Desperately Seeking Quality

Earlier this month a physician social networking website asked its subscribers to weigh in on a survey supplied by a “client” who was looking for some help with a perplexing problem.  We’re forbidden under the website’s terms of use from publishing the exact post, but it went something like this:

The Affordable Care (“ObamaCare”) Act requires Medicare to expand its “Physician Compare” Directory tool.  This is a website that currently allows potential patients to enter an address or zip code and find information about doctors such as their name, address, phone number, medical specialty, sex and whether they accept Medicare and speak more than one language.  It also reports on where these doctors obtained their medical training.

As a number of observers have observed, this federal program is not exactly a goldmine of useful information – especially with much better information put out by private sector websites.  And even the small amount of information that the federal government has put together with your tax dollars is not exactly reliable.  Articles in Forbes and elsewhere have documented that much of it seems to be incorrect, incomplete or a combination of the two.

The survey posting then went on to point out that the law of the land now requires that, by 2013, the Physician Compare website report data about the quality.

Here’s the exact wording from the Affordable Care Act itself:

“SEC. 10331 ø42 U.S.C. 1395w–5 note¿. PUBLIC REPORTING OF PERFORMANCE INFORMATION.

(2) PLAN.—Not later than January 1, 2013, and with respect to reporting periods that begin no earlier than January 1, 2012, the Secretary shall also implement a plan for making publicly available through Physician Compare, consistent with subsection (c), information on physician performance that provides comparable information for the public on quality and patient experience measures with respect to physicians enrolled in the Medicare program under such section 1866(j). To the extent scientifically sound measures that are developed consistent with the requirements of this section are available, such information, to the extent practicable, shall include—

(A) measures collected under the Physician Quality Reporting Initiative;

(B) an assessment of patient health outcomes and the functional status of patients;

(C) an assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use;

(E) an assessment of patient experience and patient, caregiver, and family engagement;

(F) an assessment of the safety, effectiveness, and timeliness of care; and

(G) other information as determined appropriate by the Secretary.”

The survey post then finally got to the point.  The unknown client, who one can only imagine to be a Department of Health and Human Services functionary tasked with implementing this language, mentioned that “we are interested in learning more about” how primary care physicians would measure things like quality, cost and the efficiency of care provided. 

In other words, we’re obligated to slap something together pretty soon here if we can only figure out how to realistically measure any of this stuff in literally tens of thousands of private medical facilities all over the country.  So we’d thought that we’d ask for your two cents before we officially mandate that you gather immense amounts of detailed new data and hand it over to us.

Too bad many of these doctors and clinics are already struggling just to stay in business.

The survey then went on to suggest a number of different measures one might use such as length of stay (shorter is better), patient satisfaction, how many referrals a doctor got, how many of a doctor’s patients were hospitalized, the volume of preventive care delivered and so on. 

We’ve written previously about such dead ends as “pay-for-performance”, but we found this particular survey request interesting for two reasons.  The first is that, although the entity posting the survey was asking about “quality”, the sheer volume of information that would have to be gathered in order to comply with the wording of the law is frankly breathtaking.  Assessments of the health status and outcomes for a statistically significant fraction of patients in each physician’s practice?  These sorts of things are only meaningful if one were to adjust for a host of individual patient-specific factors.  How sick was the patient to begin with?  How compliant are they with their medical treatment?  Do they have any other diseases making them sick?  Did their insurer allow their doctor to use the medications and procedures that would have given them the best possible chance at recovery, or were they forced to use whatever happened to be cheapest?  How long did they see the doctor in question before the results are measured?  What about the impact of the patient seeing other doctors, who might either improve the results or make them worse?  Were they allowed to see specialists?  The list goes on and on.

There is absolutely no doubt in our minds that this part of the law was written by someone living in the world of academic research.  This stuff is the very essence of elaborate clinical studies; work that routinely require dozens of research assistants, years of data collection and validation, statisticians, approval from human subjects committees and the very real risk that the physician in question will retire or pass away before the results are complete.  What other profession on God’s green Earth is expected to gather and report information of this scope and detail?  It’s roughly equivalent to soldiers in combat being asked to keep track of everything from their accuracy in shooting (“What was the functional status of each enemy soldier after you fired upon them?  Please note whether they under cover or out in the open.”), and their popularity with the civilian population (“How satisfied was each family with your search of their home?”), to the “effectiveness” of their operations, despite the fact that government higher-ups are calling the shots (“Did the Taliban return to your areas of operation in the six month period after your departure?  If so, please explain.”)

And exactly who is going to be able to collect all of this information?  It’s clear that the forcible collection of this type of data is one of the primary reasons that Medicare has implemented plans to punish clinicians who do not choose to “meaningfully use” electronic medical record systems, but much of this information is simply beyond the ability of the average clinician to gather and still have time to care for patients.  Given the rapidly developing shortage of physicians it is perhaps the right time to ask which will benefit that average American more: having all of this information (which may or may not be correct and statistically valid), or having the ability to see a doctor at all?  It appears that the Affordable Care Act has decided the answer for them.

Given the obvious complexity of obtaining this data for Congress and Medicare, it seems clear that one purpose of the survey is a plea for help from the regulated.  If doctors can be induced to recommend the terms of their own bondage it would certainly help to justify whatever standards of data collection and interpretation were ultimately adopted.  So it was particularly interesting to see some of the responses.  We’ve received permission to print two of them here.  A family practice doctor had this to say:

“I agree 100% that in a free market quality is very easy to spot. You know how? Look at successful operations. They will be delivering quality, guaranteed. In a skewed, third party controlled, overregulated, stifled, stressed system, one will have to go through crazy contortions to determine quality. You have to descend on an operation, probe it, measure it, survey it, poll it, compare it, peer into its computers and grade it. And then what have you got but a bunch of bullshit reports as proxy for free market success.”

While an endocrinologist observed:

“All measures of “quality of care” are biased in some way. Payors rate how much a provider costs them. I am frequently chided for prescribing too many glucose test strips, but I take it as a compliment and a measure of quality care that my patients are testing their sugars. Adherence to accepted guidelines? Every patient is different, and care has to be individualized. I get inquiries from payors and PBMs as to why patients aren’t on certain meds, like ACE’s or statins. My clinical judgment, none of their concern, I shred them. Patient satisfaction? As noted in the above posts, you can’t please everyone. Patients have agendas, and sometimes you don’t know what they are. You do what’s right medically and ethically, according to your clinical judgment. Hospitalizations? Depends on your patient population. Mine is filled with sick, elderly diabetics with all the complications. Many will be hospitalized. Some will die. There is no objective way to rate quality of care that can apply to all providers. I personally think that a good indicator of quality of care is peer reputation. But the bureaucrats can’t figure that into their evaluation models. And how do you prove that your model means anything at all? I agree with gdunn [Ed note: the pen name of another doctor], we need to be involved in setting any standards, and we also need less paperwork and more patient time to give patients quality care.”

With just a few short sentences, both of these individuals have shed more light on the issue of measuring “quality” than all of the academic papers on the topic combined.  How did they do it?  Well for one thing they live in the real world rather than some sort of academic utopia.  In the real world, every time you decide that you want something it has an associated opportunity cost.  If you want your auto mechanic to document how successful his repairs have been, it means he can spend less time fixing your car.  If he spends less time fixing your car he has to charge a higher rate for the work he does manage to do.  So you end up paying for that “quality” report quite directly.  Either that or he goes out of business.  It’s exactly the same in medicine.  To pretend that it isn’t is either stupidity or deceit.  Take your pick.

As our first commenting doctor observed, the economically efficient way to gauge quality is to rely on the workings of a free marketplace.  One important reason that capitalism beats the stuffing out of communism or any sort of command economy is that it’s far cheaper, more efficient and more reliable to gather information about the relative desirability of goods and services from the marketplace than from a bureaucracy.  And free-market demand for that market-based information is what allows the folks at Angie’s List make a living without the need for government subsidies.

And as our second doctor observes, one key reason that bureaucratically-generated “quality” measures are so inadequate is precisely because they are inherently biased – especially when the self-interest of your average insurance company is frequently in conflict with the personal and medical self-interest of your average patient.  The inherent conflict is even scarier if the government itself is your insurance company.  After all, if you don’t like your private sector insurance company, at least you can switch to a different one.

It rather makes one wonder why government itself doesn’t seem to be associated with any “quality” measures.  Perhaps Congress could pass a law to make them mandatory and link poor performance to automatic pay cuts for elected representatives?

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