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POLICY/PHYSICIANS: Full disclosure, well not really

There’s been a lot of debate about transparency on THCB. I believe in as full disclosure as possible about all kinds of medical data, including pay rates, utilization rates, quality indicators, etc, etc. But I also count myself among the enlightened few who realize that the individual piece-rate service level is not the place at which consumers are best qualified to make comparison judgments about the value of their care. I liken it to the computer purchaser at a corporation—sure you want to know the individual prices of the computers you buy, but what’s really important is the total cost of ownership divided by the benefit you get from them. Or take a motoring analogy, as Glen Tullman CEO of Allscripts does over at HHN on a different topic—you want to know the total cost per year for purchase, insurance, gas, repair, etc, etc for your car. You don’t care in great detail how much your mechanic charges you for an individual spark plug so that you can go to Pep boys and buy one cheaper. Instead you want to know the rough overall cost between a Yugo versus a Camry versus a Jaguar, and then within each class. That’s what the managed competition model is trying to get to.

Of course transparency does help. Joe Paduda is right when he finds the Administration’s position on not releasing Medicare physician data is too, say the least, a little odd. Unlike most of their information releases these days, this one is apparently legal and makes sense for the nation. Although I understand why the Business Roundtable is for it and equally why the AMA is no doubt against it.

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Tom LeithG. Hinson, MDSteve Beller, Ph.DspikeBarry Carol Recent comment authors
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Steve Beller, Ph.D
Guest

Actually, I’d like to see us focus on researching and discovering better ways to teach and motivate patients to comply with valid evidenced-based plans of care, as well as providing better ways to establish, evolve, disseminate, and implement such plans of care. Collaborating practitioner-researcher networks supported by new breeds of outcomes-assessment and decision-support HIT, personlized care practices, and policies creating high-fidelity healthcare systems, I contend, will accomplish this over time. While I agree that process metrics is the best we can do because of the limitations of our current broken healthcare system, I am a firm believer that success should… Read more »

Tom Leith
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Tom Leith

> I have a hard time seeing how performance can be > adequately measured in smaller practices, and I am > solo. I think the focus for internal medicine tends to be on process metrics on the assumption that the doc can’t be responsible for (willful) non-compliance on the patient’s part. Plus, we don’t really want docs to drop non-compliant patients to make their scores go up. If the DM approach works at all, I’d like to see it enabled somehow at the family doc level: like maybe my doc could find out I’m not filling my Rx often enough,… Read more »

Steve Beller, Ph.D
Guest

I accept you criticism and I don’t claim to be an expert on risk-adjustment, but from what I’ve read and seen, it can be a useful, though imperfect tool, like QUALY. There are many books and articles written on the subject, and maybe there’s an expert reading this thread who can respond, but this article seems to be an objective overview of the metric — Use of risk adjustment in setting budgets and measuring performance in primary care II: advantages, disadvantages, and practicalities Following is a slightly adjusted quote about the articles conclusions: • Use of risk adjustment could help… Read more »

G. Hinson, MD
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G. Hinson, MD

“There’s a lot written about “risk-adjustment” methods to help account for differences in patient severity when assessing outcomes.” There’s a lot written about the Big Bang, but we don’t really know what happened. “I assert this can be done affordably by developing low-cost software.” So you’re willing to buy it for us? It doesn’t benefit me to do so, unless you try and punish me for not buying it. Two flippant responses, I know, and I am sorry. But I have a hard time seeing how performance can be adequately measured in smaller practices, and I am solo. If you… Read more »

Steve Beller, Ph.D
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Dr. Hinson said: “How do you judge the quality of care provided when no two doctors take care of the same lot of patients.” There’s a lot written about “risk-adjustment” methods to help account for differences in patient severity when assessing outcomes. Nevertheless, great care should be taken in defining outcome metrics and it should include done via collaboration among all stakeholder groups. While the vast majority of performance measures in use are “process measures” (i.e., was procedure X performed and medication Y prescribed for condition Z), there are a number of outcome measures available, which include evaluate care quality… Read more »

Barry Carol
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Barry Carol

Dr. Hinson, Thanks for that very clear explanation. I fully understand and agree with your position on the malpractice issue. The metrics explanation is also very helpful. Poor or misleading information can be worse than none, and I agree that doctors don’t need any unfunded mandates that would be unduly burdensome in either time or money. I still would like easy access to information about education and credentials as well as pricing transparency information for common well care services, tests and procedures as well as easy access to what my insurer will pay specific providers for specific CPT-4 codes before… Read more »

G. Hinson, MD
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G. Hinson, MD

Barry writes: “I’m not sure I understand what the doctors are afraid of. Is it the measurement metrics that they consider unfair or misleading?” I have not seen a fair metric published. How do you judge the quality of care provided when no two doctors take care of the same lot of patients. I have a young, healthy population of patients, who generally take care of themselves. As such, I have a high number of patients to goal when it comes to their blood pressure, diabetic measures, cholesterol, etc. It would not be fair, however, to compare that to another… Read more »

Steve Beller, Ph.D
Guest

By far, the most important thing, IMO, is a focus on continuous quality improvement (CQI) by providing a mechanism that helps ensure wellness/preventive, catastrophic and end-of-life care is increasingly safer, and more effective, efficient, affordable, timely, and available to everyone. This strategy would involve linking practitioners with researchers (e.g., Practice Partner Research Network) who collaborate and use HIT to perform lab and field outcome studies; establish and evolve evidence based practice guidelines; disseminate and implement the guidelines; and get computerized assistance in making diagnostic and treatment prescription decisions personalized to the particular needs of each patient, as well as managing… Read more »

The Medical Blog Network
Guest

In defense of providers’ perspective. Spike is correct. Publishing historic quality data collected under providers’ expectations that it would stay private might be problematic. Why? Making sure that the metrics are really meaningful for quality to consumers vs. whatever else health plan wanted to measure. As Barry points out, health plan metrics might have more to do with pleasing employers and managing costs than measuring actual quality of care. It is as important to help providers improve rather than go play “gotcha” game. Simply revealing the data that providers expect to stay private is a lot like having Google turn… Read more »

Barry Carol
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Barry Carol

Wouldn’t it be a major violation of trust (at least) with physicians to start publishing quality data which used to be confidential and was collected with the understanding that it was confidential? Maybe they could make a deal with providers and then start releasing data that was collected after that deal was struck. If I projected myself into the doctor’s shoes, I think the answer is, yes, it would be a violation of trust. If I, as the doctor, would have no problem with releasing the data, that’s fine. I’m not sure I understand what the doctors are afraid of.… Read more »

spike
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spike

Contracts, especially hospital contracts, are negotiated on a one-by-one basis. We had to cut special deal for specialty docs in areas where there were few of that specialty all the time. Hospitals were even more specific in our contracts, with some having negotiated case rates and others negotiating differing per diems. How could the insurers make this pricing system transparent? And this was all just in behavioral health which is vastly less complicated (from a CPT/ICD-9 perspective) than medical. A question I asked on Joe’s blog, maybe I can ask it here: Wouldn’t it be a major violation of trust… Read more »

The Medical Blog Network
Guest

Barry, I think you speak for the “silent majority” of the American healthcare consumers.
Too bad they are so poorly represented in the wonkosphere. But that is why blogs are growing so rapidly – they give voices to those who could not have been heard.

Barry Carol
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Barry Carol

I think pricing transparency depends a lot on which of the three segments of healthcare that Amy Tuteur described (well care, catastrophic or end of life) we are talking about. In the case of well care, where she said markets can function quite nicely, I don’t see why patients should not have easy access to prices for services like: routine office visit, new patient visit, consultation of specified time length, routine physical, mammogram, etc. Also, if the doctor offers a discount from the posted price for immediate payment, make that clear. If I can learn the appropriate CPT-4 codes ahead… Read more »

The Medical Blog Network
Guest

Hey Matthew, I am not saying you are not enlightened. Very much to the contrary. But I question the word “few” and assumption that consumers cannot be trusted to make the decisions right for them. Regarding car vs. spark plug analogy, I think it is best to lay out all of the options with as much info as possible. Include both line items and various bundles. Line item pricing transparency would help fix the most egregious disparities, including what individuals vs. insurers pay. Yes, many people will be confused and would want to go for bundles, where it would be… Read more »

Matthew Holt
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Matthew Holt

My word, I’m supposed to be all humble now! C’mon Dmitry, give me license for a little sarcasm–you’re allowed to “respectfully disagree” about my level of “enlightenment!” If you can get past the computer TCO piece, what about my car vs spark plug analogy? I’m not afraid of people knowing the costs, but it needs to be “what will it cost to look after this group of people for a year for a pre-defined se of services”? Otherwise as I said to grace Marie, we’ll all be competing for the cheapest foot amputation for diabetics when we forgot to price… Read more »