I continue to care for them, I will be incentivized to no longer treat that patient.  This phenomenon is known as “cherry picking.”   In order to make a living, physicians will have the perverse incentive to stop taking care of patients who need the most care and attention.  Is this really what we want in our health care system?

I have seen examples of this understandable human behavior throughout my career.  While in my residency training, I did rotations in general surgery.  Our hospital’s surgery department had 6 surgeons, most of whom were average, or above average clinicians.  Ironically, one of the better surgeons had morbidity and mortality (quality) statistics that would have made someone think he was dangerous.  The reason for his bad numbers was that, unlike his colleagues, he was not concerned about his statistics.  He was more interested in treating patients.  He was willing to take on cases where the patients were very sick and by their nature were at high risk of bad outcomes.  In his words, he was a surgeon.  It was his job to operate on people who needed surgery.  He was willing to see the patients who his colleagues were afraid to because they did not want their quality numbers to be affected.  He was providing a vital service that no one else was willing to.  Should he have lost his livelihood for taking care of patients who no one else would?

I feel fortunate that because I am a Direct Primary Care (DPC) Physician.  I contract with my patients directly.  I provide them care and work with them to improve their health without fear of having a third party not pay me if we fall short on achieving our goals.  We can keep working at it as long as we need to, without outside interference.

Maybe the entire health care system would be better served to promote models like DPC which increase the spirit of doctor/patient collaboration, and have doctors and patients be accountable to each other without fear of punishment.  If we continue down the path we are on, the patients who need care the most are the ones least likely to get it.  We can do better than that.

Michael A. Ciampi, M.D.

Washington Post

Federal health officials, insurers agree on how to rate doctors’ quality

By Amy Goldstein

For the first time, the Medicare program and the health insurance industry have agreed on a set of ratings to gauge how well doctors do their jobs.

Leaders of the federal Centers for Medicare and Medicaid Services and the trade group America’s Health Insurance Plans announced Tuesday that they have reached a consensus on how to measure physician quality in seven medical areas, from primary care to treatment of patients with cancer or AIDS.

The ratings will not be used immediately but are intended to have a big effect within a few years on U.S. health care.

They will serve as building blocks on which both private health plans and Medicare, the vast public insurance program for older Americans, rely in shifting how doctors are paid. Increasingly, both private and public insurance are moving toward payments based on the “value” of care, rather than on how much care a doctor provides. The new measures are designed to help gauge that value.

But they also are designed to lessen the paperwork burden on physicians, who typically face different requests for quality data from each insurer with which they have contracts. From patients’ vantage point, uniform quality ratings are intended to help them compare and choose doctors.

The specific points in the agreement cover, for example, how well primary care doctors control patients’ high blood pressure, how well doctors who treat patients hospitalized for heart failure prevent readmissions, how successfully doctors keep HIV in check for patients infected with the virus, and what therapies doctors use to treat various cancers.

CMS acting director Andy Slavitt said in a call with reporters that the agreement reflects “something rare” in the U.S. health-care system: harmony among parties that often are at odds. The agreement drew immediate praise from the American Medical Association, several medical specialty groups and patient advocacy organizations, as well as the insurance industry.

The quality measures, the result of 18 months of negotiations, remain a work in progress. While the agreement is new, the scores of measures themselves are not. Nearly 90 percent match ones already approved by the National Quality Forum, a nonprofit organization that endorses evidence-based standards for measuring health care.

Federal officials and insurance executives said they will keep working to develop ratings agreements for other areas of medicine. Within each, the methods will evolve as research continues to develop ways of gauging doctors’ quality.

Helen Burstin, the quality forum’s chief scientific officer, said in an interview that more ratings eventually should be based on the outcome on patients’ health rather than the steps that doctors take.

For Medicare, the ratings list must go through federal regulations before it can be used. For private insurance, Carmella Bocchino, executive vice president of America’s Health Insurance Plans, said most health plans would adopt the list when they renew contracts with doctors.

Amy Goldstein is a national reporter for The Washington Post focused on health-care policy.

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