Posted by: notdeaddinosaur | January 27, 2015

Down the Rabbit Hole of “Quality” We Go


The Obama administration on Monday announced an ambitious goal to overhaul the way doctors are paid, tying their fees more closely to the quality of care rather than the quantity.

Holy crap: they’re really doing it. Or trying to do it. Who the hell knows what they’re trying to do? Not “them”, that’s for sure.

The United States government via the Department of Health and Human Services is going to start trying to pay for “Quality of Care” without ever defining what that means!

Doctors practice medicine, an art and a skill that sometimes involves procedures and sometimes involves cognitive services. That last one means “thinking.” When you do a procedure, usually when you are done you have something to show for it; generally a wound or a specimen. When all you do is sit and think — which includes listening to and talking with patients — how does anyone else know what you’ve really done?

One way is if you write down what you were thinking about, thus producing what we call the “medical record.” Actually, I’d be okay with this if only they looked at the right part of the record: the assessment. Instead, thanks to EMRs, the medical record has devolved into a useless mass of cut and pasted, bullet-pointed lists of history and exam items that ends up useful only to billing clerks and malpractice attorneys. At this point it’s often more of a hindrance than a help to anyone actually trying to take care of patients.

“Quality” measures are meaningless because “quality” is completely in the eye of the beholder. Actually, that last link is to a damn good post of mine. To quote myself:

Some argue that when you have an operation, the surgeon shouldn’t leave anything inside you that shouldn’t be there. Others would say that everyone taking care of patients should wash their hands before and after every patient contact. Certainly all medical professionals should maintain proper licensure and credentials. I think of those things as basic expectations; more the difference between “acceptable” and “unacceptable”. “Quality” is different from “not unacceptable.”

Enter the idea of looking at “outcomes” (another meaningless word, also previously addressed by me here and here.) To reiterate: only certain kinds of illness and injuries have measurable outcomes. Fractures (should) heal. Surgically treated illnesses (should) resolve after operation. And so on. It’s generally accepted that there is a direct causal relationship between medical treatment provided and resolution of the condition, though this is not always so. Postoperative complications are not always preventable. Some fractures won’t heal. Cancers sometimes recur. So even the measurement of “outcomes” as a proxy for “quality” is fraught with hazard.

What about the relationship between “quality” and “Patient satisfaction”? Two words:Press Ganey. Short version is that there are times (lots of times) when what people think they want from doctors is not only not what they need, but can be dangerous, useless, and expensive. The patient is not the customer (and even so, the customer isnot always right). When you actually look, it seems like the more satisfied people are, the worse their care.

But now Sylvia Mathews Burwell says:

Rather than pay more money to physicians for every procedure they perform, Medicare will also evaluate whether patients are healthier, among other measures.

This is going to sound counterintuitive, but medical care doesn’t make people healthier. Much of the time, it only makes them less sick, or keeps them from dying. I guess according to Medicare’s new paradigm, every death is a failure. What about the outrageous sums of money already being thrown at patients, usually elderly, in the last year of life? And heaven forbid we actually try talking to our patients about stopping treatment. Those conversations are hard. They take time. Time we don’t have and for which we’re not paid.

None of these “quality measures” can possibly capture compassion, dignity, empathy, competence — all the things that together define the true high quality physician. This new announcement heralds nothing but a windfall for those who can wrangle enough doctors gullible enough to fall for the high-minded rhetoric of “innovative health care delivery systems”, “population based care”, “value”, and “quality.” Mark my words: this is the day we will eventually look back on as the beginning of the end of Medicare as we know it.

Which isn’t all bad. Perhaps when this new system of Accountable Care Organizations collapses under the weight of its executive compensation, we’ll finally find our way to a single payer system, which seems to work well enough for pretty much every other country in the world.



  1. Nicely said. No one is taking into account whether or not our patients actually do anything that we say which actually would improve outcomes. “You can lead a horse to water …..” And if no one gets off this planet alive than how is death always a failure? More questions than answers!

  2. And guess which medical society is really, really excited about this:

    “HHS also announced the creation of the Health Care Payment Learning and Action Network, which is intended to spread value-based payment models to other segments of the health insurance market, including employer-based coverage and state Medicaid programs.

    The federal agency announced the new goals after a meeting in Washington between Burwell and key healthcare industry officials. They included Karen Ignagni, CEO of America’s Health Insurance Plans; Richard Gilfillan, CEO of Trinity Health; and Dr. Douglas Henley, CEO of the American Academy of Family Physicians.

    “We’re on board, and we’re committed to changing how we pay for and deliver care to achieve better health,” Henley said in a statement.”

    Morons or traitors? I can’t decide.

  3. Measuring quality of care is flawed when the outcome is the patient’s health. It’s the same problem as measuring the quality of teaching by looking at the student performance. If you want to measure quality of teaching, you have to look at the TEACHING being done. If you want to measure the quality of student learning, then you look at student performance. Measuring quality of care would require looking at the providers, not the patients.

  4. So this is like “average length of stay” when the hospital gets paid the same rate per dx, and makes more money when you kick the pt out early?

    No wait, they fixed that by not paying if the pt returns within 30 days…

    No wait, they fixed that by having observation admissions last up to 72 hours….

    And, the “average” life expectancy…if a pt lives LONGER, am I a better doctor? No wait…we spent too much money to keep the pt alive YOU loose!

    Finally, if a (salaried) doctor sees 125 pts a week, and gets paid >2x as much as I get paid (as an independent) to see 1/5th as many, who really wins (I pay myself about 40% of national standard for a family practice MD), who is really being taken advantage of?

    Dr M in Western PA

  5. As a patient and stroke survivor I look forward to this. With only an appalling 10% almost full recovery rate, anything to get our neurologists to research something useful. And no, I do not believe that; ‘All strokes are different, all stroke recoveries are different’. Anyone who believes that has never looked at objective diagnosis scans and will never write up stroke protocols that are needed. Yes, the brain is hard to understand but right now survivors are left completely to their own devices to recover.

  6. “a single payer system, which seems to work well enough for pretty much every other country in the world”

    Ahh, can you name some of those countries? I’m having real trouble thinking of any that do not have some degree of multiple pay-ers.


  8. how would docs like to be paid? and what if anything does it make sense to measure ?Please tell me you ideal system? really It matters to me thanks you

  9. […] bonus payments as “incentives” for “Quality” care. The only problem is that, as I’ve written before, all of their “Quality” measures are in fact nothing but proxies for cost, most of which […]

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