Quality v. Quantity

A few weeks ago, the medical community received unexpected good news from the government about a “simplification of quality measures:”

Strictly speaking, and contrary to what Mr. Slavitt’s tweet would lead us to believe, the agreement to the new rules was primarily between commercial insurers and CMS, the Center for Medicare and Medicaid Services. Physicians were not actually party to the deal.

Nevertheless, doctors were expected to greet the news with cheers. As Rich Duszak reported, Adam Slavitt, acting administrator for CMS, also declared that “patients and care providers deserve a uniform approach to measure [sic] quality.”

Indeed, we all deserve uniform quality measures. Equality in quality!

Taking the pulse of “industry leaders,” Becker’s Hospital Review affirmed they were confident the agreement would help “accelerate the country’s movement to better quality.” And who could possibly be against better quality? Only anti-progress reactionaries, to be sure!

But to understand this latest development, the context may be helpful.

Fifteen years ago, the Institute of Medicine, suddenly aware of the calamitous state of American healthcare, issued a call to arms urging everyone to “Cross the Quality Chasm.” And since, in those days, management gurus were repeatedly telling us that “if you can’t measure it, you can’t manage it,” the missionaries of quality dispatched in the wake of the IOM report naturally went on a quality measurement frenzy. How else could they be expected to tame the beast?

But, as Dr. Vinod Seth humbly remarked, if you measure something, is it still a quality?

“Quantifying quality” does sound a tad incoherent, doesn’t it?

So what is Quality?  To answer the question, Robert Pirsig felt compelled to combine Zen buddhism, pragmatism, and Peyote. But can we put our finger on the concept without being driven to insanity?

I like to stick to the old school realism of Aristotle, and I think ancient thinking may come handy here.

In its classical sense, a quality of a thing is a characteristic that distinguishes it from another thing: a sound is crystalline, as opposed to muffled or thundering. A person is pleasant, as opposed to rough or taciturn. Qualities separate and segregate things into respective categories.

Now, it is true that a sound can be more or less muffled, but once we focus on how muffled the sound is, we are no longer interested in muffledness as a quality. A slightly muffled sound or a super muffled one all belong to the same category of muffled sounds.

The same goes for the distinction between something good and something bad. Goodness and badness are important qualities that, in the context of any decision making, help express or articulate the ultimate reason for the choice taken: I chose this thing because it was of good quality, or I chose this option because it was a good thing to do. I refused that one because it was a thing or an option of bad quality.

Note that the stipulation is coincident with the choice: It’s not that I first determine whether something is good or not, and then make my decision. The value determination seals the choice (or perhaps vice versa).

Of course, one has to be careful here and not confuse a stated value for a demonstrated value.  I may sincerely agree with the salesman that the ostrich hide boots are of the very best quality, but I still ultimately think that parting with five hundred dollars to get them would be a bad quality trade.  As far as I’m concerned, that exchange would have been bad, since I choose instead to spend my money on the Liberace-style sequin jacket.

I could also think that something is good and later change my mind, of course. But the fact that I bought the jacket demonstrates that I found it good at the time. And, as far as its quality as such is concerned, it doesn’t matter whether I thought the jacket was very very good, excellent, or simply goodAny degree of good is still good.

Language historians may be able to tell us precisely when we dropped the “good” from the phrase “good quality” and simply shortened it to “quality,” but the fact remains that good quality—that, today, we often simply refer to as “quality”— is a dichotomizing concept: it separates the choices worth making from those we should reject. Measuring quality does nothing of the sort.

So to return to our starting point, is the simplification of quality measures something patients and physicians should cheer?

If we bear in mind that medical care consists of decisions and choices made in the face of uncertainty, then the quality of a decision can only be determined in real time, in a specific context, in light of all its alternatives. A third-party payer—public or private, single or multiple—cannot possibly obtain the needed knowledge to make that determination. For an outsider, the quality chasm is metaphysically impossible to cross. Measuring quality is grasping at straws.

Sobered by experiencing this reality for fifteen years, insurers are now paring down the number of quality measures from hundreds of disparate ones down to a handful. This may be an improvement as far as efficiency is concerned, but doing an absurd thing more efficiently doesn’t make it any less absurd.

“Michel Accad practices cardiology in San Francisco and blogs at alertandoriented.com where this post originally appeared.  He can be followed on Twitter @michelaccad

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4 replies »

  1. Quality over quantity is always important in all areas of healthcare.

    According to Pew Research Center, roughly 10,000 Baby Boomers will turn 65 today. About 10,000 more will cross that threshold every day for the next 19 years. Healthcare is expanding as our population ages.

    Many side effects appear in the process. For example, increased medical errors…


    Many steps need to be taken to make sure the increased quantity is high quality. Software and robots are helping to improve our healthcare.

  2. You’ve spelled out one of the principles of the subjective theory of value. And indeed, it’s impossible for third parties to properly value goods and services.

  3. America is the only country in history where we spend $100 million to save $10 million and are fiercely proud of it.

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  4. Here’s something to think about:
    In my opinion, the ostrich boots for $500 is a good deal, and if they look like they were made well, I would certainly consider buying them, if I had a few extra hundred bucks to spare. The Liberace jacket I would likely not take or wear for any amount of money.
    So therefore, quality is different for each person purchasing the goods or service.
    The purchaser should ultimately be the decider of quality, not a third party.
    So a patient may think spending $1000 on a MRI to rule out a disc herniation, or may feel it’s better to spend the money on a course of PT to alleviate the symptoms. The insurance company may not approve either of those.