Physicians

Measurables and Immeasurables

It all sounds simple enough. You measure everything you do. You gather claims data. You measure what works. You show measures of what works to doctors and nurses. You write protocols for doctors and nurses to follow what works. You pay more for what works. You pay less for what doesn’t work. You remove pay incentives that cause doctors to do more. You gather together doctors who lead organizations with track records for providing better care at lower costs at the White House.

You trot out the theory of evidence-based care,

1. For any given diagnosis, the doctors has a number of options, and you assume most diagnoses fall neatly into diagnostic bins.

2. Committees of doctors and others, such as health plans and Medicare medical directors, track data outcomes related to these options and develop protocols for best results.

3. Doctors follow protocols, and outcomes improve.

Voila! You have the rudiments of a national policy for providing higher quality care at lower costs.

But, as always, simply measuring care to achieve better results has sticking points. The devil is in the details. The devils are the doctors.  The scientific method and the political realities conflict. Physician and patient human nature keeps muddying the big picture. They insist on doing what they think is best based on experience. Critics say you cannot extend one organization’s results to the nation as a whole when salaried physicians dominate that organization and independent fee-for-service doctors take care of 90% of patients.

In any event:

1.Doctors resist protocols, preferring instead their clinical intuition based on their experience.

2. Hospitals and doctors lose money when they improve quality and reduce complications for which they were previously paid.

David Leonhardt, a New York Times economics expert, brilliantly explains these sticking points and how to side-step around them in his portrait of the life and works of Brent James, MD, the 58 year old chief quality officer of Intermountain Healthcare, a hospital system in Utah and Idaho, with an overwhelmingly Mormon patient constituency. According to Leonardt, “James’s answer to such skepticism — and there is a lot of it, especially beyond Intermountain — is to show results. Intermountain has reduced the number of preterm deliveries, as well as the number of babies who must spend time in the neonatal-intensive-care unit. So-called adverse drug events, which include overdoses and allergic reactions, were cut in half in the mid-1990s. A protocol for dealing with one broad category of pneumonia cut its mortality rate by 40 percent over several years. The death rate for coronary-bypass surgery was cut to 1.5 percent, from the national average of about 3 percent. Medicare data on heart-failure and pneumonia patients show that Intermountain has significantly lower-than-average readmission rates. In all, James estimates that the changes have saved thousands of lives a year across Intermountain’s network. Outside experts consider that estimate to be fair. “James gets results by being deferential to doctors and by appealing to their sense of idealism, which he calls ‘the flame.’ That flame burns brightly within the heart of any physician. It’s what brought us into medicine. That’s what defines us as a profession. And that’s your real leverage point. There are a few outliers, but don’t let those outliers get you off track.” James notes that many medical questions still have no data-proven answer. Many never will. When patients have conflicting symptoms, statistics and protocols won’t always help. Sometimes, intuition is the only good tool a doctor has.Besides, intuition, other immeasurables exist. How do you define and measure“quality” with patients and doctors when quality is in the eyes of the beholder? How do you measure the quality of physician and hospital performance, when outcomes depend mostly on patient behavior outside doctors’ offices and hospitals? How do you define compassion, bedside manner, patient expectations, trust, efficiencies and understanding of communication, promptness and convenience of access, and amenities at the point of care?To sum up, government can mandate what the doctor measures, what it will pay doctors from its deep tax treasures, but it does not have the retrospective perspective, to define or measure the unclassifiable subjective, or patient-doctor intangible relationship pleasures. 

Richard L. Reece, MD is author of Obama, Doctors, and Health Reform and blogs at www.medinnovationblog.blogspot.com.

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http://www.inceptiongallery.com/media/book4/book4.php?2068guccisuhanasoftHarris MeyerActuary108DAYS Recent comment authors
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http://www.inceptiongallery.com/media/book4/book4.php?2068gucci
Guest

Next the famous host oprah afforded tights perfectly as a cashmere cosy sweater in the super Winfrey’s preferential pieces.

suhanasoft
Guest

ANGIOPLASTY SIDE-EFFECTS
Angioplasty has proved to be a boon for patients suffering from heart diseases in the last 2-3 decades. It is efficient, economical, time-saving and involves less fuss. But in spite of that, there are a few side-effects of angioplasty as well. Let’s have a look at what could be the possible risks involved in and how to overcome them.

Barry Carol
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Barry Carol

“That’s true but it doesn’t tell the whole story. There just aren’t very many programs comparable to Kaiser across the country. It would be interesting to know what the local market percentages are for integrated systems.” Karen – What do you think accounts for this? As I’ve asked in the past, if Kaiser is such a superior model, why hasn’t it taken hold in most, if not all other markets? I can think of several potential reasons but they are all mere speculation on my part. First, it is incredibly expensive to build a self-contained network that includes hospitals. To… Read more »

Karen Mitchell
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Karen Mitchell

“That confirms that most people prefer the flexibility of a broad network vs. the limitations of a narrow network HMO as long as the insurance premium differential is not too wide.” — Barry That’s true but it doesn’t tell the whole story. There just aren’t very many programs comparable to Kaiser across the country. It would be interesting to know what the local market percentages are for integrated systems. “If they want to grow and have the capacity to handle many additional members, I would expect them to price more aggressively to pull market share away from competitors.” According to… Read more »

MD as HELL
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MD as HELL

Margalti, You really seem to know very little about healthcare law regarding “allowable” charges, EMTALA, Medicaid, TriCare, etc. The short version: When you are mandated to provide a service on demand without anyone required to pay for the sevice, it is theft by legislation. (EMTALA). When you are told what you may charge for a service and told what you are going to get, then your right of contract has been stolen. When you are told you will get 9% or 21% less this year than last year for a service (and you will like it and have no appeal)… Read more »

Barry Carol
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Barry Carol

Karen – Thanks very much for the link to the Congressional Research Service paper. It was interesting to note that the term actuarial value refers to the percentage of costs for benefits across a standard population and average medical prices. It does not speak to what any one individual would actually pay out of pocket. The paper also indicates that only 23% of the population is in HMO plans vs. a much higher percentage in PPO’s. That confirms that most people prefer the flexibility of a broad network vs. the limitations of a narrow network HMO as long as the… Read more »

Harris Meyer
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Harris Meyer

I again wanted to point out an overlooked aspect of this issue, that payers have not been eager to embrace payment methods that recognize and reward the documented outcomes improvements and cost reductions at innovative places like Intermountain, Geisinger, and Virginia Mason. See my article on this in the November issue of Managed Healthcare Executive.
http://managedhealthcareexecutive.modernmedicine.com/mhe/article/articleDetail.jsp?id=638750&pageID=1&sk=&date=
–Harris Meyer

Margalit Gur-Arie
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Margalit Gur-Arie

108Days,
I am already paying taxes for stuff I don’t support. Lot’s of stuff. Always have. It’s not stealing. It’s democracy.

Actuary
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Actuary

Response to MD as Hell, who said:
Following protocols or guidelines or rules will never save your a** in court, which is why we need tort reform for cost control more than anything else you are jabbering about.
Part of Tort Reform — which is needed to “bend the cost curve” is to establish “official, sanctioned” guidelines and to make it harder to sue an MD who followed them.

108DAYS
Guest

Margalit, one could ask you the same question..
If the government taxed you to pay for progams and/or services you disagreed with, would you have any objection or would you lay down and be taxed? Did you agree with the GM bailouts? Wal Street bailouts? Cash for Clunkers? Maybe so, eventually they’ll come up with one you don’t agree with.

inchoate but earnest
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inchoate but earnest

Barry Carol wrote: “If you compare comprehensive PPO and non-Kaiser HMO plans to Kaiser, the benefits are essentially comparable and the premiums are comparable or within a few percentage points of each other as well. Historically, HMO’s offered a lower premium in exchange for less provider choice or a narrow network vs. a broad network. With salaried doctors and electronic records, which is the direction reformers want to move in, there should be cost advantages. If there are, they should be easy to demonstrate and should be reflected in lower premiums charged to members. “ Barry, let me heist a… Read more »

rahul
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thanx for the nice posts.. sir as iam a frequent traveller it was very usefull to me i use.. International Medical Insurance

Margalit Gur-Arie
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Margalit Gur-Arie

Md as HELL, I don’t quite understand. Do you consider government taxing and paying for programs and services you personally disagree with, stealing?

MD as HELL
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MD as HELL

jd,
Even shorter: don’t rip me off and call it reform. You are just stealing from me. I will give away the world at my discretion to anyone who needs help. But I will not let you steal it from me so you can give it away and thump your chest.
If you don’t see the difference, then you really are a jd.

Karen Mitchell
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Karen Mitchell

Barry:“Kaiser, even in Northern CA where it is well regarded and has a significant market share, has not been able to offer health insurance for meaningfully less (including member co-pays and deductibles) than its traditional competitors, both for profit and not for profit.” The actuarial value of the HMO and PPO, which includes more than premiums and co-pays, is discussed in a Congressional Research Service report from April. Comprehensive HMO plans like Kaiser are about 93% efficient vs 80%-84% for PPOs with similar plan provisions. http://assets.opencrs.com/rpts/R40491_20090406.pdf I think that Kaiser and traditional insurers have different objectives in the marketplace. Insurers… Read more »