The Idiots Start To Awaken But Do Nothing

dwsr

I found this article called Doctors doubt quality metrics improve quality of care in a journal called Family Practice News.  The title immediately makes me cringe because I have been screaming about this crap coming for at least ten years.  Let me pick apart this article for you so you can understand how docs just don’t get it:

  • Quality measures may be essential to creating health care systems focused on value over volume, but physicians aren’t convinced that current quality metrics are improving outcomes. (Who said they are essential?  No one.)
  • In addition, “physicians’ views tilt negative on the effect ACOs [accountable care organizations] have had on the quality of care, and many are still not sure of their effect,” according to a report by the Commonwealth Fund and the Kaiser Family Foundation. (Of course they tilt negative.  ACOs are bogus and so it the quality trend.).
  • Overall, clinicians “were more negative about the use of quality metrics to assess their performance, even those providers who receive incentive payments based on quality,” according to the report. In addition, recent health care trends are causing nearly half of physicians (47%) to consider early retirement. (Half of docs want to quit yet somehow this new model continues?)
  • Half of all surveyed physicians responded negatively when asked if they thought “the increased use of quality metrics to assess provider performance is having a positive, negative, or no impact on primary care providers’ ability to provide quality care to their patients.” (The number is staggering but I have to say, who is in the other half?  They deserve what they get and rest assured, they will get it).
  • “I am not surprised by these data,” said Dr. William Golden, professor of medicine and public health at the University of Arkansas for Medical Sciences, Little Rock.“The implementation of quality measurements and performance incentives has often been awkward and ineffective,” added Dr. Golden, who also serves as medical director for Arkansas Medicaid. “Too many incentives use burdensome, unreliable metrics with clumsy rewards. The current situation reflects poor program design and not the failure of quality measurement as a concept.” (Burdensome Unreliable metrics with clumsy rewards. Poor program design.  That about sums it up.  But “not the failure of quality measurements as a concept”?  Looks like Dr. Golden is the king of the idiots!)

So this trend will continue because people like Dr. Golden believe in it even though once again, it is unproven.  Unproven!!!  How much money, how much time, how much anger and how many more doctors need to retire before we ditch this quality crap and move on to a better plan?

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] 

  4 comments for “The Idiots Start To Awaken But Do Nothing

  1. julie fagan
    October 7, 2015 at 3:27 pm

    I feel like a lost voice in the wilderness where I practice (Wisconsin). It’s not PC to be opposed to “improving quality.” The first commenter is right on, and if nothing else, we are being overwhelmed with various report cards, which are used to adjust our salaries (mostly downward. I would like to see hard data showing that this endeavor pays off in some meaningful way.

    I am among the early retirees (61) and these were a contributor, along with the usual EHR hassles, CPOE, ICD-10, etc.

    at our last county medical society meeting, an earnest young woman proudly displayed, in about 30 slides, all the efforts her quality improvement organization had gone to to get providers to measure and report BMI of patients in my state. I raised my hand and asked whether anyone had demonstrated that any improved health outcomes would flow from that. She was speechless…

  2. BethK
    October 7, 2015 at 9:43 am

    Having been a quality assurance professional in an entirely different field, I would say that the problem is not simply “quality assurance”, but its design and implementation. If you’re studying quality metrics, you’ve first got to decide what is the issue you are trying to maximize or minimize. In manufacturing or computer science, those are simple to define. You want more products with fewer defects manufactured with less cost. In healthcare, the goal is not as simple to define. Are we going for cost, life expectancy, less serious illness (gauged HOW?), medical visits? THEN decide how you are going to measure it in some meaningful way. If the item measured is not a significant measure of whatever outcome you’re looking for, you need to change what you are measuring, or perhaps go back and better define just what it is you are trying to maximize or minimize.

    Quality measures can never be implemented by telling people to “be more careful”. That just doesn’t work. Most people are doing the best they can. Blaming “noncompliant” patients is useless: It’s the method of delivery, the product itself, the ease or difficulty to use, cost, ease of obtaining everything needed to comply, and so forth. The same is true if you blame “lazy” or “inefficient” clinicians. Sure, you can assign more patients to each clinician, and sure, this is something you can measure, and sure you can measure how many of those patients have had certain lab tests, and how many are given treatment for some oddity in a lab test. This does not tell you ANYTHING. It is a waste of time and resources, although the people keeping track of this data would surely beg to differ.

    For instance, with the difficulties in obtaining lab tests or medications mentioned in the article, the problem with a patient not being compliant with these is not the medical issues, nor is it apathy on the part of the patient. The process is too difficult to comply with, especially for someone who may be debilitated and dependent upon others to get to the labs, follow up, and properly order the medications using this week’s protocol. True quality assurance would identify that problem, and would then change the process so it could be adhered to more easily.

    Unintended consequences are another metric. As an extreme example, it does very little good to detect and treat a condition which may not cause problems for decades and give a treatment with a high rate of immediate and serious side effects.

    The most important issue to patients is often in terms of quality of life. That is very subjective, and what you might consider to improve quality of life another person might perceive as diminishing it. The real job of the physician is to find out what the person considers to be beneficial or detrimental to their quality of life, and act accordingly. Yet, this will be considered “BAD” in healthcare quality metrics, in many or most cases. Ask your grandmother the qualities of “the best doctor” she has ever had, and she will talk about these subjective issues, which, by their nature, are not quantifiable.

    They’re using the wrong tools, misapplying the results, measuring them again, doing something to try to “fix” it that only makes the problem worse, then patting themselves on the back while increasing costs and diminishing outcomes.

    • Alan Levine
      October 7, 2015 at 9:51 am

      Wow, somebody who really gets it!!

  3. Steve O'
    October 6, 2015 at 7:55 am

    One of the central rules of evolution is that you get what you select for. Animals and plants respond to survival pressures to fit into a niche.
    When one constructs a dense network of arbitrary rules, people study the rules to maximize their reward. That, in a nutshell, describes the Federal Tax Code. The IRS doesn’t care if you pay a million or pay nothing, as long as it’s according to “the rules.”
    If rules bias the playing field – which they are guaranteed to do – the behavior of the players becomes distorted in response to the pressure of the rules. It’s a bit like playing “fetch the stick” with the dog, and then yelling at the dog for fetching the stick.
    I am seeing a lack of change in chronic illnesses. There is little pressure to improve the global outcomes; instead, a jumble of rules are tossed at the problem and whatever echoes back is scrutinized as measurable in terms of quality. One sign of mediocrity and inexperience is blaming the patient for whatever doesn’t work – and the charts are full of buck-passing allegations of ‘noncompliance’ assertions, rather than efforts to solve the problem.
    My patient who died of hepatoma a month ago, did so without a flu shot. I was dinged for that. Anyone with neurons in speaking distance from one another, gets that a dying patient with the ‘flu is probably to get an “early release” from misery. Not according to the rules!

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