The Quality of Force by Pat Conrad MD


The 6/1/14 issue of Family Practice News had an innocuous article in the the practice economics section: “Readmissions dropped by 8% from 2011 to 2012.” The author states that the “real dent in hospital readmission rate [was] according to government data.”

– 30-day all-cause Medicare readmissions were 17.5% in 2013, vice 18.5% in 2012, as released by the Agency for Healthcare Research & Quality.

If I haven’t put you to sleep yet, congratulations, because here is where it gets funny:

“Federal officials credited the Affordable Care Act with providing the tools hospitals needed to make improvements, including one that ties hospital payments to reductions in readmission rates.” Translation: our government masters decided not to pay for any additional work done, implying a presumption that the job was not done properly the first time. I had my house painted last spring by, as it turned out, a lousy con man who did a poor quality, incomplete job. And no, I didn’t pay him the balance owed until he actually finished the work, so I understand the concept. But every non-government physician knows that a comprehensively addressed, perfectly treated, good-outcome elderly patient admission can be undone a week later by a fall or a UTI that had noting whatsoever to do with the previous ailment.

Starting this October “The Medicare Readmissions Reduction Program…imposes payment penalties that will rise to 3% and will be based on readmissions for acute myocardial infarction, heart failure, pneumonia, COPD, and hip/knee arthroplasty.” Because no cardiac patient with COPD is ever at risk for a DVT or pneumonia following a knee replacement.

HHS claims that hospital-acquired conditions decreased 9% from 2010 – 2012, resulting in 15,000 fewer deaths and $3.2 billion saved. Cynics like yours truly will suspect that a lot of these now forbidden complications were simply not reported or hidden within other diagnoses, and that these savings are more extrapolated myth than fact.

Dr. Patrick Conway, the chief medical officer and director for Center for Clinical Standards and Quality at CMS – whew – “credited hospitalists for their role in achieving “dramatic progress.””

“We’ve removed almost half of the measures that were in hospital value-based purchasing …because the performance has increased so much.” But what has that “performance” really been? It means that hospitals and their physicians have treated their patients not necessarily according to their best judgment, but in keeping with CMS dictates. I’m sure Dr. Conway is a very nice gentleman in his private life, and I could not care less – in public he is a government drone, taxpayer-fed, without ever having to see patients, fill out damn codes and modifiers, or risk lawsuit and burnout. His job, competently done, is to spout unproven gibberish about quality and savings as compliments, when these are merely justifications to refuse payment to those who do the work.

What Dr. Conway and his overlord parasites cannot, and will never admit is that their “Readmissions Reduction Program” is force applied by those who don’t treat patients, against those who do. It is a scam whose only achievement has been to alter the way doctors and hospitals try to game the system to survive.

If this were as simple as house painting and the pay scales similar, then I’d probably opt for the fresh air and more provable quality measures.


Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  1 comment for “The Quality of Force by Pat Conrad MD

  1. August 4, 2014 at 8:44 am

    The thundering herd ‘reforming’ healthcare is busy drawing guidelines, standards, and operating procedures. One of the areas that they seem particularly uninformed about is the management of risk and the concept of liability.
    Unwanted things happen in the real world, and it is society’s duty to consider how to minimize the threats of unwanted occurrences. Readmission to hospitals due to inpatient caregiver or hospital error or deficiency is a reasonable goal.
    But back a dozen years or so, the Thinkers decided to identify patient Adverse Events (PAE) with error, harm and malpractice. There is a reason these things have different titles and names, and no, it’s not to allow physicians to slip by with shoddy care.
    In the legal sense, lumping these things together is to categorize hospitalization as something for which the participants have strict liability for performance. Strict liability means that the performer is responsible for outcome regardless of an assertion of error.
    Now, there is nothing wrong with strict liability, or any other sort of liability definition. But in the real world, strict liability costs money; it is a warranty of service. It’s one thing when one warranties a manufactured product; another is when one does so for a human being.
    If one wishes to warranty against rehospitalization for urinary tract infection, for instance, all patients should go out on a good antibiotic cocktail that lasts about 30 days or so. That is a reasonable way of reducing the risk of failure, notwithstanding its risk to the patient. Rehospitalization for Stevens-Johnson Syndrome is not covered on the warranty – UTI’s are, although the relative risk is worse for SJS.
    30-day risk-bearing is merely 30-day insurance issued by the hospital and doctors, with no cap on liability for payout. One can talk about “being accountable” and that – but it is risk underwriting, no less.
    We could pass a law to mandate that all US automobiles remain accident-free for 30 days after they are purchased new – that only seems fair. And the manufacturers would hustle to make sure that there are no potentially lethal defects – which they already do. But if they have to pay out when some idiot t-boned you at a red light – it’s going to cost them. And the consumer.
    There’s no way out of this game, except for the holder of strict liability to leave the dance.

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