Sunday, January 12, 2014

Measuring Medical Quality: Move Over Pay-for-Performance

Obamacare has promised to provide all of us with quality medical care that is affordable and accessible.  The very name of the law is the Affordable Care Act, which I have maintained will be short on both affordability and quality care.  Most of the country agrees with me.  The postponement for a year of the  corporate mandate to provide insurance in businesses with at least 50 full time employees was a great relief to these businesses and to Democrats across the country who were shivering from fear that voters would hold them accountable in 2014 when the country witnessed the debacle.  Was this solely a policy decision independent of politics?  I won’t insult readers’ intelligence by weighing in here.

Mandate Postponed from Electoral Anxiety?

How will the Obama and insurance company vanguards of bureaucrats ensure quality?  They will measure of bunch of silly stuff that is easy to measure but counts for almost nothing.  What really counts can’t be easily counted.  But, these guys will count what is easy to count and pretend that it matters.

Let’s have readers try their hand at measuring medical quality.  Depending upon your responses, you might gain a position with the Department of Health and Human Services.

Which of the following is the best measurement of quality of an obstetrician?
           (1)    The percentage of Pap smears done on his patient population
           (2)    The percentage of mammograms done on his patient population
           (3)    Judgment of when a Caesarean section is appropriate
           (4)    Patient satisfaction score

Which of the following is the best measurement of quality of a ccardiologist?
(1)    The doctor puts heart into his work
(2)    The doctor and his staff have a good rhythm
(3)    The doctor has a good beat
(4)    The doctor knows when chest pain is serious

Which of the following is the best measurement of quality of a pediatrician?
(1)    All appropriate vaccines are administered
(2)    The physician rates very highly on surveys grading compassion and caring
(3)    The practice uses a nurse practitioner available for same day appointments
(4)    The pediatrician knows when a sick child should be hospitalized. 

How can the government and insurance companies use your responses in measuring physician quality?  Is it possible that what truly counts in medicine isn’t that easy to measure?


  1. In your own field, there are measures to evaluate your quality: time to cecum, cecal intubation rate, perforation rate, adenoma detection rate. Peer/chart review applies to any area of medicine; we could even have all doctor's clinics and all ER rooms have video cameras, audited by a peer a random 0.1% of the time.
    Complication rate applies to any procedural specialty. Failure to diagnose, failure to rescue apply to most specialties. A peer would have to make these determinations.
    If we would only get the socialism out of medicine and largely go back to fee-for-service, the market would do a lot of the regulating by itself (believe me, people would shop around, they would talk, word would get out regarding good and bad medical care.)
    I personally am a cynic; I don't believe that the government has any sincere interest in truly measuring medical quality. Just look at state licensing boards -- you practically have to molest patients to lose your license.

    --- the radical libertarian rural surgeon

  2. I agree with some of your points and agree that you are a cynic. As far as the state of medical care today, elections matter. Fee-for-service medicine, my model, has issues related to conflicts of interest and over utilization. How's life in the rural hinterlands?

  3. Regarding fee-for-service and issues of conflicts of interest and over-utilization:

    1. If the patient is truly paying for the medical care -- then frivolous over-utilization is not likely to happen. Do we tend to over-utilize plumbers and electricians? or lawyers? Of course we think long and hard about parting with our money. (Socialism, by contrast, is about spending someone else's money.)
    2. I grant that there is a conflict of interest issue and that no system is perfect (the auto mechanic has the same issue) -- but, isn't honesty the best policy? Wouldn't an honest MD and an honest mechanic come out fine in the end by earning trust, word-of-mouth referrals, and repeat business?
    3. Life out here is cold and windy and there are cows everywhere :) (mild exaggeration.) The ranchers are trying to make business for you.

  4. Pleasse save the fee-for-service bashing. The devil we know is much better than the devil we don't. FFS incentives physicians to WORK! With a shortage of specialists and primary care, we better keep the accelerator pushed down. EVERY payment model has issues and I, for one, would like to know that when I do something, I get paid. Overutilization -- sure, probably but again, we will have to put up with issues in every payment model/scheme. Do we really belive "pay for performance" (whatever the hell that means) will be better?

  5. Not bashing FFS medicine, which is my own model. But, it's flaws need to be highlighted. There is no question that is a clear cause of overutilization which is destructive to the health care system and subjects patients to unnecessary medical care. I agree that every reimbursement model is flawed. The physician community bears some responsibility, in my view, for the current state of affairs. One reason that we are being 'reformed' is because we never reformed ourselves. Do you agree that our profession stood idly by and failed to act proactively thereby letting other forces take over?

  6. I have overutilization because for a year I've had a problem that the doctors check everything else but the suggested tests. You want to talk about how glad I would be to get rid of FFS? If they were graded on did they get the right answer, I'd not have as many complications right now because the original issue was missed. I put in writing each symptom and most of them are ignored.