Quality Metrics and Hb A1C

This NY Times articles clearly points out, without knowing it, the problem with grading doctors on bogus metrics.  I have been pounding my chest about this issue on this blog for years.  It is unethical to pay a doctor on the lab test results of his or her patients. The article in questions describes the dilemma of using drugs to treat diabetes.  The issue is that “it’s becoming clear, researchers say, that there’s far too little evidence on how diabetes drugs affect the heart to make rational evidence-based judgments.”  But evidence be damned when you allow doctors to be paid on the Hb A1C levels. And the article inadvertently shows the results of this:

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  • While this measurement is a good predictor of risk, “the question is, who benefits from intensive blood sugar lowering and which drugs are best for whom?” said Dr. Harlan Krumholz, a cardiologist at Yale.
  • The target level varies among patients, though many do not realize it. They and their doctors often aim, at times obsessively, for an A1C level of seven.
  • None of that has stopped doctors from urging patients to lower blood sugar at all costs. But many of their patients, particularly older ones, often take other medications, too.
  • “They were always upping the dosage of drugs, wanting to get to seven” he said. “One doctor was very adamant and very demanding. He told me if I didn’t do what he said, I would not be here much longer.”

Who benefits? Obsessively aiming for an A1C of 7? Urging patients to lower blood sugar at all costs? Adamant? Demanding?

This is what you get with “pay-for-performance”.  It needs to be abolished.

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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] 

  10 comments for “Quality Metrics and Hb A1C

  1. Randy
    June 7, 2017 at 10:24 pm

    This is a pet peeve of mine as well, especially since it’s become increasingly clear an A1C of 7 is not appropriate for many patients. Part of the trouble is the government can only grade you on things that are measurable. This means that things that are measurable take on an oversized importance and things that are not measurable are relatively ignored.

    Of course any physician that has been around for any length of time knows there is a lot we do that isn’t easily measurable. There is no way to measure my taking a couple of extra minutes to talk to a patient about a dying parent, or slow things down examining a little kid so they won’t be scared. The government doesn’t care much about those things since they can’t track them, so over time they receive less emphasis from physicians not because they are any less important, but because they can’t be measured.

    Add to this that the standards used by the government often lag current medical recommendations as in the case of A1C’s, and “quality measures” not only won’t improve medicine but actively harm it.

    • RSW
      June 7, 2017 at 10:36 pm

      Why harp on “the government” exclusively? CMS is just starting to copy what the private insurers and Medicare Advantage plans have been doing for years.

      • Randy
        June 7, 2017 at 11:10 pm

        I’ve been solo around 15 years. CMS is and has been by far the main player in this in my practice. I have not felt similar pressures from private insurers.

    • Pat
      June 7, 2017 at 11:22 pm

      Which is why blood alcohol levels are an awful, arbitrary way of determining impairment. Ours is a moron society, making rules to comfort and assuage the dumbest, laziest, and most brutal. “Idiocracy” came true, and I have contempt for our present, despair for our future.

  2. Pat
    June 7, 2017 at 12:34 pm

    And don’t forget, every one of these “quality” targets can be used to skewer doctors in malpractice cases.

  3. June 7, 2017 at 8:32 am

    Wouldn’t it make more sense to pay for fewest episodes of hypoglycemia? I mean, if you were truly looking for quality of care (and not killing people). It’s all a bunch of horse shit. You can’t grade individual doctors based on population health.

    • Perry
      June 7, 2017 at 10:23 am

      You’re right but they’re going to forge ahead and do it anyway.

      • RSW
        June 7, 2017 at 1:32 pm

        And the morons at the AAFP think it’s wonderful.

  4. Steve O'
    June 7, 2017 at 7:50 am

    My helpful little EMR “reminds” the doctor to start a medication for SBP >140 or DBP >90 on a single reading. None of this “come back and let’s recheck it!” Write the prescription for an antihypertensive. If you don’t “treat hypertension” right away on the “first diagnosis,” you lose quality points. If the patient is on warfarin and hits the deck with syncope, oh well, the EMR doesn’t care. Just put in the right ICD-10 code for intracranial bleed. Why is this sounding more and more like an eight-bit video game? Hit the power-ups!
    And, thank God, we are soon to be rid of ICD-10! Before you start the party, note that ICD-11 is due out this year and there is a beta version on-line.

    • Theresa
      June 8, 2017 at 12:36 am

      It’s ridiculous! So many of my patients have elevated blood pressures in the office that are not replicated at home. Stupid EMR has no way for me to “capture” this as “structured data.” (I hate that these tech terms are now more commonly spoken and heard than “first do no harm.”)

      So let these insane system judge me as an inadequate doctor for leaving my nervous nellies alone and documenting their called in home blood pressures in my addendums.

      My theory is that the last decade of my professional life has all been about being judged by entities who don’t understand a flying you know what about the practice of medicine. It’s infuriating.

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