9486 in the collection  

Is Quality Improvement Improving Quality? A View from the Doctor's Office





Checking on the accuracy of the information being used against us is a full-time job. . . .
Do we really want doctors who are motivated by wall plaques announcing their score on some "quality improvement" initiative? Will our enthusiasm for getting high grades, being declared superior to our colleagues, and earning performance bonuses overcome our profession's traditional capacity for critical thought and reliance on empirical data?




Do we want teachers in this same competitive rat race? And, as Vonnegut shows, it gets worse.

A psychiatrist addresses the issue here.

Richard Rothstein cites what happened in the Soviet economy when State industrial planners established targets for enterprise production, and punished managers who failed to meet them. There were targets, for example, for the number of shoes to be produced. Factories responded by producing only small shoes.


by Mark Vonnegut, M.D.

During the time I have been practicing medicine, the dominant ethos seems to have changed. We have gone from doing the right thing for the patient no matter what to doing the right thing for the patient as long as it doesn't hurt our hospital or practice or the insurance company too much.

Years ago, I started receiving report cards from insurers that told me how I was doing relative to other practitioners in terms of hospital utilization, medications, referrals to specialists, and other cost measures. My numbers were usually good, and I could pat myself on the back for practicing cost-effective medicine and saving someone somewhere thousands of dollars. These were strictly educational efforts, without any rewards or penalties. My job was to do the right thing for my patients no matter what, and the insurer was not presuming to tell me how to do it. The fact is that my patients were mostly healthy children who didn't need much medical care.

Now these educational efforts have grown teeth. If I don't meet certain goals, the insurer can and does withhold a dollar or two per patient per month, depending on the metric I have failed to meet. Since there are so many of these programs, we can easily be talking about many thousands of dollars. Bear in mind that while we are dealing with these reports and trying to figure out how to do better, we have to keep taking care of the patients coming through the door.

Having teeth means these programs come down as edicts; they may or may not have a scientific basis or be applicable to our practice or population, but we must either go along with them or go out of business. We've been marked down for not having an asthma plan for someone who no longer has asthma or for patients' not having had appointments, immunizations, or tests that they have in fact had. Checking on the accuracy of the information being used against us is a full-time job. If a patient gets a prescription from a specialist for a nongeneric drug, it often counts against the primary care provider. If I don't use the electronic-prescribing program because it fails frequently, especially after 5 p.m., I don't meet my electronic-prescribing goals and stand to lose dollars I can ill afford to lose.

Beyond complaining about details, however, we should be thinking about the effects these programs will have on medical care as a whole. Do we really want doctors who are motivated by wall plaques announcing their score on some "quality improvement" initiative? Will our enthusiasm for getting high grades, being declared superior to our colleagues, and earning performance bonuses overcome our profession's traditional capacity for critical thought and reliance on empirical data? The reality is that whatever time I spend managing my care plans for patients with asthma or attention deficit–hyperactivity disorder or obesity and other quality-improvement initiatives is time I'm not spending taking care of my patients. At this point, the notion that any of these programs actually improves the quality of care is speculative and debatable.

With the health-maintenance-organization (HMO) model of health care delivery, it quickly became clear that it was advantageous to take care of people who didn't need much care. Avoiding unemployed and poor people was generally a good idea, because they tend to have more problems. There was a great deal of talk about preventive care, but what really happened, as far as I could see, was that successful HMOs were able to siphon off billions of dollars and become the corporations they are today by taking care of young, healthy, employed, middle-class people. Switching to HMOs became a way of protecting employers and their employees from the cost of taking care of the less-well — and the less-well-off — patients whose ever-increasing health care costs then had to be borne by a diminished pool of insurance purchasers. In a similar way, by excluding large categories of care and people with preexisting conditions, managed care made enormous profits, not a dime of which was ever returned to patients in the form of reduced premiums.

I can't help suspecting that underneath all these quality-improvement and pay-for-performance initiatives lies yet another scheme that will work out very well for insurers and very badly for providers and patients. The tens of thousands of dollars I'm going to lose out on for failing to achieve my electronic-prescribing or obesity-management goals has certainly caught my attention, but it's not the big prize. The big prize will come from creating a multitude of grading systems that rate doctors against one another, making them increasingly dependent on quality-improvement goals and payments while distracting them from patient care and making reimbursement more complicated than ever. Overhead will go through the roof. My practice already needs a full-time nurse and receptionist dedicated exclusively to quality-improvement initiatives. The incentives for getting rid of sick and poor patients will be stronger than ever. During the past 25 years, I have stayed current and eagerly sought out and adopted every new advance that could possibly help me to help my patients, but from where I sit, these programs seem to have everything to do with money and power and next to nothing to do with improving care.

Meanwhile, U.S. doctors today have less and less to say about the care of their patients. All the complex lessons they learned in medical school are being swept aside for template care. Maybe I overestimate the next generation, but I can't imagine that young, creative people who are bright and talented enough to get into medical school will put up with this nonsense for very long. They aren't becoming physicians so they can fill in checklists and be told by a phone-bank operator what they can and cannot do for patients.

The way things are going, I fear that soon, because there is no code or template for it, I'll have to stop being curious about my patients. Open-ended questions and waiting for patients to tell me what's on their mind will have to go. No one will die, but I, for one, will be a little lonelier. And if these so-called quality-improvement programs turn out to be elaborate cost-shifting schemes, many sick people will be deprived of medical care, and the overall costs for all of us will go up.

At a minimum, we should be working harder to determine whether these programs really will improve care before adopting what is a very radical and far-reaching change in the way medical care evolves and is delivered. If we adopt a multitude of quality measures that have not been validated, we are very likely to end up with more quality problems than we started with. We all went to medical school — if all else fails, we could try science.


Dr. Vonnegut is a pediatrician in Quincy, MA.

— Dr. Mark Vonnegut
New England Journal of Medicine
2007-12-


---

INDEX OF OUTRAGES

Pages: 380   
[1] 2 3 4 5 6  Next >>    Last >>