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Quality Metrics Have A Negative Impact on the Quality of Care

Posted on October 29, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

A few months ago I asked the question about whether ACOs were more about good accounting than they were improving care. Here’s a summary of the fear:

I think this is a massive challenge with value based reimbursement. We require certain data to “prove” that there’s been a change in how organizations manage patients. However, I can imagine hundreds of scenarios where the organization just spends time managing how they collect the data as opposed to actually changing the way they care for patients in order to improve the data.

I recently came across an article from HealthLeaders Media which says things may be even worse than I described. Not only do quality metrics not improve care, but they may actually have a negative impact on the care provided.

The article cites a survey by the Commonwealth Fund and Kaiser Family Foundation which highlights this result. Here’s an excerpt from the article:

Of the 1600 primary care physicians surveyed, 55% said the growing use of quality metrics to assess provider performance is having a negative impact on the quality of care. Less than a quarter said that quality metrics have a positive impact on healthcare quality.

Fifty-five percent of the nation’s primary care physicians are currently receiving financial incentives based on quality or efficiency measures. Fifty-two percent cited concerns around programs that impose financial penalties for unnecessary hospital readmissions.

Amy Mullins, MD from the American Academy of Family Physicians also has this zinger of a quote, “It often seems [payers] are measuring to measure, not measuring to improve quality.”

This is one of the major challenges associated with trying to legislate or regulate payment based on quality. If you get it right, then the incentives will encourage providers to improve care. If you get it wrong, doctors will jump through the hoops and care will not improve and may even get worse.

I recently wrote that Digital Health is Hard. I think building appropriate quality metrics that actually encourage improved quality care is even harder. Many say that this is the time when we learn from our experiences. I just feel bad for all the guinea pigs who are being tested on without a choice.

Best Doctor at the Lowest Cost

Posted on April 3, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We have a real challenge in healthcare that won’t be easy to solve. In fact, we may not solve this problem. The challenge is knowing the quality of care that’s being provided by a doctor. This matters for so many things. Ideally we could base reimbursement on the quality of the care as opposed to the volume of care. If we had a good measurement for quality of care, none of us would go to doctors who didn’t provide a high quality of care.

Think about how it currently works. If a doctor’s costs or outcomes compare unfavorably with their colleagues, most of us will say, ‘That doctor’s patients are sicker than other doctors’ patients.” In many cases, that very well could be the case. I remember a similar discussion in the clinic I worked at where one doctor was always given the really complex patients, but then they all wondered why he was always running behind.

The problem is that we don’t have any really good ways to know if someones costs and outcomes are off because they have sicker patients or because they aren’t very good doctors. Plus, this doesn’t even really take into account the long term implications of the care that’s provided by a doctor. Maybe the up front cost was more, but the long term cost to the healthcare system and patient might end up being much less.

Like I said, we may never solve these problems because they are incredibly complex. I know that many people would look to big data to help solve this challenge. Big Data can do great things, but far too often it’s the cop out answer to really addressing the challenge. This is especially true because then it usually leads to us not having the data available for us to really solve the problem.

Even most doctors can’t judge the quality of care that another doctor provides. If it’s a doctor from their specialty that they work with on a regular basis, then they likely have some idea. However, except in really complex patients (which most aren’t), the interaction between doctors is pretty minimal. This isn’t a knock on doctors. It’s just the reality that if a doctor doesn’t have much interaction with another doctor, what basis do they have to know the quality of care another doctor provides?

All of the various doctor ranking systems miss this completely. Most users of those systems mistakenly assume that the ranking or ratings on those sites somehow reflect the quality of the doctor. As discussed above, there’s no way for these sites to assess the quality of the doctor. Instead, these websites rank and rate based solely upon customer service and not quality of care. Customer service can be an important factor in selecting a doctor, but quality of care measures would be infinitely more valuable.

How then do we measure the quality of care provided? I haven’t even mentioned the complexities around consistency of care. Some of my blog posts are better than others. The care provided by a doctor to one patient might be great, and the next patient only good. Plus, this also doesn’t take into account the quality of the patient. What if the patient withholds information which prevents the doctor from providing really quality care? Should we hold doctors responsible for the poor care they provide because of the patient’s choices?

This is a really slippery slope to start, but I’ve heard people talking about it. I’m sure it makes doctors cringe to even think about it. I don’t expect my doctor to be perfect, but I think it is good for doctors to be accountable. That’s just a really hard thing to do.