Wherefore Art Thou Quality?

Author: Michael Wasserman MD

Originally published: Tuesday, March 3, 2015

Sylvia Burwell, Secretary of Health and Human Services, recently wrote an article in the New England Journal of Medicine about how Medicare is moving toward a “value-based” payment system. This is meant to improve health care in the United States. It sounds like a wonderful concept. The Secretary is certainly to be commended for working toward improving the quality of care provided to our nation’s seniors. Who wouldn’t want greater value in their health care? Who doesn’t want improved quality?

Unfortunately, that isn’t the important question, as the answer to that question is obvious. The real question is, “What is quality?” The problem in trying to answer that question isn’t just how we measure quality but how we define it.

A recent New York Times article brought up a similar question by addressing the concept of reducing patient suffering. How do we measure the physician’s ability to connect with a patient on a level that allows the doctor to determine what is important to that patient?

Any parent of a teenager has heard the refrain that life isn’t worth living when something didn’t go right that day at school. Quality exists along a continuum that is constantly changing. Most people would agree that being completely demented and bedbound without the ability to move at will constitutes a poor quality of life. The family of a patient with early-onset Alzheimer’s disease will complain about quality-of-life changes, and they don’t think that they can tolerate any further decline. However, a few years later, when the disease has entered its moderate or severe stage, starting a new medication that helps a mom remember her daughter’s name can feel like a godsend to that family.

Secretary Burwell makes it sound like transformative changes are right around the corner, saying that by 2016, 85% of all Medicare fee-for-service payments will be “tied to” quality or value. While the Centers for Medicare & Medicaid Services (CMS) are to be commended for their focus on quality, this is just a beginning, and we have only started to open Pandora’s box.

From Medicare’s perspective, quality means that a physician’s office is required to code a “quality measure” when they submit a bill, regardless of how or whether the measure truly influences health care quality. Of course, physicians will “comply” with these requirements in order to get paid. Thus, CMS can boast that that by 2018, more than 90% of all fee-for-service payments will be tied to “quality measures.”

Let’s discuss the types of quality measures that we are talking about. If a doctor’s office offers a patient over age 65 a pneumococcal vaccine, makes sure that they list all of their medications, and documents that the patient have an advance directive, that confers the status of having worked toward achieving “quality” measure reporting. In the meantime, are doctors actually asking their patients about their quality of life? Are they reviewing all of their medications and determining whether the side effects are worth the benefit?

Documentation of current medications in the medical record is a quality measure. However, it requires only that a patient’s medications all be documented in the medical record. While this is a good start, it is doubtful that this confers significant improvement in the delivery of care to that patient. Perhaps in the future, this measure will require that the potential risks and side effects of each medication be evaluated and monitored. On the other hand, use of high-risk medications in the elderly seems to be a pertinent measure, but only if that measure is actually used. Herein lies the rub. Most medical practices will choose the measures most easily documented and coded, not the ones that will have the greatest impact on the delivery of care to their patients.

Many years ago, an 88-year-old patient of mine was getting weaker and weaker, because his urologist was “treating” his prostate cancer with expensive hormonally castrating medications. The urologist was happy, because my patient’s prostate-specific antigen (PSA) count was zero. The medications were successfully killing the prostate cancer, but they were making my patient’s life miserable. After discussing what was important to the patient, we decided to stop this treatment. He is still alive, active, and functional today at the age of 96. His PSA consistently runs around 15. Quality is not based only on a physician checking off a box in his office or a number on a lab report; it also requires the ability to interact with patients in order to determine what is important to each patient.

The ultimate rub with any program like this is how it operates. Many stakeholders continue to espouse the belief that electronic health records are somehow the solution to all our problems. A wise computer programmer once told me that computers are dumb as posts and only as good as the people who program them. Technology can assist us, but it won’t care for the patients. Patients already complain about doctors who look only at the computer screen and don’t make eye contact with them. Requiring physicians to run down a list of checkboxes in order to get paid and somehow inferring that this will direct them to deliver the best care is naive.

The list of quality measures certainly focuses on a number of important areas and encourages physicians to focus on issues that they might otherwise ignore. This is good. But it doesn’t help them achieve the ability to communicate well with their patients or develop the type of interpersonal relationship that can lead to frank discussions regarding what truly is quality to each individual. Perhaps we will make the most progress when we adjust our focus from trying to measure quality to training physicians on how to connect with and talk to their patients about it.