Quality measures began as tools to quantify the healthcare
process, using outcomes, patient perceptions, and organizational structures associated
with the provision of high-quality health care. Overall, the goals should focus
on delivery of care that is effective, safe, efficient, and equitable. Did you notice a particular word
missing? Yes, I missed the word physician
too, because they have been left out of the conversation entirely.
Measuring quality healthcare by a patient lab result
is like recording a patient’s temperature by waving the thermometer near their
face. One has little to do with the
other except for the slight appearance of connection. Quality must be measured by physician outcomes and not those of
patients. For instance, our county does
not have fluorinated water. Measuring
the percentage of children that have cavities is a patient outcome and not an accurate reflection of medical care
provided. A physician outcome would be calculating the percentage of children
who received a prescription for supplemental fluoride during their office
visit.
If the intended goal is to reduce unnecessary ER
visits, then we must determine the root cause.
Patients with private insurance rarely go to the ER for non-emergencies
because they pay a large out-of-pocket cost.
Those on Medicare or Medicaid visit the ER for free. There is no disincentive to visiting the ER, but
there needs to be. In addition, it makes
no sense to penalize me for an unnecessary ER visit if I have not seen and
evaluated the patient in my office. The
common sense solution is to figure out how many patients seen in my office were
then seen in the ER within 24 hours.
That may be a quality indicator.
Asthma and diabetes are two chronic conditions with
large costs to the healthcare system. Compiling
statistics about the number of patients who are not well controlled on daily
medications is a patient outcome. How about looking at whether or not patients
who presented with these conditions were prescribed the proper maintenance
medications in a timely fashion? How
about checking whether we emphasized the importance of daily use of these
chronic medications in our clinical note?
Those are physician outcomes and
could be used to determine quality. Why are we allowing patient outcomes, for
which they alone bear responsibility, to burden us as physicians?
How about paying me for the time spent completing oral
rehydration for a moderately dehydrated child in my office? It takes a few hours to orally rehydrate an
infant or small child properly. In my
humble opinion, it is time well spent and avoids an ER visit. I bill for extended time, but am rarely
paid. It is one of the most satisfying
things I do, no parent has required more than one session in my office to be
successfully taught this skill to use at home with successive children. Return on investment for those three hours is
unbelievable and pays dividends for years; a parent will almost never need to
go to the ER for dehydration again. How
about a metric covering the amount of money saved by patients, insurance, and
the government once a pediatrician has taught this essential skill to a family?
My fifth suggestion would be to look at the
percentage of children under 5 years of age seen for well child visits annually,
rather than viewing value from percentage of children up-to-date on
immunizations? In states, like
Washington, there are vaccine exemptions for every reason under the sun. That metric penalizes a physician for a patient outcome, of which they
have no control? A physician outcome would be documenting
the recommendation for immunizations during a well visit by the primary care
physician.
A metric tracking exceptional physical exam skill is
another worthy physician virtue. For instance, how frequently does a
pediatrician diagnose rare congenital conditions when evaluating a new patient? Top notch physical exam skills are essential and
it this metric would preferentially favor experienced physicians who pay close
attention to detail. In 15 years, my list includes a half dozen boys with undiagnosed
undescended testicles, two children with
choanal atresia requiring surgical intervention, 4 with chromosomal deletion
syndromes, and my “holy grail”, an undiagnosed aortic coarctation (narrowing of
the main vessel supplying blood to the body) suspected based on physical exam
alone.
My idea of “value” is best illustrated by sharing my
coarctation story. A boy came into my
office for a well child visit. He had
some behavioral issues, had seen multiple pediatricians over the years due to
frequent moves, and brought scant records with him. He was restless and it was difficult to
palpate femoral pulses, but I do this on each and every child at their yearly
physical. Despite my persistence, I was unable
to palpate them successfully. A quick glance
at his slightly elevated blood pressure, 128/90, made me pay closer attention. I repeated it myself with a similar
result.
I discussed my concerns with the family, referred
him to a cardiologist, and called to discuss the case with the specialist. Doubtful, the cardiologist told me she would let
me know what she thought after evaluation.
Indeed, my diagnosis was spot-on! He underwent surgical correction for
his congenital anomaly, (like the others who have transferred in to my practice)
and it was a success. He became quite
the star athlete in high school and is entering college this fall.
Value can be defined as both a noun and a verb. The former denotes having importance, worth, or usefulness. Experienced
physicians have stories exactly like the one above; because our care provides
tremendous value to the patients we serve.
Business people in healthcare prefer to use value as a verb because it signifies having
a monetary gain attached. Government and
insurance companies should stop wasting dollars and cents chasing visions of value,
rather use common sense and give physician
outcomes the attention they deserve. Healthcare will be on better footing now and
into the future.
No comments:
Post a Comment