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The Quality Disconnect in Healthcare

Posted on February 2, 2017 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

There’s a big problem with the current healthcare model. There’s no real financial incentive to make sure you’re practicing the highest quality care possible. Doctors don’t get paid for quality. Patients don’t select a doctor based on the clinical quality of the doctor since the patient has no way of measuring a doctor’s clinical quality. The clinical quality a doctor provides doesn’t move the needle on her business.

Certainly, I’m not saying that doctors don’t provide quality care. It is also true that over time a doctor could grow a reputation as a poor quality doctor, but those are usually only the extreme cases that end up in court with big medical class action lawsuits.

What’s amazing is that most doctors can’t event evaluate the quality of another doctor. An orthopedic surgeon has no way to evaluate how well an ENT is doing quality wise. Doctors of the same specialty could evaluate a colleague’s clinical quality, but that doesn’t happen in the current system.

In a perfect world, we could create payments based on the quality of care a doctor provides. That makes a lot of sense and it’s what we do in a lot of other industries. We pay people who provide higher quality more than we pay people who provide lower quality. The problem in healthcare is that we don’t have any good way to measure quality.

While I believe there’s no good way to measure quality, that doesn’t mean that it won’t keep organizations from trying. In fact, that’s the basis of much of MACRA and the PQRS program before it. Same goes for Accountable Care Organizations (ACOs). These are all efforts to evaluate the quality of care that’s being given and reimburse based on those quality indicators. Most doctors will tell you, that’s not a very good system if you want quality.

What’s screwed up about these quality measures is that they do nothing to actually lower the cost of healthcare. Poor quality care only represents a small portion of the massive premium we pay for healthcare in the US. The real costs come from outrageous drug pricing, pallative care, medical liability fears, and chronic conditions. Those are the four areas we should really be focusing our efforts on. The problem is that there’s not a lot of will in healthcare to address these challenging issues.

Consumers Are Still Held Back From Making Rational Health Decisions

Posted on November 25, 2014 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Price and quality of care–those are what we’d like to know when we need a medical procedure. But a perusal of a recent report from the Government Accountability Office reminded me that both price and quality information are hard to get nowadays.

This has to make us all a little leery about trends in health reform. Governments, insurers, and employers want us to get choosy about where we have our procedures. They justify rises in copays and deductibles by saying, “You patients should start to take responsibility for the costs of your own health care.”

Yeah, as responsible as a person looking for his car keys in the dark. Let’s start with prices, which in many countries are uniform and are posted on the clinic wall.

Sites such as Clear Health Costs and Castlight Health prove what we long knew anecdotally: charges in the US vary vertiginously among different institutions. Anyone who had missed that fact would have been enlightened by Steven Brill’s 2013 Time Magazine article.

But aspirations become difficult when we get down to the issue at hand–choosing a provider. That’s because US insurance and reimbursement systems are also convoluted. We don’t know whether a hospital will charge our insurer their official price, or how much the insurer will cover. It might feel righteous to punish a provider with high posted prices (or prices reported by other consumers), but most patients have a different goal: to keep as much of their own money as they can.

We can gauge the depth of the cost problem from one narrow suggestion made in the GAO report that yet could help a lot of health consumers: the suggestion that Centers for Medicare & Medicaid Services (CMS) publish out-of-pocket expenditures for Medicare recipients as well as raw costs of procedures (page 31). Even this is far from simple. HHS pointed out that 90% of Medicare patients have supplemental overage that reduces their out-of-pocket expenditures (page 43). Tracking all the ancillary fees is also a formidable job.

Castlight Health is out in front when it comes to measuring the real impact of charges on consumer. They achieve great precision by hooking up with employers. Thus, they know the insurer and the precise employer plan that covers each individual visiting their site, and can take deductibles, exclusions, and caps into account when calculating the cost of a procedure. A recent study found that Castlight users enjoyed lower costs, especially for labs and imaging. Some nationwide system built around standards for reporting these things could unpack the cost conumdrum for all patients.

Let’s turn to quality. As one might expect, it’s always a slippery concept. The GAO report pointed out that quality may be measured in different ways by different providers (page 26). A recently begun program releases Medicare data on mortality and readmissions, but it hasn’t been turned into usable consumer information yet (pages 27-28). Two more observations from the report:

  • “…with the exception of Hospital Compare, none of CMS’s transparency tools currently provide information on patient-reported outcomes, which have been shown to be particularly relevant to consumers considering common elective medical procedures, including hip and knee replacements.” (Page 21)

  • “CMS’s consumer testing has focused on assessing the ability of consumers to interpret measures developed for use by clinicians, rather than to develop or select measures that specifically address consumer needs.” (Page 25)

Some price-check sites simply don’t try to measure quality. A highly publicized crowdsourcing effort by California radio station KQED, based on the Clear Health Costs service, admitted that quality measures were not available but excused themselves by citing the well-known lack of correlation between price and quality.

Price and quality may not be related, but that doesn’t relieve consumers of concerns over quality. Can you really exchange Mount Sinai Hospital in New York for Daddy-o’s Fix-You-Up Clinic based on price alone? Without robust and reliable quality data, people will continue choosing the historically respected hospitals with the best marketing and PR departments–and the highest prices.

A recent series on health care costs concludes by admonishing consumers to “get in the game and start to push back.” The article laments the passivity of consumers in seeking low-cost treatment, but fails to cite the towering barriers that stand in the way.

The impasse we’ve reached on consumer choice, driven by lack of data, reflects similar problems with analytics throughout the health care field. For instance, I recently reported on how hard a time researchers have obtaining and making use of patient data. Luckily, the GAO report cites several HHS efforts to enhance their current data on price and quality. Ultimately, of course, what we need is a more rational reimbursement system, not a gleaming set of computerized tools to make the current system more transparent. Let’s start by being honest about what we’re asking health consumers to achieve.

The Financial Need for Quality Improvement in Healthcare Infographic

Posted on November 3, 2014 I Written By

John Lynn is the Founder of the 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 and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I recently received a well done infographic on the negative financial impact of poor quality healthcare on the health system. The infographic was created by Caradigm, a population health company. I think you’ll find some interesting insights in the benefits of quality healthcare in this infographic.
Need for Quality Improvement in Healthcare

Data Sources:
GE Healthcare. “Clinical Decision Support Decision: Defining our Problem Statement. 2011.
The Advisory Board. 2008. based on Kleven, RM. “Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals 2002.” 2007.
The Advisory Board. “The Tip of the Iceberg: Adverse Events are Costing You More than Ever.” 2011.
GE Reports. “The Unknown Killer: Healthcare Associated Infections.” 2011.
NEMJ “Care in US Hospitals” July 2005.
HealthAffairs. Reducing Waste in Health Care. December 2012.
Centers for Medicare and Medicaid Services, “National Patient Safety Initiative: Saving Lives Saving Money,”