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.