THCB

Quality Like Beauty Is In the Eye Of The Beholder

For as long as I can remember we have told ourselves that the health care priorities of the American people are access, cost  and quality.  However there was never a consensus as to what exactly we meant by quality, let alone how to measure it, or pay for it.  The truth is that there are many ways of defining quality and our research shows that different players define quality very differently. Patients, physicians , employers, insurers, the I.O.M, hospital managers, drug companies, the NCQA, public health experts, demographers and policy wonks all focus on different indicators of quality.  Clearly quality,  like beauty, is in the eye of the beholder.

Patients tend to define quality as meaning affordable access to almost everything.  Naturally they care about the outcomes of their own care. They tend to believe that more care is better than less. The demeanor and bedside manner of doctors and nurses, being treated with respect and courtesy, are important. They often judge hospitals the way they judge hotels; good food and a nice atrium make a difference.  As Ian Morrison has written “good quality is being in a waiting room with people who have more money than you”.

The Institute of Medicine has equated quality with the avoidance of medical errors (adverse events) and patient safety , and the pursuit of ways to improve these.

Most Employers tend to equate quality with having happy , uncomplaining employees at the lowest possible cost.  A minority of progressive employers , such as those who participate in the NBGH and PBGH meetings, also focus on “value” and the use of sticks and carrots to influence the behavior of their employees and pay for performance incentives to influence  providers.

Insurers have focused on those things they could count and measure, often based on claims data – such as treatment and prescribing patterns and the use of generics. The concept of comparative effectiveness  (or better still, cost-effectiveness) appeals to them.

Drug companies tend to equate quality with the use of brand name drugs, as opposed to generics, and high levels of compliance and adherence to drug regimens.  They link quality to high levels of reimbursement for their drugs, the scale of R&D spending , innovation and a strong pipeline.

Physicians tend to define quality not just in terms of outcomes but also with having happy patients. They equate quality  with  access to new technology, a low hassle factor and autonomy, good ancillary services, the absence of obstacles to appropriate care and being part of a strong team.

Public health experts and demographers tend to focus on population statistics such as immunization rates, life expectancy, maternal and infant mortality rates, or deaths amenable to medical care.  They are also likely to compare statistics from different countries and different segments of the population and to talk about disadvantaged groups and disparities.

Policy wonks tend to focus on the use of evidence-based-medicine, the use of practice guidelines, appropriate and inappropriate care. They advocate the use of process measures (such as the use of beta blockers for heart attack patients), intermediate outcomes measures (such as the control of blood pressure, A1C, INR  and cholesterol) and “real” outcome measures including the impact of care on mortality, morbidity , disability and quality of life. Unfortunately these are surprisingly rare.

It would seem to me that almost all of these ways of defining, and where possible measuring, quality have some validity.  But the different perceptions of different groups tends to promote a Tower of Babel, with each group making very different assumptions about what is important.    The public ,unlike most of the other groups, tends to believe that medicine provides clear right and wrong answers and that all care should be as error free as , say, flying an airplane, if the “correct” treatments are used. They are puzzled when told that only a fraction of medical care is “evidence-based” and they assume that drugs should only be used for conditions for which they have been approved (they recoil from the concept of off-label use). Most people also believe that there is much fraud , waste and abuse in the system but only a few people believe that they themselves have received unnecessary care.

Some parts of the future are pretty certain.  There will be a growing focus on quality and many more and better ways to measure it.   There will be changes in reimbursement to promote better quality and to pay for better performance.  Health care delivery systems will change and the health care system will evolve and keep on changing.   Other things are much harder to predict.    As Susan Dentzer wrote in Health Affairs, paraphrasing Ralph Waldo Emerson, “quality is not a destination but a journey”.   What will the new definitions of quality be, and who will define it?  How will we measure it? Will we focus more on “value” – however we define that — than on quality?   How much, and how, will we use cost-effectiveness as a criterion for making decisions about care? In a world of scarce resources, cost containment and tough choices, as Mark Pauly has written:     “perhaps a little less quality for a lot less money might be acceptable”.

It is clear that some improvements in quality will save money. But it must also be true that other improvements – ensuring that more people get the appropriate care – will add to the cost of care.  Keeping people out of hospitals and emergency rooms will reduce spending, but keeping some people alive  longer may cost more.  I like the argument that the more we improve quality the less we will have to cut care. But, contradictory as it may seem, I also believe that the more we improve quality, and believe we are getting good value for our money, the more willing we will be to spend more money on care.

Humphrey Taylor is Chairman of the Harris Poll, Harris Interactive.

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michael turpincoryPamela Wible MDFat BastardDr. Rick Lippin Recent comment authors
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michael turpin
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Bravo, Humphrey. As usual, you are on the mark !

rbaer
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rbaer

Pamela,

There are enough patients out there who are attracted by robotic surgery, waits so short that they require overcapacities, birthing suites, talking how hospital x looks shabby compared to hospital y with the nice marble and fountain …. the individuals driving up costs are either sick (and of course that why we have health care), or demanding, or both.

cory
Guest
cory

If you look at the older industrial literature, quality is defined quite specifically. Quality is “conformance to standards”. Good definition – takes the emotion out of it. No issues of “justice” or “fairness” or whatever any one wants to throw out there. What does it mean for medicine? Defining quality is simple- conform to standards you set up. The really, really hard problem is defining the standards. This usually requires a detailed input by people with a knowledge of medicine. And lots of debate – what is an acceptable rate of infection or hypoglycemia? No one could be against quality-… Read more »

Pamela Wible MD
Guest

When patients are asked to define and design ideal clinics and hospitals they do not want the latest and greatest of everything. They are conservative and have a “less is more” attitude. They design economically-sustainable locally operated clinic such as this one: http://www.youtube.com/watch?v=dtEFIFqhw6I

Community-designed health care is the best way to provide affordable and high-quality health care for the nation in a culturally-sensitive manner:
http://www.beckershospitalreview.com/hospital-leadership-and-executive-moves/putting-communities-in-charge-of-hospitals-future.html

Pamela Wible MD

rbaer
Guest
rbaer

You may think I am saying that because I am a physician, but you are only half right. A lot of the population data that you cite is poor for the US, but this probably has more to do with poverty than with the quality of US health care. I worked/trained in Germany, France and now the US; the US doctors are very well trained and selected (although matched by the French docs, and the academic are mostly smart anywhere) … but I agree that they (we) have wrong incentives, and often do aggressive therapies that do not help or… Read more »

Fat Bastard
Guest

Quality is a very objective thing when it is measured. US Health care is the leading cause of death and injury. US MD are the highest paid in the world in spite of the fact that they are the 3rd leading cause of death and injury. 100,000+ Americans die each year from health care acquired infections and that is based on the 27 states that voluntarily report. The average hospital make 10 medication errors per day. The odds of getting a health care infection in the US is 1 in 10. Health care in the US sucks and anyone who… Read more »

Dr. Rick Lippin
Guest

Thanks- I may be wrong but the word quality also implies fairness?

rbaer
Guest
rbaer

“But the different perceptions of different groups tends to promote a Tower of Babel, with each group making very different assumptions about what is important. The public ,unlike most of the other groups, tends to believe that medicine provides clear right and wrong answers and that all care should be as error free as , say, flying an airplane, if the “correct” treatments are used. They are puzzled when told that only a fraction of medical care is “evidence-based” and they assume that drugs should only be used for conditions for which they have been approved (they recoil from the… Read more »