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The sound of the whistle is getting louder.

The locomotive of change in healthcare is barreling down the tracks toward us.  We all feel helpless, unable to get off the tracks before it runs us over.  Change has been unkind over the past few decades – alienating doctors and patients from each other and turning a relationship that relies on trust into one full of suspicion.

Doctors want to be able to practice medicine without the hassle, and patients want good care from doctors.  Why can’t change get us back to this?  With healthcare being the mess it is today, why is change still so scary to nearly everyone?

The question of Quality

The problem that most consumers of healthcare face is that they don’t know who to trust.  What constitutes high-quality healthcare?  This question is also reverberating through the medical community as more “Pay for Performance” programs are adopted – linking physician pay with quality measures.  What quality measures?  Who makes them?

Clearly healthcare is broken; both patients and physicians are dissatisfied with the way that our system pays for healthcare.  Our system is perfectly designed to make doctors do the following:

• Do more procedures (needed or not).
• Spend less time with patients – Paid on a “per visit” basis, doctors make more by seeing more.
• Disregard coordination of care – Time spent communicating with colleagues decreases pay for both physicians.
• Ignore “best practices” – Quality takes time.  Bad doctors are paid more than good ones.
• Not worry about the cost of care – Threat of lawsuits and patient expectations often drive physicians to order more tests than necessary and use  medications seen on TV.  It costs docs nothing to over-spend.

The care we desire is not at all like the care we pay for.  This makes changes in the payment system not only financially important, but tied directly to the quality of care.  “You get what you pay for,” and we are paying for quantity and ignoring quality.

But to pay more for quality, it is essential to be able to first define quality.  There are many stories of misguided guidelines that were supposed to increase quality, but ended up hurting patients (a good example was given by ER physician White Coat).  So how can quality be encouraged without causing these problems?

Angry Patients

Patients bear the brunt of the problems in healthcare, because healthcare is about them.  Bad doctors are better off than their patients.  Hurried doctors are frustrated, but their patients may be harmed.  A full waiting room is a good thing for a doctor but a bad thing for a patient.  This has caused a great deal of anger – much of it directed towards doctors.

Another problem patients face is that they don’t know what good care looks like.  How do you choose a doctor?  How do you know you are getting the best care for your problems?  A lot of people have the same mistrust of healthcare providers that they do with auto mechanics (but with mechanics, at least you know how much they are charging you).  Medicine, on the other hand, has always been a black box for patients – both in quality and cost.  Care is given and billed for, and patients have no idea if they have gotten their money’s worth.

Recently there have been huge changes in the behavior of patients; they double-check doctors on the Internet and openly question care given (”doctor, won’t that drug destroy my liver?”).  This mistrust has caused alternative medicine to flourish and has spawned multiple doctor-rating sites on the Web.  Physicians can complain about all of this, but the reality is that patients are very dissatisfied with the care they are getting and are starting to do something about it.

Foxes guarding Chickens

Seeing the dissatisfaction of patients, the insurance industry has begun to rate physicians.  They use the data they get from money they pay out to various parties to make judgments on the quality of care given.  How many mammograms is a physician ordering?  What percent of drugs prescribed are generic?  What are immunization rates, percent of diabetics getting the proper care, and number of elderly people getting flu shots?  All of these can be inferred from the claims data.

They have used this data to send “report cards” on quality and to rate physicians on their websites.  They have also been the first to go after “pay for performance” – programs that depend on the measurement of quality to determine who deserves the bonus and who doesn’t.  But there are huge problems with the insurance companies’ serving as the ones who measure and reward quality:

1. Their data is inaccurate.  I checked the accuracy of an insurance company report card against the clinical data on my EMR.  50% of the deficiencies they reported were wrong.  I subsequently sent them back a report card on their report card, chiding them for the poor quality of their work.  They never answered.
2. Their self-interest is obvious.  The main goal of a publicly-held insurance company is to maximize their profits.  To let them determine which physicians will get extra payment is like having a fox guard the chicken coop.  They are far better served to judge quality as low and not give bonuses than they are to send lots of bonus checks.  I tried to find out the data behind one P4P bonus I got (which I thought was suspiciously low) and the insurer was “unable” to supply me with the information.

No Alternative

While physicians rail against the dangers measuring quality and rating physicians, most don’t give an alternative.  The current system is untenable and unfair to those who try to practice quality medicine.  We have no alternative but to change it, and encouraging the value of care (high quality at lower cost) needs to be the goal of any system.

Given this fact, I accept the fact that I will be graded.  My quality has to be measured for the system to at all change.  I am frustrated with being penalized for doing what’s right, and so see the need for my care to be measured in some way.  It will happen; it’s only a question of who will grade and on what basis.

What is Needed

Here are the questions that must be addressed to have any hope for real success:

1. Whose Data?  Claims data is inaccurate and owned by those with too great a self-interest.  The data used needs to be taken directly from clinical care, and not from how it is billed.  But self-reporting by doctors is equally flawed, as they will do so in a way that maximizes their own benefit.
2. What Data?  What are good measurements of quality?  There are some clear guidelines that most physicians agree on, but the issue of patient compliance always comes up.  Is ordering a mammogram the measure, or is it if the patient actually gets one done?  What about quality of service (which patients want to see)?
3. Who makes the call?  Insurance companies, doctors, and patients all have their self-interest, so none should run the show and none should be excluded.  Doctors have to be confident that correct data is used, while insurers need to have some control over what they pay out.  Patients will be inherently (and justifiably) suspicious of any system that excludes them.
4. How is it reported?  Measurement is worthless if the data is ignored.  All parties need to see the numbers.  Some doctors would rather the data be kept hidden.  By definition, half of all physicians are below average.

Given these factors, this is what I see as necessary components of any rating or pay-for-performance system:

• Clinical data (not claims data) needs to be collected.  EMR adoption should focus on this.
• Data should be gathered and analyzed in a way that minimizes the self-interest of the various parties involved.
• Quality needs to be defined and agreed-upon.  The comparative studies by the government should help, but physician involvement (as I said in my last post) needs to be high in the process of determining the definition of quality.
• Measurement should take patient compliance into account, rewarding physicians for ordering tests or prescribing medications.  Ideally, patients would somehow be motivated by the system to be more compliant (as is the case in some P4P programs).
• Quality of service is important as well.
• Reports of quality need to be accessible to all parties.

The devil, of course, is always in the details.  But change seems inevitable, and the only way that this change will have a chance of improving things is if these things are taken into account.  Do we really want to wait for a government mandate?  Do we really want to depend on politicians to tell us how to practice medicine?  Either we become part of the solution, or we live with what is handed to us.

The basic transaction of healthcare is simple: doctor cares for patient and patient pays doctor for that care.  Both doctors and patients have huge motivation to make sure this transaction happens as fairly as possible.  We need to be the engine behind change in healthcare, not the woman tied to the tracks.

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